Menopause

Patient picks for Menopause and HRT

Women's health

Should you be worried about postmenopausal bleeding?

You've endured the hot flushes and the mood swings. You've survived the heavy, irregular bleeding. Once you come out the other side, maybe the menopause isn't so bad - after all, you don't have to put up with periods every month. But then you start bleeding again, and you're not sure if it's normal.

by Dr Sarah Jarvis MBE, FRCGP

Women's health

Perimenopause

Perimenopause refers to the transitional phase that occurs before menopause. It typically begins several years before menopause, although the exact duration can vary from woman to woman. During perimenopause, a woman's body undergoes hormonal changes as the ovaries start producing less oestrogen. Symptoms include hot flushes, night sweating, mood changes, vaginal dryness, and changes in libido.

by Dr Hayley Willacy, FRCGP

What is menopause?

A natural menopause occurs because as you age your ovaries stop producing eggs and making oestrogen (the main female hormone). This represents the move from the time in your life when you can have children (the reproductive years) to the time when you can no longer conceive. The fall in oestrogen levels can cause various symptoms, discussed later in the leaflet.

What age does the menopause happen?

The average age of the menopause in the UK is 51. Your menopause is said to be early if it occurs before the age of 45.

Menopause symptoms

The menopause is a natural event. Every woman will go through it at some point. You may have no problems; however, it is common to develop one or more menopause symptoms which are due to the dropping level of oestrogen. About 8 out of 10 women will develop menopausal symptoms at some point. Around a quarter of women have very severe symptoms.

Hot flushes

These will occur in about 3 in 4 women. A typical hot flush (or flash) lasts a few minutes and causes flushing of your face, neck and chest. You may also sweat (perspire) during a hot flush.

Some women become giddy, weak, or feel sick during a hot flush. Some women also develop a 'thumping heart' sensation (palpitations) and sudden feelings of anxiety during the episode.

The number of hot flushes can vary from every now and then, to fifteen or more a day. Hot flushes tend to start just before the menopause and can persist for several years.

Sweats

This commonly occurs when you are in bed at night. In some cases they are so severe that sleep is disturbed and you need to change your bedding and nightclothes.

Other symptoms

Possible further symptoms may develop, such as:

• Headaches.

• Tiredness.

• Being irritable.

• Difficulty sleeping.

• Depression.

• Anxiety.

• Palpitations.

• Aches and pains in your joints.

• Loss of sex drive (libido).

• Feelings of not coping as well as you used to.

Changes to your periods

The time between periods may shorten in some women around the menopause; in others, periods may become further apart, perhaps many months apart.

See the separate article called How menopause can affect you at work.

How long do symptoms last?

Menopause symptoms may only last a few months in some women. However, for others symptoms can continue for several years. Some women may have early menopause symptoms that start months or years before their periods stop (peri-menopausal symptoms).

More than half of women have symptoms for more than seven years.

What causes early menopause?

There are certain things such as some medical conditions that may cause an early menopause - for example:

• If you have surgery to remove your ovaries for some reason, you are likely to develop menopausal symptoms straightaway.

• If you have radiotherapy to your pelvic area as a treatment for cancer.

• Some chemotherapy medicines that treat cancer may lead to an early menopause.

• If you have had your womb (uterus) removed (hysterectomy) before your menopause, your ovaries will still make oestrogen. However, it is likely that the level of oestrogen will fall at an earlier age than average. As you do not have periods after a hysterectomy, it may not be clear when you are in 'the menopause'. However, you may develop some typical symptoms (see below) when your level of oestrogen falls.

• An early menopause can run in some families.

• In many women who have an early menopause, no cause can be found.

If your menopause occurs before you are 40, it is due to premature ovarian insufficiency (also known as primary ovarian insufficiency). Read more about premature ovarian insufficiency.

How does menopause affect your body?

Following the menopausal transition, a woman's body may change in several ways:

Skin and hair

You tend to lose some skin protein (collagen) after the menopause. This can make your skin drier, thinner and more likely to itch. See our feature on How to manage skin problems at menopause.

