What is the Menopause?
You have reached the menopause if six months have passed since your last period. Around this time, the ovaries stop producing eggs. As the ovaries close down, they produce smaller quantities of the hormones that had been building up the lining of the womb every month to make the body ready for pregnancy. As well as regulating periods and maintaining pregnancy, the hormone oestrogen triggers all the changes in the female body that begin at puberty. So, as oestrogen production declines, the body starts to change.
When does the menopause usually start?
Nowadays, the average age for a woman's last period is 51, though changes quite often begin in the early forties. Many women have menopause symptoms and irregular periods for several years before their periods finally stop altogether. This time in a woman's life is called the climacteric, or 'perimenopause', when the ovaries gradually stop their normal functioning.
The experience of menopause can vary a great deal. It might feel like a blessing to some women. For most, it just means fewer, more irregular, lighter periods, with maybe a few mild menopausal problems, which gradually stop after two to five years. But there can be downsides. Though the menopause isn't a disease - in fact it's a natural, inevitable phase of life - for some women it can be a real challenge.
There are emotional and psychological changes to adjust to, as well as physical ones. A woman's sense of who she is, and her place in the world, may be changing as well. For as many as 4 in 10 women, some menopausal changes are bothersome but only a few have unpleasant symptoms that last many years after their periods have stopped.
What problems are common at the menopause?
Hot flushes and night sweats
usually lasting for just a few minutes. Your face, neck and chest may go red and blotchy. You might start to sweat and feel your heartbeat get faster. When these flushes happen at night, they are known as night sweats. As a rule, hot flushes are at their worst for a year or so after the last period.
Sleep problems
Not surprisingly, night sweats can make it difficult to sleep. Some women also feel more anxious during the menopause, and this may also disturb sleep. Poor sleep can affect your mood, memory and concentration.
Vaginal dryness and soreness
Oestrogen is a sex hormone. When there is less of it in the blood, the vaginal lining gets thinner and doesn't produce as much fluid. When there is less lubricating fluid and the vagina gets drier, it may feel itchy and sore. This inflammation - called atrophic vaginitis - may also affect the bladder and urethra, and make you more likely to get cystitis and thrush.
Sexual issues
Sex hormones have a lot to do with sex drive. Yet some women find their interest in sex is unaffected; or even that, once free of periods and the chance of pregnancy, their sex drive and enjoyment get stronger. But more often, interest in sex and the need for it reduce around the menopause. And of course if vaginal dryness and urinary problems make having sex uncomfortable, this will reduce interest all the more. Together, these changes may make the stress and discomfort some women feel around the menopause even worse.
Medical treatment for menopause problems
According to NHS Choices around one-third of women experience some or all of the above symptoms shortly after the menopause, and slightly more women have them later on - more than 10 years after their final period. These problems can be treated by your GP. But if left untreated, they tend to continue or get worse.
HRT or not HRT? That was the question
For years Hormone Replacement Therapy (HRT) was the treatment of choice for the discomforts of menopause. It wasn't a perfect answer but at first it looked like a 'win-win' treatment. (As women get older, they face a growing risk of having heart disease and a stroke; HRT was thought to prevent these problems.) Then the Women's Health Initiative found the opposite - that women on HRT were more likely to have a heart attack or a stroke, and more prone to get breast cancer.
HRT today
Because of these safety fears, the number of women in the UK taking HRT fell from 2 million to fewer than 1 million between 2003 and 2007. But lately medical opinion has changed about the balance of benefit compared to risk. Doctors now seem to be moving back towards offering HRT to women whose hot flushes and atrophic vaginitis are persistent and moderate to severe. Research has shown that low-dose oestrogen is effective for many women, although some require larger doses to relieve hot flushes.
But because HRT is not risk free, doctors recommend that patients should take the lowest dose that relieves their symptoms (possibly using a vaginal cream rather than a pill), and for the shortest amount of time (depending on the problem). It is also best used by women early on in their menopause. HRT is not recommended for women with a high risk of stroke, heart disease, blood clots or breast cancer. And HRT users should be re-assessed by their GP at least once a year.
To find out more about HRT treatment, visit Women's Health Concern
Looking on the bright side
Having hot flushes may cut your risk of developing breast cancer by as much as half, according to a recent US survey of 1,437 postmenopausal women. They were asked about various menopausal symptoms, including hot flushes, night sweats, insomnia, vaginal dryness, irregular or heavy menstrual bleeding, depression and anxiety. Those women who said they had suffered from hot flushes had the lowest risk of developing breast cancer.
