The menopause: everything you need to know

What is the menopause and at what age do women go through it?

The menopause is defined as the moment when menstruation comes to a complete stop. Diagnosis is generally clinical and confirmed when a woman’s periods have ceased for a period of at least one year. It does sometimes, however, need to be confirmed through a hormone analysis.

In Spain, the average age of women going through the menopause is 51.4. However, this can certainly differ depending mainly on genetic and environmental factors. For example, exposure to toxic substances (tobacco or treatment such as chemotherapy), illnesses that affect the ovaries, such as endometriosis, and surgery that encourages ovarian tissue loss.

In between 1 and 4% of women, ovarian activity ceases before they reach 40 years of age. This is considered premature menopause, currently known as premature ovarian failure (POF) or premature ovarian insufficiency (POI). Medical analysis of the situation is applicable in cases such as these. Frequently, substitution treatment with oestrogen, the main hormone that the ovaries normally produce, is needed.

What are the phases of the menopause?

There are three phases or periods to the menopause, as indicated below:

1. Perimenopause or menopause transition. This period in a woman’s life varies in length but tends to last between 2 and 5 years. It begins with the first symptoms (fundamentally menstruation issues) and ends the year after a woman’s last period.
2. Menopause. This is a woman’s last menstrual period.
3. Postmenopause. This is the stage following the menopause. It is when the body adapts to the lack of oestrogen in terms of hormones and metabolism. It needs to establish preventive strategies in order to control osteoporosis and increased cardiovascular risk.

Causes and symptoms of the menopause

The menopause occurs when a woman is between 45 and 55 years of age. It is a normal or physiological process in a woman’s life that takes place when ovarian activity ceases and leads to a decrease in oestrogen production. This hormone has a number of different roles at different levels and a lack of it leads to the symptoms associated with this period in a woman’s life.

A good understanding of some the changes that are to be expected during this stage of a woman’s life can help to ensure that she can continue to live life to the full and begin preventive strategies if necessary. Furthermore, up to 15% of women experience no symptoms whatsoever.

Initial symptoms of the menopause

• Irregular menstrual periods. This is the most characteristic of all the symptoms and can begin up to 10 years before the menopause. It can include shorter or longer cycles, periods of some months with no bleeding, a significant increase or decrease in menstrual bleeding and so on.
• Vasomotor-related symptoms including hot flushes, sweating at night, cold chills, migraines or headaches and so on. Their intensity, frequency and duration can vary but they tend to persist for between 6 months and two years at around the time of the menopause. Sometimes, the symptoms are infrequent and, in 20% of cases, they can affect the woman’s quality of life.
• Changes to metabolism and distribution of fat. Women’s metabolism tends to slow down and losing weight becomes difficult. Weight gain and fat around the abdomen are common.
• Psychological symptoms. These include insomnia, irritability, mood swings, emotional issues, apathy, decreased libido, lack of concentration and memory and so on. Most of these issues are slight and transitory. However, they do sometimes need to be treated.

Medium to long-term signs and symptoms

• Urogenital atrophy. This is a thinning and shrinking of the genital and vaginal mucous membranes caused by a deficit in oestrogen. It can cause dryness and discomfort during sexual intercourse, itching and burning. It can also cause incontinence when there are other added risk factors.
• Thinning and loss of elasticity of the skin, thinning hair and thinning breast tissue that is replaced by fat.

Complications associated with the menopause

How the menopause evolves depends fundamentally on genetic factors and lifestyle.

• Osteoporosis. This is decreased bone mass caused by a deficit in the calcium absorbed by the bones. It is associated with an increased in the risk of fractures, particularly in the hips and vertebrae.
• Increased cardiovascular risk. Oestrogen protects women against hypertension, atherosclerosis, heart attacks and strokes. The risk of these pathologies increases following the menopause, which is why prevention is so important.

When should I consult a gynaecologist? What information should I gather prior to the appointment?

The difference between what is normal and what is pathological determines the impact of this period on a woman’s quality of life. When women experience changes that are worrying, the best course of action is to seek professional advice. Before the appointment, it is helpful to use a calendar to track and then explain what is happening and how often it is happening. Women should also look into their family background.