Genital area

Lack of oestrogen tends to cause the tissues in and around your vagina to become thinner and drier. Learn more about vaginal dryness (atrophic vaginitis), also known as genitourinary syndrome of the menopause (GSM). These changes can develop months or years after menopause:

• Your vagina may shrink a little and expand less easily during sex. You may experience some pain when you have sex.

• Your vulva (the skin next to your vagina) may become thin, dry and itchy.

• You may notice that you need to pass urine more frequently and may even leak.

• Some women develop problems with recurrent urine infections.

'Thinning' of the bones (osteoporosis)

As you become older, you gradually lose bone tissue. Your bones become less dense and less strong. The amount of bone loss can vary. If you have a lot of bone loss then you may develop osteoporosis.

If you have osteoporosis, you have bones that will break (fracture) more easily than normal, especially if you have an injury such as a fall. Women lose bone tissue more rapidly than men lose it, especially after the menopause when the level of oestrogen falls. Oestrogen helps to protect against bone loss.

Cardiovascular disease (heart disease)

Your risk of disease of the heart and blood vessels (cardiovascular disease), including heart disease and stroke, increases after the menopause. Again, this is because the protective effect of oestrogen is lost.

Oestrogen is thought to help protect your blood vessels against atheroma. In atheroma, small fatty lumps develop within the inside lining of blood vessels. Atheroma is involved in the development of heart disease and stroke. You can reduce this risk by looking at other risk factors - don't smoke, stay at a healthy weight and eat a healthy diet.

Is there a test for menopause?

Hormone blood tests

Your doctor can usually diagnose the menopause by your typical symptoms. Hormone blood tests (hormone levels) are not needed to confirm that you are going through the menopause. However, they may be helpful in some cases - for example, in women aged under 40 years if a premature menopause is suspected. The test done in primary care is usually follicle stimulating hormone (FSH) which is raised in the menopause. Anti-Müllerian hormone is not tested for the diagnosis of the menopause and is mainly used in secondary care fertility clinics; GPs cannot usually request this blood test.

Other blood tests or scans may be undertaken in some women, but these are generally to look for other causes of symptoms rather than to diagnose the menopause.

It is important that you keep up to date with the national cervical screening programme and breast cancer screening programme, if you are in the age ranges for these programmes.

Menopause treatment

Without treatment, the symptoms discussed above last for several years in most women.

Hormone replacement therapy (HRT)

HRT is a very effective treatment for the symptoms of the menopause. It replaces the oestrogen hormone that your ovaries stop making once you are menopausal. It has benefits and risks. Find out more about hormone replacement therapy (HRT).

If your main symptoms are in your vagina and genital area or if you are getting urinary incontinence symptoms, you are likely to benefit from using treatment that is inserted into your vagina or just applied to your genital area as a cream or used inside the vagina as a ring. Read about treatment for vaginal dryness and urinary symptoms. This vaginal HRT can be used alone, or with systemic HRT that is taken as a patch, spray, gel or tablet.

Systemic HRT is available as:

• Tablets.

• Skin patches.

• Gels to apply to the skin.

• Sprays.

There are several brands for each of these types of HRT. All deliver a set dose of oestrogen (with or without progestogen) into your bloodstream.

HRT alternatives

There are treatments other than HRT for menopausal symptoms. As a rule, they are not as effective as HRT but may help relieve some symptoms. See the separate leaflet called Alternatives to HRT for menopause symptoms.

See our feature on How to make the menopause a little easier.

Can you get pregnant after the menopause?

Although women become less fertile as they get older, it is still possible to get pregnant around the time of the menopause. So, if you are sexually active and don't want to become pregnant, you will need to consider contraception:

• Until a year after your last period if you are 50 or over.

• Until two years after your last period if you are under 50.

Assessing when to stop contraception is more difficult if your periods have stopped due to your current contraception. For example, the implant, the hormone coil and some pills can cause your periods to stop.

If this applies to you then you have two choices. You can either continue contraception until the age of 55 (at which time all women can stop), though you may need to change the type of contraception at age 50. Or you can have a blood test at the age of 50 - if this shows that you are in the menopausal range then you can stop your contraception one year after the blood test.

See the separate leaflet called Contraception for women over 40.