Perimenopause and Menopause

The current average life expectancy of a woman in the UK is 81

Women now often live 30 years after their menopause; this period of their lives is extremely important.

The average age of Menopause all over the world is about 51 years.

What is meant by perimenopause?

It is also known as menopause transition – the time when a woman moves from ovulating every month and having normal periods (menstruation), to a time when this stops.

During this time, the number of ovarian follicles becomes less and this results in low estrogen levels and high FSH (Follicular Stimulating Hormone) levels. This is what causes the symptoms of menopause.

The perimenopause usually lasts around 4 years (2-8 years) It usually commences around the age of 47 yrs (39 – 51 yrs)

What is meant by menopause?

A woman is called “post menopausal” when she has not had any periods or bleeding for one year. The average age is 51 years all over the world, although some women can still have regular periods even after this age. It is uncommon to have periods after the age of 55 years.

Any bleeding after one year of no bleeding is known as Post-Menopausal bleeding and has to be taken seriously. Medical advice should be sought as cancer needs to be ruled out urgently.

What are the common symptoms of the perimenopause and menopause?

8 out of 10 women experience the following symptoms but only 3 in 10 women seek help.

  • » hot flushes and night sweats (the most common symptoms)
  • » vaginal dryness/urinary problems
  • » tiredness and sleep disturbance
  • » mood swings
  • » lack of concentration
  • » loss of libido ( loss of interest in sex)
  • » osteoporosis

Do women always have to have tests to diagnose menopause?

After the age of 45, a diagnosis made on symptoms alone (clinical diagnosis) is often enough, unless there are also other health problems which may cloud the picture. Your GP will make that decision.

Between 40-45 years – Diagnosis is based on clinical symptoms (Hot flushes, no periods) & some blood tests.

Under 40 years (diagnosis is “premature menopause” or “primary ovarian insufficiency”). Your doctor should ideally refer you to a gynaecologist, as this needs specialist input and tests.

When should a woman stop using reliable contraception?

It is recommended that women should use effective contraception every time to avoid unwanted pregnancy (condoms/coil/sterilisation/pill) for at least two years after their last period if the periods have stopped before the age of 50.

If above the age of 50 years, it is recommended to use reliable contraception every time for one year after the last menstrual period.

If on Hormone Replacement Treatment, consult your doctor for further advice.

What can a woman do to help herself avoid or reduce the frequency of hot flushes which is usually due to a lack of estrogen in the menopause?

It is important to eat low down in the food chain, which means plenty of vegetables/fruit/grains/berries/lentils/nuts and seeds and water. Many of these foods are excellent sources of natural phytoestrogens (Lignans and isoflavones).This will not only help with hot flushes, but also with general overall health and wellbeing.

Avoid becoming overweight by regular gentle exercise, and avoid a diet high in Trans fats/saturated fats and processed foods (biscuits/cakes/chocolates/ready meals). Reducing the amount of alcohol you drink, and red meat in your diet, and not smoking, can all help in reducing cancer and heart disease risk.

Suggestions for Keeping hot flushes at bay (start in early forties)

  • » Breakfast – 250 ml of soya milk with porridge oats and nuts/flaxseed powder or 100g soya yoghurt with berries
  • » Calcium and Vit D – 500mg (unless diet deemed adequate)
  • » Mid morning snack – handful of mixed nuts/fruit/edamame beans/soy nuts
  • » Lunch –Salad with beans/chickpeas/hummus or vegetable bean soup
  • » Dinner – Tofu stir fry and vegetables/ lentil dal /miso soup
  • » Regular Sustained Exercise – Walking, Running, swimming, yoga and other low impact exercises have shown to help with hot flushes. Aerobic exercise can improve psychological health and quality of life. (mood, insomnia).
  • » Avoid or reduce alcohol /caffeine intake

How can a woman prevent Osteoporosis?

  • » Weight bearing exercises, under supervision
  • » Walking 30 min/day, especially while sunny
  • » Yoga and Tai Chi improves mood, posture and balance
  • » Healthy diet ( Tofu/brazil nuts/low fat yoghurt/soy milk/fish/spinach)
  • » Regular exercise
  • » Supplement of Calcium and Vit D -500mg and diet
  • » HRT prevents osteoporotic fractures but benefit declines soon after stopping, hence not recommended for this alone.
  • » Consult GP or specialist for further medical options if indicated ( for example strong personal or family history)

How can a person help in reducing risk of Alzheimer’s disease?