Particular attention should be paid to the following signs:

• Persistent menstrual issues over at least three months, particularly if this happens before a woman reaches 40.
• Heavy bleeding during periods with coagulation or lasting over 7 to 10 days.
• Renewed bleeding following confirmed menopause (over one year without any menstrual bleeding).
• Frequent hot flushes (more than 2 to 3 times a month).
• Significant changes of character and insomnia.
• Pain during sexual intercourse, genital dryness or significant discomfort.
• Urine leakage associated with physical exertion or the urgent need to urinate or inability to hold urine in.
• Bone fractures that are not caused by injuries or by only slight injuries.

Treatment for the menopause depending on the phase

1. Preventive treatment to minimise the impact of the menopause

In most cases, the best means of prevention is in a woman’s own hands. Long-term healthy lifestyles have proven to decrease the risk of multiple complications.

• Good practices include having a healthy diet, eating five meals a day, prioritising fruit and vegetables, eating foods that contain calcium such as legumes and dairy produce, avoiding excess caffeine and theine, avoiding very hot food and drinks that can cause hot flushes, reducing alcohol consumption and avoiding smoking.
• Regular physical exercise. This improves the metabolism and combats cardiovascular risk, the risk of osteoporosis and insomnia. It also improves mental health.
• Pelvic floor exercises. Professional help should be sought in order to learn how to do these. However, women who have included them in their daily routine have helped to prevent and treat genital prolapses and incontinence.
• Good sleep patterns. Women should have a regular sleep pattern, avoid late and large evening meals and do relaxing activities in the evenings.
• An active sex life. Whether with a partner or alone, frequent sexual stimulation encourages lubrication and healthy genital mucous membranes and it helps to improve libido. During the menopause, sexual arousal loses some of its hormonal aspect and so other stimuli such as hearing, sight and foreplay need to be promoted.
• Increased hydration of the skin and hair, in addition to the genitals. Specific hydrating substances and other natural substances, such as tea tree oil, are available and lubricants can be used during sexual intercourse.

2. Medical treatment of the symptoms and complications associated with the menopause

When hygiene and diet are insufficient to control symptoms, gynaecologists can prescribe one of a range of different options depending on what the predominant symptoms are.

• Vasomotor symptoms. Above all, hot flushes. Natural therapy with plant-derived phytoestrogens can suffice in mild cases. However, moderate to severe cases may require replacement hormone therapy with oestrogen . This is available in a range of different versions including tablets, patches and sprays. This means of treatment improves overall menopause symptoms and decreases patients’ risk of osteoporosis and cardiovascular risk when their oestrogen deficit is premature. However, medication should only be taken under medical advice and for a limited period of time. 
• Mood swings. When they are a predominant symptom, mood swings can be treated with low doses of anti-depressants and psychological guidance.
• Pelvic floor and sexual dysfunction. These need to be addressed as a whole and from different aspects. Vaginal oestrogen in gel form or in tablets work locally to improve mucous membrane quality with limited side effects. Incontinence also often needs to be treated through physiotherapy and pelvic floor exercises, bladder retraining and, finally, pharmaceutical drugs in order to decrease symptoms in the bladder or surgery when anatomical abnormalities are severe.
• Osteoporosis. Each woman’s doctor must assess her specific risk. The first option should always be to prevent by taking the aforementioned measures. Sometimes, calcium and vitamin D supplements are needed. More severe cases may need to be treated with pharmaceutical drugs to inhibit bone resorption.

Can women have children during the menopause? 

Nowadays, since our life expectancy has increased, a third of women’s lives are spent going through the menopause. Women are often living their personal and professional lives to the full during this period. For this reason, increasingly more women choose to have children at this time in their lives. However, natural fertility radically decreases after 40 years of age and, when the menopause begins, it can be reversed in only a small number of cases. Therefore, the ovaries are unable to produce viable ova for pregnancy.

What options are available in these cases?

1. Whenever possible, the best possible option is prevention. Awareness of ovarian biology and potential individual risk factors can help women to plan motherhood more appropriately. If a woman decides to postpone becoming a mother, the best option is to preserve her fertility.
2. It is possible to have children even when the menopause has been confirmed and without this having an impact on the prognosis. Patients need to undergo treatment such as gamete donation (oocyte donation or dual donation) or embryo adoption. These are common courses of treatment with good chances of success.

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Dra. Esperanza de la Torre, ginecóloga en Instituto Bernabeu