Further information and advice
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References
1. Acupuncture for treating menopausal hot flushes: a systematic review.
Lee MS, Shin BC, Ernst E.
Climacteric 2009; 12(1): 16-25
SR of 6 RCTs (309 participants). Five studies found no difference in frequency, severity or frequency x severity of hot flushes between the intervention and control groups. Conclusions: There was no convincing evidence that acupuncture was beneficial for menopausal women who experienced hot flushes.
Link to Abstract
2. Acupuncture for vasomotor menopausal symptoms: a systematic review.
Cho SH, Whang WW.
Menopause. 2009 Sep-Oct;16(5):1065-73.
SR of 11 studies (764 participants). Conclusions: There is no evidence from RCTs that acupuncture is an effective treatment in comparison to sham acupuncture. Some studies have shown that acupuncture therapies are better than hormone therapy. However, the number of RCTs is small, and the methodological quality of some of the RCTs was poor.
Link to Abstract
3. Adult weight change and risk of postmenopausal breast cancer
Eliassen AH.
JAMA. 2006 Jul 12;296(2):193-201.
These data suggest that weight gain during adult life, specifically since menopause, increases the risk of breast cancer among postmenopausal women, whereas weight loss after menopause is associated with a decreased risk of breast cancer. Thus, in addition to other known benefits of healthy weight, our results provide another reason for women approaching menopause to maintain or lose weight, as appropriate.
Link to Abstract
4. Alcohol Consumption and Risk of Postmenopausal Breast Cancer by Subtype: the Women’s Health Initiative Observational Study.
Li CI et al.
Published online August 23, 2010 in JNCI (Journal of the National Cancer Institute). doi:10.1093/jnci/djq316
Alcohol use may be more strongly associated with risk of hormone-sensitive breast cancers than hormone-insensitive subtypes, suggesting distinct etiologic pathways for these two breast cancer subtypes.
Link to Abstract
5. Botanical and dietary supplements for mood and anxiety in menopausal women
Geller SE, Studee L.
Menopause 2007 - Volume 14 - Issue 3 - pp 541-549 doi: 10.1097/01.gme.0000236934.43701.c5
Five of seven trials of St. John's wort for mild to moderate depression showed a significant improvement. The one randomized, controlled trial of ginseng in postmenopausal women reported improvements in mood and anxiety. All three randomized, controlled trials of ginkgo found no effect on depression. In four of eight controlled trials, kava significantly reduced anxiety. Black cohosh significantly reduced depression and anxiety in all studies reviewed. St. John's wort and black cohosh appear to be the most useful in alleviating mood and anxiety changes during menopause. Ginseng may be effective, but more research needs to be done. Finally, ginkgo and valerian do not appear to be useful in reducing depression or anxiety in this population.
Link to Abstract
6. Botanical and dietary supplements for mood and anxiety in menopausal women.
Geller SE, Studee L.
Menopause 2007 - Volume 14 - Issue 3 - pp 541-549 doi: 10.1097/01.gme.0000236934.43701.c5
Five of seven trials of St. John's wort for mild to moderate depression showed a significant improvement. The one randomized, controlled trial of ginseng in postmenopausal women reported improvements in mood and anxiety. All three randomized, controlled trials of ginkgo found no effect on depression. In four of eight controlled trials, kava significantly reduced anxiety. Black cohosh significantly reduced depression and anxiety in all studies reviewed. St. John's wort and black cohosh appear to be the most useful in alleviating mood and anxiety changes during menopause. Ginseng may be effective, but more research needs to be done. Finally, ginkgo and valerian do not appear to be useful in reducing depression or anxiety in this population.
Link to Abstract
7. Efficacy of black cohosh-containing preparations on menopausal symptoms: a meta-analysis.
Shams T, Setia MS, Hemmings R, McCusker J, Sewitch M, Ciampi A.
Altern Ther Health Med. 2010 Jan-Feb;16(1):36-44.
SR or 9 trials (7 in meta-analysis). Conclusions: Preparations containing black cohosh improved these symptoms overall by 26% (95% confidence interval 11%-40%); there was, however, significant heterogeneity between these trials.
Link to Abstract
8. Exercise for vasomotor menopausal symptoms.
Daley A, Stokes-Lampard H, MacArthur C.
Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD006108. DOI: 10.1002/14651858.CD006108.pub2.
Cochrane SR of 6 trials. Conclusions: The existing studies provided insufficient evidence to determine the effectiveness of exercise as a treatment for vasomotor menopausal symptoms, or whether exercise is more effective than HRT or yoga.
Link to Abstract
9. Exercise for vasomotor menopausal symptoms.
Daley A, Stokes-Lampard H, MacArthur C.
Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD006108. DOI: 10.1002/14651858.CD006108.pub2.
Cochrane SR of 6 trials. Conclusions: The existing studies provided insufficient evidence to determine the effectiveness of exercise as a treatment for vasomotor menopausal symptoms, or whether exercise is more effective than HRT or yoga.
Link to Abstract
10. Isoflavone therapy for menopausal flushes: a systematic review and meta-analysis
Howes L G, Howes J B, Knight D C
Maturitas 2006; 55(3): 203-211
Seventeen RCTs (n=1,503) were included: 5 studies (n=458) of red clover and 12 studies (n=1,045) of soy.
Authors conclusions: Isoflavone supplementation may result in a slight to modest reduction in the number of daily menopausal flushes, with greater reductions in women with a high number of daily flushes at baseline. DARE appraisal: …difficult to comment on the reliability of the authors’ conclusions.
Note all authors had links to red clover manufacturer.
Link to Abstract
11. Isoflavone therapy for menopausal flushes: a systematic review and meta-analysis.
Howes L G, Howes J B, Knight D C.
Maturitas 2006; 55(3): 203-211
Seventeen RCTs (n=1,503) were included: 5 studies (n=458) of red clover and 12 studies (n=1,045) of soy.
Authors conclusions: Isoflavone supplementation may result in a slight to modest reduction in the number of daily menopausal flushes, with greater reductions in women with a high number of daily flushes at baseline. DARE appraisal: …difficult to comment on the reliability of the authors’ conclusions.
Note all authors had links to red clover manufacturer.
Link to Abstract
12. Mind-body therapies for menopausal symptoms: A systematic review.
Innes K.E. Selfe T.K. Vishnu A.
Maturitas. 66 (2) (pp 135-149), 2010.
SR or 18 trials (12 RCTs) of various interventions (yoga and/or meditation-based programs, tai chi, and other relaxation practices, including muscle relaxation and breath-based techniques, relaxation response training, and low-frequency sound-wave therapy). Conclusions: findings of these studies suggest that yoga-based and certain other mind-body therapies may be beneficial for alleviating specific menopausal symptoms. However, the limitations characterizing most studies hinder interpretation of findings and preclude firm conclusions regarding efficacy.
Link to Abstract
13. Non-hormonal interventions for hot flushes in women with a history of breast cancer
Rada G, Capurro D, Pantoja T, Corbalán J, Moreno G, Letelier LM, Vera C.
Cochrane Database of Systematic Reviews 2010, Issue 9. Art. No.: CD004923. DOI: 10.1002/14651858.CD004923.pub2.
Cochrane SR including 2 trials of relaxation therapies. One of two studies on relaxation therapy showed a significant benefit. Conclusions: Clonidine, SSRIs and SNRIs, gabapentin and relaxation therapy showed a mild to moderate effect on reducing hot flushes in women with a history of breast cancer.
Link to Abstract
14. Non-hormonal interventions for hot flushes in women with a history of breast cancer.
Rada G, Capurro D, Pantoja T, Corbalán J, Moreno G, Letelier LM, Vera C.
Cochrane Database of Systematic Reviews 2010, Issue 9. Art. No.: CD004923. DOI: 10.1002/14651858.CD004923.pub2.
Cochrane SR. Two studies of homeopathy showed no evidence of benefit.
Link to Abstract
15. Non-hormonal therapy of post-menopausal vasomotor symptoms: a structured evidence-based review
Cheema D, Coomarasamy A, El-Toukhy T.
Arch Gynecol Obstet. 2007 Nov;276(5):463-9. Epub 2007 Jun 26.
SR including 7 trials of black cohosh. Conclusions: There is evidence that clonidine, paroxetine, venlafaxine, gabapentin and black cohosh may be beneficial in the treatment of menopausal vasomotor symptoms in some women.
Link to Abstract
16. Non-hormonal therapy of post-menopausal vasomotor symptoms: a structured evidence-based review.
Cheema D, Coomarasamy A, El-Toukhy T.
Arch Gynecol Obstet. 2007 Nov;276(5):463-9. Epub 2007 Jun 26
Link to Abstract
17. Non-hormonal therapy of post-menopausal vasomotor symptoms: a structured evidence-based review.
Cheema D, Coomarasamy A, El-Toukhy T.
Arch Gynecol Obstet. 2007 Nov;276(5):463-9. Epub 2007 Jun 26
Link to Abstract
18. Nonhormonal therapies for hot flashes in menopause.
Carroll DG.
Am Fam Physician. 2006 Feb 1;73(3):457-64.
