Women can be confused about the problems of the menopause.

These are confusing times for women going through the menopause. There is a wealth of information on the ‘change of life’ – not all of which is credible – and advice on medical management seems to be forever changing. A few years ago it seemed hormone replacement therapy (HRT) was the root of all evil but now it’s back in fashion.

So no one can blame women for having so many unanswered questions about what is normal, what is safe, and if they are they going crazy! For many women, the menopause opens the door not just to physical symptoms, but also to a range of emotions.

Usually the menopause occurs between the ages of 45 and 55; the average age in the UK is 51. A woman reaches the menopause once she has not had a period for one year (this is when she becomes postmenopausal). At this time, her ovaries stop functioning, no further eggs are released and oestrogen levels fall.

Often, however, periods become irregular or missed for quite some time before this; only occasionally do they suddenly stop. This transition, prior to the cycle stopping completely, is known as the peri-menopause.

Premature menopause

Premature menopause – which occurs in women under the age of 45 – affects one per cent of women under 40. It has been suggested that early menopause is on the increase, but this is most likely due to the fact that premature menopause is now better recognised. Nevertheless, some younger women do struggle to get a diagnosis.

“I have a number of patients in the peri-menopause at the age of 40 and getting the menopause by 48, if not earlier,” says Pat Jones, a nurse specialist in general practice based in Rugby. “When someone in their late thirties sees their doctor complaining of depression and tearfulness, they may end up on antidepressants, when they are in fact in the peri-menopause and should be treated for menopausal symptoms.”

Low levels of oestrogen can lead to changes in women’s health. As women with premature menopause lose the protective benefits of oestrogen earlier, they are at greater risk.

“Premature menopause is a serious health issue,” says Farook Al-Azzawi, consultant gynaecologist and director of the Gynaecology Research Unit at the University Hospitals of Leicester. “There is a 400 per cent increase in heart attacks and strokes if a woman develops the menopause under the age of 40.

“The earlier the menopause is, the higher the chance of cognitive dysfunction in the seventies and eighties. But the earlier the use of oestrogen, the lower the incidence of developing cognitive dysfunction and other problems.”

Much more than hot flushes

Hot flushes and sweating attacks are often the first symptoms that spring to mind when it comes to the menopause.

They are certainly troublesome for many women, but they aren’t necessarily the main symptoms, or indeed the worst.

Depression, mood swings, sleep disturbance, tiredness, forgetfulness, irritability and headaches can be particularly distressing.

Says Mr Al-Azzawi: “It’s the combination of symptoms that leads to a state of feeling helpless. The hot flushes and sweating wakes the woman during the night, giving her sleeplessness. This, combined with the lack of oestradiol in the brain, makes it difficult for her to concentrate and her memory starts to deteriorate. With that comes nervousness, irritability and mood swing.”

One of the first symptoms of the menopause may be dry vagina. The skin becomes thinner and lack of oestrogen may mean the glands in the vagina aren’t producing as much lubrication. “Sex becomes painful, which puts women off at a time when the libido is not typically at its best,” says Ms Jones.

This can be a very embarrassing problem for women, but there is a range of lubricants available over the counter, or if the problem persists oestrogen creams are available on prescription.

Longer-term health risks

The reduction in oestrogen levels increases the risks of osteoporosis, heart disease and strokes. Although these diseases are more likely to affect us as we get older anyway, the risks increase with each year after the menopause.

Oestrogen plays a role in protecting the heart. It affects the blood cholesterol levels and also regulates the circulation of low-density lipoproteins (LDL – the ‘bad’ cholesterol) and high-density lipoproteins (HDL – ‘good’ cholesterol). After the menopause, blood cholesterol and LDL levels go up.

Similarly, changes in hormone level have a significant impact on a women’s bones and contribute to bone loss and the chance of developing osteoporosis.

As oestrogen levels fall after the menopause, the rate at which bone is broken down increasingly outstrips new bone production.

