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Why does the menopause occur?

The menopause occurs because the ovaries are no longer able to perform the function of ovulation (producing an egg each month). When a woman's ovaries can no longer respond to hormonal signals from the brain they stop producing the female sex hormones oestrogen and progesterone. It is the fall in the levels of these hormones in the bloodstream that gives rise to the symptoms of menopause.

Research into the menopause is relatively recent. One hundred years ago, when life expectancy was shorter, most women did not live long after the menopause and so little was known about it.

What is the menopause like?

Every woman will experience the menopause differently. A lot of women hardly notice the change in their life, except for the fact that their periods might become irregular. On the other hand, there are a lot of women who find that their lives are almost completely changed, because they suffer from all the symptoms in the worst possible way.

What kinds of discomfort might the menopause cause?

Women going through the menopause often experience hot flushes. They may sweat a lot and become flushed. The attacks can happen at any time, and frequently occur as often as several times an hour at the beginning of the menopause. Each hot flush usually lasts for three to six minutes.

Some women have difficulty sleeping. They may have trouble falling asleep, be restless and then wake up during the night bathed in sweat. Some women sweat so heavily that they have to get up and change their sheets several times a night.

Some women suffer from depression, mood swings, tiredness or headaches. Others have problems remembering things. Some have a low tolerance threshold and get angry more easily. This can often be confusing for the rest of the family. Physical changes are also taking place. During the menopause a woman's skin becomes thinner. A lack of oestrogen often means that the glands in the vagina don't produce as much lubrication as before and this may cause stinging around the vagina during sex. Some women don't feel like having sex whereas others find that their orgasms become less intense. The lack of oestrogen also affects the bladder and women may find they need to pass water more often.

In recent years there has been a lot of interest in osteoporosis (thinning of the bones) in connection with the menopause. The fall in oestrogen means that over the years, the bones of a menopausal woman become more likely to collapse or fracture. There is a gradual rise in the risk of heart disease and stroke after the menopause. Again, the falling oestrogen level results in unfavourable changes in the cholesterol and fat levels in the blood which causes a predisposition to these diseases.

What can be done to relieve symptoms?

Medical treatment, which works by adjusting the hormone levels, is available for women who are troubled by symptoms of the menopause. Some hormonal treatment will result in the reappearance of periods, although period-free medications are also widely available. This treatment is called hormone replacement therapy (HRT) and involves the woman receiving a small daily dose of oestrogen. Women who have not had a hysterectomy will also be given progesterone.

HRT is effective at relieving hot flushes and vaginal dryness. Many women report an improvement in their general sense of wellbeing. However, HRT is not a magic fix and if a woman's disturbed mood or behaviour is due to underlying problems at home or at work, then HRT cannot be expected to improve matters. HRT is often taken for a short spell of six months to a year to relieve hot flushes. If a woman continues to take HRT for a longer period of two years or more, then there is evidence that it will give her increased protection against heart disease, strokes or osteoporosis later in life in her 60s and 70s. There is some early research evidence suggesting that HRT users are also less likely to develop Alzheimer's disease and also cancer of the bowel.

How is HRT taken?

There are many ways of taking HRT. The most usual is a daily tablet, but alternatives include skin patches, a small pellet or implant under the skin, a gel applied daily to the skin, or a nasal spray.

What are the side effects of HRT?

The majority of women have no side effects, but the following are fairly common:

• nausea
• breast tenderness
• weight gain
• fluid retention.

These symptoms often settle after the first few months of treatment but if not, then it is worth consulting your doctor or gynaecologist in order to adjust the medication.

Is HRT safe?

On balance, women taking HRT live longer than women who do not take HRT. However, as well as the side effects mentioned above there are other potentially more serious problems that may be linked to HRT.

Women taking HRT are at a slightly increased risk of developing breast cancer. To put this in perspective, a study published in 1997 has given us figures for this risk. If 1000 European women who do not take HRT are followed from age 50 to age 70, 45 of them will develop breast cancer in this time. If these same women were to take HRT for five years, two extra women among the 1000 would develop breast cancer over 20 years. If they were to take HRT for 10 years then six extra among them would develop breast cancer. For 15 years of HRT treatment, this would increase to 12 extra.

Since most women take HRT for around two years to control their menopausal symptoms, the risk is clearly very low. However, all women taking HRT should attend for breast screening and perform regular self-examination for any lumps. Women with close relatives who have had breast cancer or who have had breast cancer themselves should see a specialist before starting HRT.

There is also a slightly increased chance of developing a venous thrombosis (blood clot in the veins of the leg) while taking HRT. The risk is greatest in the first year but decreases thereafter. Women with a previous episode of thrombosis or with close relatives who have had thrombosis need special blood tests before starting HRT.

The decision regarding whether or not to receive treatment will mean weighing up the benefits against any possible risks. Hormone therapy is only available on prescription, so the doctor will be able to advise you before recommending treatment.

What else can be done to make the menopause easier?

Vaginal dryness can also be relieved by short courses of oestrogen creams or pessaries that are inserted into the vagina. There is also a special vaginal ring containing oestrogen that can be left in the vagina for three months, where it slowly releases oestrogen into the vaginal tissues.

Other medications that are effective in relieving menopausal symptoms are tibolone and clonidine.

Diet and lifestyle

It has been shown that regular exercise such as walking for 20 to 30 minutes three or four times a week can improve your health and add years to your life. Exercise strengthens the bones, increases wellbeing and can help make sleeping easier. Eating the right food is also very important. For healthy bones, the body needs about 1500mg of calcium each day from dairy products like milk products and cheese. Eat plenty of fruit and vegetables. Recent research shows that eating five pieces of fruit or vegetables a day can help prevent illness. There is also some evidence that soy flour can reduce menopausal flushings.

Smoking is never good for your health.

A positive attitude can help make the change of life less traumatic. The menopause is the beginning of a new phase in life and most women have many great years ahead of them.

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