Link to Abstract
19. Physical Activity and Postmenopausal Breast Cancer: Effect Modification by Breast Cancer Subtypes and Effective Periods in Life
Schmidt et al.
Cancer Epidemiology Biomarkers & Prevention, 2008; 17 (12): 3402 DOI: 10.1158/1055-9965.EPI-08-0479
Researchers assume that physical exercise reduces the risk of cancer through hormonal mechanisms instead merely by a reduction of body fat or other changes in physical constitution, as it has often been assumed.
Link to Abstract
20. Phytoestrogen supplement use by women.
Kurzer MS.
J Nutr. 2003 Jun;133(6):1983S-1986S.
Extracted phytoestrogens are marketed in numerous forms as dietary supplements. Consumers of phytoestrogen supplements tend to be peri- and postmenopausal women looking for an alternative to hormone therapy. Numerous claims are being made for benefits to heart, bone, breast and general menopausal health. The research supporting these claims are not strong. The strongest data show that phytoestrogens reduce the number and intensity of hot flashes, although the reduction is a modest 10-20%. The data on bone metabolism are suggestive of possible benefits whereas the effects on the breast are the most poorly understood. Although most animal studies have shown cancer-preventive effects, a few recent studies suggest that soy phytoestrogens may stimulate breast cancer cell growth under certain circumstances. Until safety with respect to breast cancer is established, phytoestrogen supplements should not be recommended, particularly for women at high risk of breast cancer.
Link to Abstract
21. Phytoestrogen supplement use by women.
Kurzer MS.
J Nutr. 2003 Jun;133(6):1983S-1986S.
Extracted phytoestrogens are marketed in numerous forms as dietary supplements. Consumers of phytoestrogen supplements tend to be peri- and postmenopausal women looking for an alternative to hormone therapy. Numerous claims are being made for benefits to heart, bone, breast and general menopausal health. The research supporting these claims are not strong. The strongest data show that phytoestrogens reduce the number and intensity of hot flashes, although the reduction is a modest 10-20%. The data on bone metabolism are suggestive of possible benefits whereas the effects on the breast are the most poorly understood. Although most animal studies have shown cancer-preventive effects, a few recent studies suggest that soy phytoestrogens may stimulate breast cancer cell growth under certain circumstances. Until safety with respect to breast cancer is established, phytoestrogen supplements should not be recommended, particularly for women at high risk of breast cancer.
Link to Abstract
22. Phytoestrogens for vasomotor menopausal symptoms.
Lethaby A, Marjoribanks J, Kronenberg F, Roberts H, Eden J, Brown J.
Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD001395. DOI: 10.1002/14651858.CD001395.pub3.
Cochrane review of 30 trials. Conclusions: Most of the trials in this review were small, of short duration and poor quality. Some trials found a slight reduction in hot flushes and night sweats with phytoestrogen-based treatment but overall there was no indication that phytoestrogens worked any better than no treatment. There was no evidence of harm with short term use.
Link to Abstract
23. Phytoestrogens for vasomotor menopausal symptoms.
Lethaby A, Marjoribanks J, Kronenberg F, Roberts H, Eden J, Brown J.
Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD001395. DOI: 10.1002/14651858.CD001395.pub3.
Cochrane review of 30 trials. Conclusions: Most of the trials in this review were small, of short duration and poor quality. Some trials found a slight reduction in hot flushes and night sweats with phytoestrogen-based treatment but overall there was no indication that phytoestrogens worked any better than no treatment. There was no evidence of harm with short term use.
Link to Abstract
24. Psychoeducational interventions to alleviate hot flashes: a systematic review.
Tremblay A, Sheeran L, Aranda SK.
Menopause. 2008 Jan-Feb;15(1):193-202.
SR or 14 studies of various interventions involving 475 patients, 9 trials of relaxation techniques of which 5 were positive. Conclusions: Psychoeducational interventions, including relaxation, seem to alleviate hot flashes in menopausal women and breast cancer survivors; however, the methodological quality of published research is either fair or poor.
Link to Abstract
25. Psychoeducational interventions to alleviate hot flashes: a systematic review.
Tremblay A, Sheeran L, Aranda SK
Menopause. 2008 Jan-Feb;15(1):193-202.
SR including 5 studies that evaluated psychoeducational interventions, including education, counseling, cognitive-behavioral strategies, and mindfulness-based stress reduction. All showed an improvement but in the two largest studies, participants also received drug therapy too.
Link to Abstract
26. Risk factors for onset of menopausal symptoms: results from a large cohort study
Sabia S, Fournier A, Mesrine S, Boutron-Ruault MC, Clavel-Chapelon F.
