Key facts
The average age of menopause diagnosis in the UK is 51 years although this varies by ethnicity
It is estimated that 20 per cent of UK women have had a hysterectomy and, although the ovaries may be preserved, the menopause is often earlier than normal in these cases
Menopausal symptoms typically last from five to seven years, but some women continue to experience them for up to 10-15 years
Hot flushes and night sweats are the most commonly reported symptoms of the menopause
Hot flushes can be related to drugs that affect vascular reactivity, such as some antihypertensives, and to antidepressants when prescribed at high doses
Recognising the menopause
The menopause occurs when a woman stops menstruating permanently due to the loss of ovarian follicular activity and is diagnosed after a woman has had 12 months without periods (amenorrhoea), which typically occurs between 45-55 years of age. The average age of menopause diagnosis in the UK is 51 years, although this varies by ethnicity.
The menopause is preceded by the peri-menopause when the ovaries gradually stop functioning, oestrogen and progesterone levels fall, and women experience altered and irregular menstrual cycles. Some may start to experience these symptoms from their late 30s onwards.
Around one in 10 women have an early menopause between 40-45 years of age. Menopause before the age of 40 years is categorised as premature ovarian insufficiency and occurs in around 4 per cent of women. If early or premature menopause is suspected, referral to a GP is necessary as investigation and HRT is usually indicated.
Although the menopause is usually a natural event, it is important not to forget women who have had surgical removal of the ovaries, usually occurring at the time of a hysterectomy. It is estimated that 20 per cent of women in the UK have had a hysterectomy, most commonly between the age of 40 and 50 years. Although the ovaries may be preserved, the menopause in these women often occurs earlier than normal.
Sometimes chemotherapy or radiotherapy treatment for cancer can cause ovarian failure. Sudden cessation of ovarian function due to surgery or treatment can lead to severe menopausal symptoms and HRT is often indicated as a result.
Period irregularity and cessation
Most women experience irregularities in their menstrual cycle in the years leading to the menopause, which typically last for up to four years (the perimenopause). The cycle may shorten to two to three weeks or lengthen with many weeks or even months between periods. Only about one in 10 women’s periods will stop abruptly. Perimenopause is usually diagnosed based on irregular periods and the presence of vasomotor symptoms such as hot flushes.
Duration of symptoms
The duration and severity of symptoms experienced in the menopause vary markedly. Menopausal symptoms typically last for five to seven years, but some women continue to experience them for up to 10-15 years.
Hot flushes and night sweats
Vasomotor effects are the most commonly experienced menopausal symptoms. Together with irregular periods, they may be the first sign of ‘the change’. Hot flushes are often described as a sudden sensation of heat in the chest, face and head followed by flushing, perspiration and sometimes chills. Headaches and palpitations are other common vasomotor symptoms.
Urogenital symptoms
Urinary and genital symptoms occur due to the effects of diminishing oestrogen levels, which cause thinning and shrinking of the tissues of the vulva, vagina, urethra and bladder.
Multiple symptoms can result including vaginal dryness and irritation, and urinary symptoms such as a frequent need to urinate and also urinary tract infections.
Loss of oestrogen changes the urethral and vaginal bacterial flora, resulting in a higher (more alkaline) pH, predisposing both to infection.
As women age, a loss of muscular tone in the pelvic floor muscles together with thinning of vaginal and urethral tissue can lead to urinary incontinence. There may be insufficient vaginal secretions for comfortable sexual activity, so discomfort or pain on intercourse (dyspareunia) may be experienced.
Vaginal dryness and urinary symptoms tend to increase in severity over time and in some women may not present until five to 10 years after the menopause.
Musculoskeletal symptoms
Joint, bone and muscle pain may be experienced and are commonly reported.
Altered sexual function
Some women experience lower libido (sex drive) during and after the perimenopause partly due to diminishing levels of oestrogen and testosterone. Vaginal dryness leading to discomfort or pain during intercourse may further reduce libido. Some women experience higher libido once they no longer need to use contraception and are no longer worried about the risk of pregnancy.
Sleep disturbance and fatigue
Some women notice disturbed sleep during the menopause in association with irritability, poor concentration and depression. Night sweats can further cause or aggravate disturbed sleep. Sleep deprivation can lead to fatigue during the day and difficulty concentrating on tasks at work or home.
Mood disorders
It is common for women to experience loss of confidence, low mood, irritability, forgetfulness, difficulty in concentrating, panic attacks, anxiety and depression at the time of the menopause.
Hair and nail changes
Many women notice that their hair grows more slowly and becomes thinner. Nails can become brittle. These problems can add to their distress.
Practical guidance
There is some evidence that hot flushes and night sweats can be helped by weight loss (if applicable), by stopping smoking and by exercising regularly.
Practical measures such as wearing lighter clothing and/or dressing in layers, turning down central heating, sleeping in a cooler room and using fans may help. Some women find that symptoms are triggered by spicy foods, caffeine and alcohol, so these could be avoided.
Pelvic floor muscle training is an effective intervention for urinary symptoms, particularly for stress and mixed incontinence related to the menopause. This is perhaps best guided by a therapist but women who wish to try it themselves can access information from resources such as the Squeezy NHS Pelvic Floor app.
Complementary therapies
There is some evidence that black cohosh, isoflavones (in red clover) and St John’s wort may relieve vasomotor symptoms during the menopause, but the constituents, quality, purity and safety of the products may not be known.
Women sometimes take these supplements expecting them to be safer than prescribed medicines but in many instances their safety may be worse or unquantified. There are potential interactions between St John’s wort and tamoxifen, anticoagulants and anticonvulsants, for example. Black cohosh may inhibit CYP3A4 and so could potentially increase the risk of adverse effects with drugs metabolised by this enzyme.
Some complementary therapies such as red clover contain constituents with oestrogen-like properties (phytoestrogens), and these are also found in food such as soya. There are many studies looking at the effectiveness of these food substances, but the results are variable and generally show little value. They should not be used in patients with a history of breast cancer.
Bioidentical hormones are offered by private clinics in a mix of plant-derived oestrogens, often together with progesterone and testosterone in quantities based on the results of saliva and/or blood tests. They are formulated as creams, lozenges and vaginal preparations. NICE points out that “the efficacy and safety of unregulated compounded bioidentical hormones are unknown” as they are not subject to the usual regulatory processes for medicines.
If you would like to trial some of these complimentary therapies we at Kiveton Delivery Pharmacy can order the relevant product from reputable suppliers for you. Please get in touch.
or try from our website ;
Talking therapies, exercises and relaxation
Cognitive behavioural therapy (CBT) can be considered for low mood and anxiety associated with the menopause (a NICE recommendation). There are online resources for CBT but it is generally advised that it should be initiated by a psychological therapist.
Breathing exercises and structured relaxation may be helpful – for example, click here
Mindfulness may be another method to reduce stress and help with relaxation. There are a number of online apps such as Headspace. Also visit the Be Mindful and NHS websites.
Pelvic floor exercises
Exercise can also reduce stress, anxiety and the likelihood of depression. For some general advice on suitable activities to signpost or recommend, see the NHS website.
When you should see your GP:
Premature or early menopause suspected
Unexplained vaginal bleeding
Significant upset with vasomotor symptoms which may require HRT
Suspected depression
Significant urogenital symptoms
Blog date 06/06/2022