East Melbourne VIC 3002
Learn the five stages of menopause to get a better understanding of the changes that occur in an important era of your life. In the majority of women, the changes are gradual, but symptoms can be life-changing and often need to be addressed.
Natural menopause is the permanent cessation of menstrual periods for 12 months in the absence of a pathological cause, such as ovarian removal as part of treatment. The median age for menopause is 51.4 years, which implies that the follicles or egg-containing cysts on the ovary have been completely depleted. This results in a state of significantly low oestrogen production and a significant increase in the controlling pituitary hormones FSH and LH. FSH is the hormone that acts on your ovaries to make eggs develop, and LH is the hormone that releases the egg.
Menopause that occurs between the ages of 40 and 45 is called early menopause, and menopause that occurs before 40 years of age is often due to a condition called primary ovarian insufficiency.
The issues related to an early menopause or the early part of the transition to this stage revolve around worsening symptoms, an increased risk of heart disease, osteoporosis or weakening of the bones and poor brain function including such things as memory and brain fog.
During this early transition, you are often still ovulating or producing an egg, although your fertility has naturally declined. The commonest early symptom is irregularity of your periods, which often becomes shorter and varies from cycle to cycle. The pituitary hormone FSH often starts to increase, suggesting a reduced number of eggs, but your oestrogen hormone level is often within the normal range. It is important to realise that blood tests are useful if they are at one extreme or the other. In other words, they definitely indicate a menopausal state, or they definitely indicate that you are not menopausal. However, they are of limited value as natural variation day to day can be as much as 40% and results that are in the mid-range may not be helpful at all.
However, some women still develop symptoms such as hot flushes, insomnia and brain fog even in the early transition and treatment may need to be considered.
This is towards the end of the transition period and on average occurs 3-4 years before the definitive menopause or absence of periods for 12 months.
It is a continuation of the early transition period. The pituitary hormones, especially FSH, continue to rise and often go above the level of 30, whereas when you were in your 20s and early 30s, the level would typically be somewhere between 2-8. Oestrogen levels may have continued to decline, but are still above the menopausal levels, which are typically below 50 and often below 20. Symptoms continue to become more dominant, especially the symptoms of hot flushes, brain fog, mood changes, insomnia and reduced libido.
Rather than having shorter cycles, you may start missing periods and have cycles lasting 50- 60 days.
This perimenopausal period is often the time to start having mammograms, as this period is often towards your mid to late 40s, unless you have a reason to have earlier mammograms, such as a family history or symptoms. This is also the time to consider having a bone density study to exclude osteopenia or mild weakening of your bones, or osteoporosis, a significant weakening of your bones, especially your spine, femur and wrists. This is often an important time of your life to ensure that your diet is adequate, that you are exercising regularly, and you have had a cardiac check initially with your GP, who should monitor your blood pressure, monitor your cholesterol and body fats and ensure that your cardiac function is normal often with the aid of radiological procedures, and if there is any concern, a referral to a cardiologist.
It is important in consulting with women at this time to discuss their symptoms in detail, the pros and cons of menopausal hormone therapy and what tests may be important to assess general well-being. Treatment involves the consideration of the pros and cons of menopausal hormone therapy, which has been shown to be ideally given as a transdermal treatment using patches, gels and natural progesterone.
Although we have spoken of periods becoming less frequent, they can actually become heavier and problematic. This is because of anovulation or failure to produce an egg during a cycle, which can result in heavier periods due to a condition called anovulatory dysfunctional bleeding. There are many simple ways of treating these heavier periods. It is always important counselling women concerning menopausal hormone therapy to discuss and control symptoms. Medical information suggests that there is evidence that women over the age of 60 using menopausal hormone therapy may have adverse outcomes with respect to an excess risk of coronary heart disease, stroke and blood clots in the lungs or legs. However, studies have now shown that there is no doubt that using hormone replacement therapy transdermally or through the skin with gel or patches does not alter blood clotting and does not increase the risk of venous thromboembolism or blood clots and probably has very little effect on stroke risk. However, there is much less data in perimenopausal women and under the age of 50 and women in the 50-59 year age group, and it is important, therefore, to individualise and discuss the pros and cons in detail. The information from the Women’s Health Initiative, which is a study involving 27,000 postmenopausal women, shows adverse outcomes can exist with menopausal hormone therapy, especially in women over 60 (average age 63 ), where symptoms are usually dominant and require treatment.
