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Menopause

What is the menopause?

Sally Hope is a retired GP. She is a researcher with a special interest in women's health. She is the co-author of several books on the menopause (see ‘Resources and information’), and talks about the menopause from a medical perspective. You’ll also find clips from Sally’s interview in some of the other topic summaries. As a menopausal woman, Sally also has a personal interest in the menopause.

What is the menopause?
Menopause means the ‘last menstrual period’. However, many women say they are ‘going through the menopause’ when talking about the time leading up to their final period when they notice changes in their menstrual cycle and the onset of symptoms such as hot flushes and sweats. Women are said to have reached the menopause when they haven’t had a period for one year. In the UK the average age at which women reach the menopause is around 51, however, some women can go through the menopause earlier or later. A menopause before the age of 45 is an ‘early’ or ‘premature’ menopause (see ‘Early (premature) menopause’).

 

The average age of the menopause hasn’t changed for 2000 years even though girls are getting...

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You can’t predict when it’s going to happen. It’s going to be some time between 45 and 55. The average age of the menopause in the UK is 50 years and nine months. Very interestingly, it hasn’t changed through time. We know that the time your periods start, your menarche, has altered wildly over times. In Elizabethan times it was about 18 and now when I was a girl 40 years ago the average was about 14 to 16 and now it’s right down to 9 or 10. And so girls are having their periods at primary school but the interesting thing is the age our periods stop, the menopause, hasn’t changed through time. In fact, Hippocrates wrote a really interesting little bit about an extremely old woman whose periods stopped and she was 50. So it hasn’t changed for two thousand years and the reason for that is because we are born as babies with the eggs in our ovaries and they have a sell-by date and so the menopause is actually, when your ovaries run out of eggs. You don’t produce any more eggs so you don’t cycle and that has a sort of standard ticking sell-by date that hasn’t changed.

Women often ask how long the menopause is likely to go on for. It varies a lot. While a third of women have no symptoms at all, most women have at least two or three years of ‘hormonal chaos’ as their oestrogen levels decline before the last period. This is called the perimenopause. Women are said to be postmenopausal any time after their last period. However, a small minority still have hot flushes in their eighties.
 

Women often can’t tell exactly when they have reached the menopause

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The menopause is medically defined as your last period ever, which seems very simple but there are a number of problems with that. Firstly, how do you know if the period you’re having is going to be your last one? You don’t. You only know retrospectively that it’s got to be for a year so you have to actually write them in your diary and then, because I can’t remember anything these days, so you look back and think, “Oh, yes. I haven’t had one since June 2009.” So that’s the first problem. Second problem is some women, who’ve had a hysterectomy, taken their womb out, don’t have that menopause, the menstrual marker of having a period every month so how do we know that they’ve gone through the menopause. And also a lot of women now have the Mirena intrauterine contraceptive device levonorgestrel progesterone, which stops you having periods. And there are also other long acting contraceptives like the injection in your arm Depo-Provera or Implanon (now Nexplanon) and those all stop your periods or the mini-pill and all those people don’t know where their periods are either. So there are some problems with that.

What are the symptoms?
Irregular periods and hot flushes and sweats are usually the first signs that the menopause has begun. Other symptoms that may occur include sleep disruption, loss of sex drive (libido), vaginal dryness, urinary problems, joint and muscle aches, changes in skin and hair, weight gain, anxiety, mood swings, depression, and poor memory and concentration.
 

Sally describes the changes in periods women might expect during the menopause.

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Some women in the perimenopause get irregular periods and that’s often why they come and see me, as a GP, because they’re worried there has been a change. And what happens is, when your perimenopause is starting, is your periods actually get closer together and that drives women mad because, you know, you can just about put up with a period once a month, every five weeks but if it comes to be every three weeks or sometimes even fifteen days you just never get a break from being premenstrual and bleeding but that is actually very common. So they go closer together for a year or two and then gradually come further apart and you get a period every six to eight weeks and then they stop or you have one every three months and then they peter out. So there’s a change. Also women may get heavier bleeding. And that’s really due to fibroids. Those are benign lumps of muscle in the uterus that every woman has over the age of 40 but it stops the womb contracting down and stopping the bleeding and so your periods can get heavier. And the factor of heavier periods and more frequent periods means that we all become anaemic and that makes us tired and grumpy and lethargic. And so it’s quite important if you’re feeling very tired to go to your GP and check that you’re not anaemic because you may just need iron to feel better or there are other ways to lessen your periods.