  • » Yoga/Tai-Chi/Pilates – improves tone and balance & also helps pelvic floor and urinary continence
  • » Encourage to join group activities and maintain social network.
  • » Encourage new hobbies – Sudoku, crosswords, learning a musical instrument
  • » Fresh fruit/vegetables/nuts/turmeric spice.
  • » Spinach and berries, especially for helping maintaining vision.

What are the common urinary problems in the perimenopause/menopause?

Urgency and Urge Incontinence – Avoid too much tea/coffee/smoking.
» See GP who may recommend lifestyle changes/Bladder Drill/ medication

Stress Incontinence ( leaking of urine on coughing/sneezing/running etc)
» See GP who may recommend Pelvic Floor Exercises/ Physiotherapy/ tablets/referral to a specialist for tests and surgery if indicated.

Blood in the urine
» See GP for urgent attention to rule out serious causes.

Symptoms of urine infection (burning/increased frequency) need to be investigated and treated by your doctor if proven infection.

Are there some common gynaecological problems a woman may suffer during the perimenopause/menopause?

  • » Heavy Periods
  • » Post Menopausal Bleeding
  • » Uterine Prolapse
  • » Vulval itching/soreness

What are possible tests that the doctor may recommend?

Depending on the condition, the following tests may be suggested

  • » Blood Tests
  • » Cervical smear
  • » Pelvic Ultrasound Scan
  • » Hysteroscopy (Camera test)

Common questions a woman may wish to ask her GP or specialist when considering Hormone Replacement Therapy (HRT)

  • » Should I take HRT?
  • » When should I start it?
  • » What are the side effects?
  • » What are the benefits?
  • » What about the recent press reports?
  • » How long should I take it for?
  • » What happens if I have had a hysterectomy?
  • » What are the other alternatives available?
  • » Should I have patches or tablets?
  • » Should I have regular check ups?
  • » Am I at increased risk of breast cancer?
  • » Can I have HRT if I have had cancer?
  • » Can I have HRT if I have had thrombosis?

What is Hormone Replacement Therapy (HRT) and what are the precautions before and during treatment?

HRT provides low doses of estrogen and progestogens (rarely testosterone) to try and replace the levels the body lacks in the post menopausal period.

HRT is available as tablets, skin-patches, gels or nasal spray.

A cream, pessary, or vaginal ring containing estrogen works best for local vaginal symptoms. This can be used for as long as a woman needs to help with local symptoms.

Before starting HRT, your doctor will take a thorough history from you and examine you appropriately.

Your GP or specialist will talk you through various preparations, risks and benefits before recommending HRT.

Be aware of family history and mention to your doctor of relevant information, including allergies and medications.

Continue to follow a healthy lifestyle and diet.

Make sure you attend the screening programmes as recommended by the NHS such as smear tests and mammograms.

Be Breast Aware.

A menopausal woman is advised to take HRT only when she finds that her quality of life is affected by her symptoms, usually hot flushes and natural methods are not working.

HRT is effective for symptomatic relief and its use is justified when symptoms adversely affect quality of life.

The lowest effective dose for a particular woman should be used for the shortest period needed.

Treatment should be reappraised at least annually with the GP or specialist.

HRT is usually recommended for the shortest possible time a woman needs it to reduce risk of breast cancer. This is usually 2-3 years and up to 5 years.

If a decision is made to stop HRT, it should be phased out slowly in symptomatic women to prevent return of symptoms.

If menopausal symptoms return after stopping HRT, women may wish to consider restarting it and, provided they are fully informed of the risks, it should not be withheld.

If a woman is counselled properly of the risks and wishes to take HRT for longer, then she may be prescribed HRT after discussion with her GP/specialist.

Vaginal Dryness and some urinary symptoms may be helped with local use of lubricants and if appropriate, vaginal estrogen.

Generally, a woman with a history of cancer (especially Breast or womb) is not recommended (contraindication) to have HRT. If it is to be used, this would be a highly specialised decision made by a team of experts.

Similarly, a personal history of thrombosis is considered a contraindication for HRT. With a family history, certain tests may be needed before starting HRT.

The risk of thrombosis is the greatest in the first year of starting HRT. A history of heart disease (ischemic heart disease, peripheral arterial disease) is considered a contraindication for the use of HRT.

There are other preparations available that can help with hot flushes.

Are there alternative methods for managing hot flushes?

Many of these medications and preparations have not been fully studied, hence their effects on the body and on other drugs that one may be taking is not fully understood.

  • Herbal medicine such as Red clover and sage have been used to relieve symptoms
  • Alternative medicine – acupressure, acupuncture and homeopathy.
  • Complementary therapy – aromatherapy & HRT.
  • Other medical treatment.

Nitu Bajekal
Consultant Gynaecologist
April 2013