The one message, however, with all of this confusing data, is that the benefits almost always outweigh the disadvantages in women in the 50-59 year age group, which is the time when symptoms are often at their worst. Looking at the risks and benefits of menopausal hormone therapy in women in the 50-59 year age group and looking at the advantages compared to the disadvantages, we find the following (this is women who have been on treatment for five years or more, and it is per 1,000 women).
There will be 3 additional breast cancer cases, but taking into account all major medical conditions, there will be 5 fewer deaths per 1,000 women years. These figures do not take into account, obviously, the improvement in quality of life associated with the treatment of difficult or significant symptoms. In women on oestrogen therapy alone who may have had, for example, their ovaries removed, the number of breast cancer cases is actually reduced by 2.5 per 1000 women years, and again the overall mortality per 1,000 women is lower by 5.5 per 1000 women years.
You may have noticed that the symptoms that you develop during menopause are similar to and just as severe as the symptoms you had in the perimenopausal period. Menopause implies that your periods have ceased for 12 months or more. As we mentioned during this period, your pituitary hormones have continued to increase while your oestrogen level has continued to decline. This is the time especially where symptoms are distinct and may be more severe, and heart health, bone health and brain function are all at the forefront of our consideration.
As we stated earlier, every woman has their own unique experience when it comes to menopause and with that in mind, every woman has different symptoms of different severity. The common symptoms, as we stated, are insomnia, hot flushes, brain fog, mood changes, fatigue and reduced libido. Any symptom that is interfering with your quality of life or is problematic for you needs consideration with respect to treatment. This is an important time to see Associate Professor Len Kliman to individualise your treatment and go through all the pros and cons of menopausal hormone therapy, and to discuss alternative treatments which are also available. It is important to realise that there is an answer to every problem with respect to this transition that is occurring as part of your normal life experience.
At this stage of menopause, in the first 6 months especially, your low oestrogen level will have stabilised, and the majority of women have noticed any symptoms that they are going to develop by now. As we mentioned, it is important to consider your general health, especially cardiac, bones, cholesterol and breasts, including imaging such as mammography and appropriate blood tests. This is the time when specialist review is particularly important. Associate Professor Len Kliman concentrates on tailoring treatment to your specific needs and monitoring the important aspects of your health at this time.
Particularly after the age of 60, your long-term health priorities need to be discussed. Continuing regular checks, management of any cardiovascular disease and monitoring of your general health and bone health needs to be concentrated on. Libido and vaginal dryness need to be addressed as specific concerns. This may be a time when pelvic floor changes become noticeable, such as prolapse symptoms, urinary incontinence symptoms and bowel symptoms. It is important to consider the use of vaginal oestrogen if you have ceased menopausal hormone therapy, as there are a number of studies that have indicated vaginal oestrogen, just used twice a week, helps your supporting tissue (collagen) become more robust and reduces the incidence of both prolapse and incontinence.
This is the time when it is important to maintain a healthy lifestyle, a balanced diet, an appropriate weight and exercise, as well as consider your mental wellbeing. Your general practitioner, in particular, at this time will monitor your blood pressure, cholesterol and general health and wellbeing to ensure that you are in the best possible condition to protect your long-term health.
Associate Professor Len Kliman is also available for important reviews during this important phase of your life.
There are some excellent books and search engine sites to provide useful scientific information. It is important not to seek advice or information from people on the net who do not have the appropriate qualifications or knowledge. I would highly recommend the book by Kaz Cooke called “It’s The Menopause”. The book is written with Kaz Cooke’s usual sense of humour, but she has gone to great lengths to use qualified, excellent specialists to help her write this book. Because she is an Australian author, she is able to indicate resources that are available within this country.