 

Why some women have no hot flushes while others may experience ‘thousands an hour’ is a mystery

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The first thing to say is a third of women have no symptoms at all and that’s fine. One of the fascinating things from my point of view trying to have an interest in the menopause, is we really don’t understand it. Why is it that you and I can be going through exactly the same thing of our ovaries running out of eggs and us not producing the cycling anymore, our periods, and yet I have ten hot flushes a day and someone else might have none, and someone else has a thousand. It doesn’t make sense to me. I think there’s a sort of hot flush molecule that is yet to be discovered. So the basic symptoms are hot flushes. In American literature they’re called hot flashes, which sound even worse I think, and it’s a feeling of great heat going through your body and sometimes people sweat quite profusely with it and you can actually watch it happening on the screen, measure the skin change, so it has a very profound physical basis. And we know that some women may have two or three hot flushes a day, sometimes at night.

I always get them when I’m trying to lie down and go to sleep. Some women have a thousand hot flushes in an hour, you know, and we don’t understand the difference. We know that it can be made worse by stress and so a lot of the complementary therapies for relaxation and yoga do have a basis in that if you’re very calm your cardiovascular system is calm, your blood pressure drops, your pulse drops and you feel better and you seem to have less. They are sometimes precipitated by alcohol, alas, or hot curries or spicy food or hot drinks even.

Sometimes it’s hard to tell whether symptoms are caused by the menopause or by other factors in midlife. Women may be working full-time, caring for teenage children as well as elderly parents, or going through marital problems - all can add to the burden of coping with menopausal symptoms (see ‘Family, health and life events’).
 

It can be ‘incredibly difficult’ to tell if depression at midlife is caused by the menopause or...

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Well, depression is common all the time anyway. One in three women have depression at some point in their lives and it’s often incredibly difficult, as a GP, or in myself to know whether I’m depressed because I’m grumpy and emotionally labile [likely to change] because I’m having terrible night sweats and I haven’t had a decent night’s sleep for a month, or whether I’m depressed because it is such a difficult time in our lives. I mean we are in the middle of a cog of perhaps looking after elderly, frail parents or in-laws, perhaps having a partner having a midlife crisis, perhaps having problems with our own work and image as we’re facing the menopause and not wanting to be old in this culture where everything is about youth.

And then we have stroppy teenage children, who aren’t leaving home and not getting a job and not working or we’ve got slightly older children who are going through marital problems or having babies or we’ve got absolutely everyone from every possible aspect coming in on us as the woman provider fixing everything. So it’s not surprising we feel a bit stressed. And then we’re feeling hot, menopausal and can’t remember the name of our cat. So it’s a rather tricky time and I think we need to recognise that and actually recognise that perhaps we need some us time. And not be super human wonderful people all the time. Just give ourselves treats. Feel better.

What treatments are available?
According to Sally, most women see the menopause as ‘a natural milestone in their lives and get through it on their own’. Alongside diet and exercise, most choose common sense self-help approaches to minimise the effects of their symptoms (e.g. wearing cotton clothing and using a fan to help with hot flushes) rather than take prescription medication.

A considerable number of women have tried complementary therapies for symptom relief. However, as Sally says, ‘very few trials have been done and the ones that have been done have shown very poor results’. She does, however, recommend a diet rich in phytoestrogens such as soy, lentils and chick peas.
 

Sally talks about the risks associated with some herbal remedies, and the benefits of including...

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The only thing that has really got a good evidence base that really reduces hot flushes are what are called the phytoestrogens. Phytoestrogens are very interesting molecules that you get from eating the beans and peas legumes so it’s tofu, soya, lentils, chick-peas, any beans, peas. And there is something called red clover, which comes in a variety of different preparations, and good randomised controlled trials on red clover tablets have been shown to reduce hot flushes and symptoms of anxiety by 80 per cent.

There are some Chinese herbs that actually were shown to cause liver failure. And black cohosh was the one where there have been a number of liver failure things so I don’t advise that.

I think a lot of people think because it’s over-the-counter and herbal it must be safe and they’re surprised when you tell them that black cohosh has actually killed six people from liver failure or that actually they’re quite powerful things. Like you must tell your doctor if you’re on other medication because things like St John’s Wort actually interact with a huge number of different drugs including anti-epileptics, anti-depressants, warfarin, chemotherapy. So they have a powerful action.

For some women, hormone replacement therapy (HRT) continues to offer relief from menopausal symptoms such as hot flushes by replacing oestrogen. It's available in many forms including tablets, cream or gel, a skin patch or an implant (see ‘Hormone replacement therapy (HRT)’).

Hormone replacement therapy (HRT) is recommended for some women, for effective relief of severe menopause symptoms such as hot flushes and in young women following early menopause up until about 50 years old. As with any medication, HRT has benefits and risks and these should be discussed with your doctor. For most symptomatic women under 60 years or within 10 years after menopause, use of HRT for up to 5 years is safe and effective, Most experts agree that if HRT is used on a short-term basis (no more than five years), "the benefits are generally gelt to outweigh the risks" (NHS Choices 2016- HRT). However it will not be suitable for some women because of their medical history.

