As a busy gynaecologist one of the most common complaints I see on a day to day basis are problems related to the menopause.
What is the menopause?
The menopause signals a time of change in a woman’s life hence the common term “change of life”. It is when ovulation ceases and periods stop. The ovaries in effect stop producing eggs and most of their hormones mainly oestogen but also progesterone and testosterone. Fertility ceases and therefore she no longer needs to consider contraception.
For a large number of women, this change happens with very little ill effects and they happily enter a more carefree and exciting phase in their lives. However, for a group of women, this phase becomes extremely uncomfortable and very distressing. It is this group that we as gynaecologists see and help.
The average age of menopause is approximately 52 but the normal range is between 45 and 60. If it is before 40 it is called ‘premature menopause’ and that has a number of problems on its own.
Briefly, premature menopause or premature ovarian failure often has no known cause. It may be a genetic problem, as part of an overall gland failure or surgically induced when the ovaries are removed either by surgery or destroyed by radiotherapy or chemotherapy.
The symptoms of menopause
- Change in the menstrual cycle: Periods may suddenly disappear or become irregular lighter or heavier. Everybody is different
- Hot flushes: This is one of the most common symptoms of menopause and the most distressing. These are characterized by a feeling of intense heat that usually begins around the face and neck causing a flush. The face is red and may be sweaty. The heat then moves to the rest of the body. It can last from a few seconds to many minutes. They are common at night and there can be several during this time resulting in sleep deprivation and exhaustion. They may also be accompanied by general sweating, nausea, tiredness and heart palpitations.
- Vaginal Dryness: I find this to be the most complained about long-term symptom. As with the mouth the vagina needs to be comfortably moist at all times. The vaginal mucosa (skin) is extremely sensitive to hormones so when they disappear the skin becomes thin, less elastic, dry, irritating, and sore and becomes susceptible to infections such as thrush. Intercourse becomes dry and uncomfortable with pain, bleeding and difficulty with penetration.
- Urinary symptoms: Many women complain of frequency, waking up at night to pass urine, urgency and leaking when coughing, sneezing or laughing. These symptoms are because of a lack of hormone acting on the urinary tract.
- Mood swings and other emotional problems: Hormone lack can exacerbate other life problems such as domestic issues, aging, children and relationship issues.
- Sexual issues: In some women, there is a marked change in their sexuality around the menopause. Feelings and desires may change. Intercourse can be dry and uncomfortable. Tiredness due to sleep disturbances can further decrease her desire. The aging process and related body image issues can all lead to a loss of desire. Low or absent Oestrogen, progesterone and testosterone levels can all reduce one’s libido.
- Other less obvious changes: Dry skin, itchy crawly skin, coarse hair growth, weight gain, aching joints, and muscles can all occur.
Management of the menopause
The first thing I do when I see a woman with menopausal symptoms is listen. I take a full and detailed history going into detail of all her symptoms. I also go into detail about general health issues.
I then do a full and detailed physical examination including a smear test and a vaginal swab. I then do an internal vaginal examination paying particular attention to the vaginal skin, the wall of the vagina (looking for prolapsed), and the internal vaginal organs such as the uterus and ovaries.
I then order some blood tests which include lipids (cholesterol), full blood count, liver, and kidney function tests and hormone tests.
If indicated I order a pelvic ultrasound and a bone density examination (to rule out osteoporosis).
I then see her again, collate all these results and then work out a management plan with her.
Treatment of the menopause
For a large number of women simple advice, reassurance of normality and support is all that is required.
There are however those women who will need HRT or hormone replacement therapy. This is where the controversy exists. The popular media and certain interest groups have condemned the use of HRT.I believe very strongly that where the indication exists and as long as the risks and benefits are fully discussed and understood there is definitely a place for HRT in the treatment of menopause.
HRT can alleviate hot flushes, vaginal dryness, low sex drive, urinary symptoms, sleep disturbances and a multitude of symptoms that make the menopause a miserable time for the woman, her partner, and her family.
HRT can be given as pills, patches, implants and/or a vaginal cream or pessaries.
The best thing to do is discuss these issues with your doctor and together work out whether HRT is appropriate for you and if so what the best way of delivering the hormone is.