What happens during the menopause?

The menopause is the time in women’s lives that marks the end of all menstrual cycles. In many cases, the menopause leads to symptoms that affect quality of life.

Here to provide a detailed insight into the menopause, including symptoms, age of onset and treatment options such as hormone replacement therapy, is Professor Dushyant Sharma, highly experienced consultant physician in endocrinology.

What is the menopause?

The menopause is a process of change in women's lives, around the age of 50 years, in which their ovaries stop producing female hormones like oestrogen and progesterone. This is a naturally set clock that causes the pituitary gland to become overactive and start making more of other hormones like the luteinizing hormone. This process of hormonal change causes multiple symptoms.

Overall, the menopause is a stage in life that initially leads to irregular menstrual periods and the subsequent stopping of periods altogether. After a year of having no periods, it can be said that a woman has entered the menopausal stage.

Between what ages does the menopause typically occur?

The typical age of the menopause is 50 years, but there can be variability. Some women, for example, begin the menopause years earlier. Others, in contrast, continue to have their periods for a few more years beyond the age of 50.

In some cases, women see their periods stop quite early in their life. This condition is called primary ovarian insufficiency or failure, and it can be related to various reasons. By nature, women should have enough oestrogen levels until the age of 50, but if they have an early menopause, then hormone replacement therapy should be provided until the age of natural menopause.

What can happen if the menopause is left untreated or unnoticed?

The menopause is not a disease or a pathological condition; it is a natural stage in a woman’s life. All women go through this stage. However, during the menopause, women have to go through the transition from having normal periods to having no periods at all, and then not having enough female hormones. This hormonal change causes many symptoms, which can lead to changes in behaviour and mood.

Thus, the transition has to be managed appropriately and this is where the difficulty lies, because an estimated 70 per cent of women suffer from menopausal symptoms. In addition, almost one third of women have serious symptoms that require support, hormonal supplements and treatment. Hence, understanding the symptomatology and the transition phase of the menopause is very important.

Unfortunately, symptoms can also start to appear even before the menopause has occurred. Symptoms can be present even in the perimenopausal stage and these can last as much as seven to 10 years after menstrual cycles have stopped. It is a long time period that women have to go through where they are suffering as a result of these symptoms.

The second aspect of this transition is that when oestrogen support stops at the time of the menopause, bone health, muscle health and cardiovascular health also start suffering. In many cases, this leads to a rapid decline in bone mineral density after the menopause.

Is treatment always necessary for the menopause?

Treatment is not always necessary. If there are no symptoms, women do not require treatment. This is because most symptoms are mild and manageable, even without the need of hormone replacement therapy or alternatives.

A change in lifestyle, a change in dietary pattern, a better understanding of the transition phase and moderate physical activity are sometimes sufficient enough, so pharmacological treatment is not always necessary. However, one third of the time, symptoms are so serious that women are required to opt for pharmacological treatment, which mostly is in the form of hormone replacement therapy.

During times when hormone replacement therapy is not needed or hormonal replacement therapy is contraindicated, then alternative treatment has to be considered. Some women prefer alternative treatment to hormone replacement therapy, so every situation needs to be individually assessed.

Another important aspect about the menopause is that this phase should always be discussed with the appropriate specialists. In most cases, primary care physicians are very good at discussing these matters and providing support, but there are certain situations when an endocrinologist or a gynaecologist are needed to provide the support.

Do people only suffer from the menopause once in their lifetime?

Some women have symptoms during the perimenopausal stage (two or three years before the menopause) when hormonal changes are actually biochemical and not visible. Once symptoms start appearing, then women continue to suffer from them unless they are addressed. These symptoms can last for years and years.

Many of these women overcome their symptoms in five to seven years’ time, but again, this is a long time and they should not continue to suffer. The menopause is not a trouble and it is not something that should not be discussed; in most occasions, it can be easily addressed. This is why I advocate so strongly that the menopause should be discussed with a specialist as early as possible.

How long does the menopause typically last, and how will it affect my life?

The average age of the menopause is 50 years, but the period can start to become irregular or heavier several years before the actual periods stop. This happens because the normal cyclicity of the female hormonal changes (which usually happen on a monthly basis) start becoming irregular. This might initiate the onset of symptoms right there.

Approximately two to three years might need to go by for this irregularity to pass and a woman’s period to stop completely. Once a woman has not had a period for a year, then the menopause has been achieved.

The postmenopausal stage stays for five to seven years more, in which symptoms related to the menopause might continue. These symptoms are mostly in the form of hot flushes, feeling unwell, mood changes, joint pains, muscular pains, sexual difficulties, vaginal dryness and pain during intercourse. Of these symptoms, the troubling ones are the hot flushes, which occur due to vasomotor instability and the lack of support there.

What is the role of hormone replacement therapy exactly?

Hormone replacement therapy in women who are going through the menopause or have gone through the menopause is very important. It is mainly recommended to replace oestrogen and progesterone.

Oestrogen is the hormone that helps control most of the symptoms of the menopause. However, oestrogen alone can precipitate endometrial metaplasia and it can also lead to cancer in certain situations. For this reason, many women are prescribed with progesterone along with oestrogen, to keep the uterus lining healthy and ensure that it is not exposed to a higher risk of trouble in the future.

With oestrogen, the risk of breast cancer also needs to be assessed and if a family history of breast cancer is found, then oestrogen should not be given in such situations. Despite this, each case has to be individualised and the benefits and risks weighed, so that management is planned accordingly.

The dose of the progesterone has to be adjusted as per the oestrogen supplement. As of today, there are better forms of progesterone compared to what was available before. An example of progesterone is micronized progesterone.

Oestrogen, on the other hand, can come in the form of tablets, patches or gels. Occasionally, oestrogen can be used topically in localised areas as vaginal creams, which are less troublesome in regards to side effects compared to the oral alternative.

Again, hormone replacement therapy is a complex process that has to be discussed individually, in which treatment has to be tailored as per the need, the risk and the benefits expected. It can be contraindicated in certain situations.

If hormone replacement therapy is not appropriate, are there other options?

When hormone replacement therapy is contraindicated, is not needed or is not the appropriate option, then there are options available that can be explored and discussed. The treatment option recommended will depend on the main symptoms that are causing trouble at the time.

In many occasions, antidepressants such as selective serotonin reuptake inhibitors (SSRIs) have been found to be beneficial. If these are not effective, simple lifestyle changes, dietary changes such as having less fatty food and more fruits and vegetables, moderate physical activity - these have a profound impact on general wellbeing.

If you require expert endocrinology care for the management of your menopause symptoms, or simply wish to know more about hormone replacement therapy, do not hesitate to visit Professor Dushyant Sharma’s Top Doctors profile today.