How can GPs help women through the menopause?
According to Sally, women sometimes consult their doctor during the menopause for reassurance that their symptoms are ‘normal’ and that they are ‘not going mad’. She sometimes runs menopause evenings to talk about women’s health issues and to provide an opportunity for ‘women to get together and talk over a coffee’. She acknowledges, however, that lack of time, knowledge and interest in the menopause can make it difficult for GPs to provide the type of support which women need at this stage of their lives (see ‘Consulting the doctor’ and ‘Advice for health professionals).
 

The menopause is not always a high priority for GPs

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I think there are a number of issues. Firstly, in general practice we’re so focused on government targets, which we have to do, the government is pelting us with targets on things like cardiovascular disease, diabetes, asthma, cancer, mental health, that menopause is a Cinderella subject. We get no payment for doing it and so a lot of GPs have it as an extraordinarily low priority and really I happen to have an interest in it both personally, because I’m going through the menopause, and I’ve been working in this area for twenty years. So I have that knowledge base, which I’ve found personally very helpful to keep me on a even keel but I think most GPs, to be honest, don’t have the time, don’t have the interest, don’t have the information in their minds about all this. And often I find women coming in who’ve read some excellent websites or books and are actually much better informed than the average GP and that’s nice because you educate us as you come into the surgery. But quite often we don’t support women very well.

She recommends that women look for information on the menopause and how to keep healthy on websites such as Menopause Matters, The British Menopause Society, and The National Osteoporosis Society (see ‘Support networks’ and  ‘Sources of Information’).
 

Sally shares her ‘top tips’ for women going through the menopause

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You’re not alone. You know, because sometimes it’s three in the morning when you get up and you’re soaking with sweat and you feel so tired and you’ve got a busy day tomorrow and your husband is snoring away and you think, you feel so alone - so you’re not alone. It’s self-limiting, even though it feels as though it’s going on forever, it does get better for most people, the vast majority, everyone really. Use it as a way to get yourself healthier. Use it as a positive lever to get the right weight, get fitter, lower your blood pressure, lower your risk of breast cancer, be kind to yourself. Use it as a way of giving yourself a bit of you time to do whatever you like, as you’re going through the menopause you deserve it. Do something that pleases you just for you rather than doing everything for everyone else.


NICE - National Institute for Health and Care Excellence recommends that GPs:
"Give information to menopausal women and their family members or carers (as appropriate) that includes:
•    an explanation of the stages of menopause 
•    common symptoms and diagnosis 
•    lifestyle changes and interventions that could help general health and wellbeing
•    benefits and risks of treatments for menopausal symptoms
•    long-term health implications of menopause. 

Give information on menopause in different ways to help encourage women to discuss their symptoms and needs." (NG23 November 2015)

What is the latest research about the menopause?
As the debate about using HRT as a medicine of choice for women going through the menopause continues, research has turned to finding alternative treatments which relieve menopausal symptoms while protecting women from the risk of breast cancer, strokes, and heart disease. Sally believes that Selective Estrogen Receptor Modulators (SERMs), such as Tamoxifen which is currently used in treating breast cancer, may hold the key to developing an alternative hormone replacement therapy which offers women both protection against breast cancer as well as minimising menopausal symptoms. As Sally explains, however while research is underway, 'we wait in hope' for a breakthrough.
 

Research is being carried out on Selective Estrogen Receptor Modulators (SERMs) which may one day...

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Well, the holy grail that everyone is looking for is a hormone replacement therapy that makes us look beautiful, keeps our memories absolutely razor sharp, helps our bones, helps our hearts but doesn’t give us breast and womb cancer. And if somebody invented that molecule I would take it straightaway. And those are called SERMs, Selective Estrogen Receptor Modulators. SERMs, Selective Estrogen Receptor Modulators.

Now, the first SERM is tamoxifen, which is used for breast cancer treatment because it switches off the oestrogen receptors in the breast and prevents new breast cancers and prevents metastases spread of breast cancer. And you might think if you took something like that it would be very bad for your bones but it’s not. You actually have brilliant bones on tamoxifen. So it actually turns on the oestrogen receptors in the bone but it turns off the ones in the breast.

So people got very excited about that but the problem with tamoxifen is it gives you hot flushes because it’s doing something in the brain, switching off the oestrogen receptors. So everyone is looking for the molecule that will switch on the oestrogen receptor in the brain, so you don’t get hot flushes and you don’t lose your memory but switch it off in the breast, switch it on in the bones.

It’s important to remember that although for some women the menopause can have a significant effect on their quality of life, not everyone has problems. As Sally points out, ‘thirty three per cent of women have no symptoms at all and don’t even know they’ve gone through the menopause’.


 

Last reviewed July 2018.

Last updated July 2018.

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