As well as taking HRT to replace lost oestrogen, a number of lifestyle changes can be taken to help prevent onset of heart disease and osteoporosis. Losing weight (if overweight), exercising, stopping smoking, cutting down on alcohol and eating a healthy (primarily Mediterranean) diet can make a significant difference.

Weight-bearing exercise is particularly important for strengthening bones. Feet and legs must support the weight, so examples include walking, running, dancing and aerobics. Ensuring there is adequate calcium in the diet is also key for maintaining good bone strength.

HRT: Myths and facts

In 2002, the results of the Women’s Health Initiative (WHI) study on HRT caused alarm for doctors and patients. This was a major study, looking at the risks and benefits of HRT, and it was published in the respected Journal of the American Medical Association.

The results made worrying reading: they showed that HRT increased the risk of breast cancer, strokes, heart attacks and deep vein thrombosis (DVT). In fact, the study was stopped early as the incidence of breast cancer reached pre-specified safety limits. Alarming headlines in the newspapers followed and 50 per cent of women in the USA and 30 per cent of women in the UK stopped taking HRT. Subsequent studies have now discredited most of these findings – and helped to put them into perspective.

It was suggested there were a number of flaws with the WHI study. Crucially, many of the patients were older than the average woman beginning HRT in her early fifties (average age was 63) and were overweight.

The study had two arms, oestrogen only given to women who’d had a hysterectomy and the combined preparation of oestrogen and progestogen (synthetic progesterone) pill to women.

This is standard practice, as women who have a womb must receive progesterone to protect the womb, while those who have had a hysterectomy receive the oestrogen-only preparation.  In the WHI study, it was the oestrogen and progestogen combination that caused the controversy.

“The progestogen used in the study is one of the worst ones that we know – and it is not used in Europe,” explains Mr Al-Azzawi.

“Furthermore, we have moved from tablets to a skin preparation such as patches or gel during the last 15 to 20 years.

Only in certain circumstances where the woman cannot absorb the oestrogen do we carefully administer oestrogen by tablets.”

Data from younger women in the WHI study showed there was actually a reduced risk of heart attack in this group.

Another large study gathered data from 30 trials involving nearly 27,000 women. This concluded that among women under 60, there was a 39 per cent reduced death rate among those taking HRT and there was no effect among those over 60.

Benefits versus risks

In 2004, the British Menopause Society (BMS) issued the statement: “HRT still offers potential benefit to outweigh harm, providing the appropriate regimen has been instigated in terms of dose, route and combination.”

Reassuringly, the risks seen with HRT do not occur until after five years of use. To put this into perspective, Mr Al-Azzawi points out: “If you look at the incidence of breast cancer per 1000 women, HRT users versus non-HRT users, 45 cases in 1000 non-users becomes 51 cases in 1000 after five years of use, and 62 cases in 1000 after ten years of use.” It is also worth weighing up the increased risk for breast cancer against other risk factors. Says Ms Jones: “The increased risk with HRT is still very low; if women drink two units of alcohol a day, or are obese or even slightly overweight, don’t exercise and eat a high-fat diet, their risk of breast cancer is greatly increased.

“Women can do something about the other risk factors, while HRT could give them more benefits which could help to avoid late-onset diabetes by bringing down their insulin resistance and help prevent osteoporosis. There is also now evidence that HRT helps to prevent colon cancer and Alzheimer’s disease, while promoting skin healing and general well-being.”

Many women have to try a number of forms of HRT before they find the one that is right for them. It is not advisable to stop HRT abruptly, however, as oestrogen receptors need to be shut down gradually.

Not all women take to HRT for various reasons, and many like to try alternative therapies. Although the BMS warns there is not strong evidence supporting non-oestrogen-based treatments, some women do swear by phytoestrogens, which are plant-derived oestrogens, and the best-known varieties are isolfavones, lignans and coumetstans, found in foods such as soya, legumes and linseed.

Given that there is no ‘one for all’ solution for coping with the menopause, most women find it takes a certain amount of trial and error – and patience. But with the range of products now available, combined with self-help measures, all women should be able to find ways to relieve their symptoms and/or reduce the longer-term health risks associated with this major time of change.