Maturitas. 2008 Jun 20;60(2):108-21. Epub 2008 May 29.
Large cohort study of 28,000 women in France. Findings: Among dietary factors, rapidly absorbed sugars and snacking were positively associated with the risk of onset of menopausal symptoms.
Link to Abstract
27. Risk factors for onset of menopausal symptoms: results from a large cohort study.
Sabia S, Fournier A, Mesrine S, Boutron-Ruault MC, Clavel-Chapelon F.
Maturitas. 2008 Jun 20;60(2):108-21. Epub 2008 May 29.
Large cohort study of 28,000 women in France. Findings: The risk (of onset of menopausal symptoms) was positively associated with smoking and alcohol consumption.
Link to Abstract
28. Risk factors for onset of menopausal symptoms: results from a large cohort study.
Sabia S, Fournier A, Mesrine S, Boutron-Ruault MC, Clavel-Chapelon F.
Maturitas. 2008 Jun 20;60(2):108-21. Epub 2008 May 29.
Among dietary factors, rapidly absorbed sugars and snacking were positively associated with the risk of onset of menopausal symptoms.
Link to Abstract
29. Soy extracts versus hormone therapy for reduction of menopausal hot flushes: indirect comparison.
Bolaños-DÃaz R, Zavala-Gonzales JC, Mezones-HolguÃn E, Francia-Romero J.
Menopause. 2011 Mar 3. [Epub ahead of print]
An indirect comparison of meta-analyses evaluating severity of hot flushes in postmenopausal women on HRT or soy extracts looked at 19 studies on how a treatment, either hormones or soy, compared to a placebo. It compared the average number of hot flashes in 760 women who had treatment with 770 who did not.. HT and soy interventions showed a significant difference in efficacy for the reduction of hot flushes in postmenopausal women when each treatment was compared with placebo. However, using indirect comparison, there is a statistically significant difference between HT and soy extracts in their effects on hot flushes.
Link to Abstract
30. The effect of acupuncture on postmenopausal symptoms and reproductive hormones: a sham controlled clinical trial.
Sunay D, Ozdiken M et al.
Acupunct Med 2011;29:27–31.
RCT involving 53 postmenopausal women. Half were given sham acupuncture, half received traditional Chinese acupuncture twice a week for 10 weeks. After treatment, total MRS, and the somatic and psychological subscale scores were significantly lower in the acupuncture group than the sham group (all p=0.001). The severity of hot flushes was found to be significantly decreased after treatment in acupuncture group (p=0.001). In the acupuncture group LH levels were lower and oestradiol levels were significantly higher than sham group (p=0.046 and p=0.045, respectively) after treatment, but there was no difference in FSH levels.
Link to Abstract
31. The role of phytoestrogen therapy in relieving postmenopausal symptoms
Szkutnik-Fiedler D, Jedrzejczyk M, Grześkowiak E, Bartkowiak-Wieczorek J, Seremak-Mrozikiewicz A, Drews K, Mrozikiewicz PM.
Ginekol Pol. 2010 Dec;81(12):929-34.
Link to Abstract
32. Treating hot flushes in menopausal women with homeopathic treatment: results of an observational study.
Bordet M., Colas A., Marijnen P., Masson J., Trichard M.
Homeopathy. 97 (1) (pp 10-15), 2008.
Open, multi-national prospective, pragmatic and non-comparative observational study (98 physicians in 8 countries, 438 patients). Conclusions: The results of this observational study suggest that homeopathic treatment for hot flushes in menopausal women is effective.
Link to Abstract
33. Trifolium pratense isoflavones in the treatment of menopausal hot flushes: a systematic review and meta-analysis.
Thompson Coon J, Pittler M H, Ernst E.
Phytomedicine 2007; 14(2-3): 153-159
SR of Five RCTs (400 patients). Conclusions: There was evidence of a marginally significant effect of Trifolium pratense isoflavones in the treatment of hot flushes in menopausal women, but the clinical relevance of this effect was unclear. Adverse events during short-term use were not apparent but data on long-term administration were missing.
Link to Abstract
34. Trifolium pratense isoflavones in the treatment of menopausal hot flushes: a systematic review and meta-analysis.
Thompson Coon J, Pittler M H, Ernst E.
Phytomedicine 2007; 14(2-3): 153-159
SR of Five RCTs (400 patients). Conclusions: There was evidence of a marginally significant effect of Trifolium pratense isoflavones in the treatment of hot flushes in menopausal women, but the clinical relevance of this effect was unclear. Adverse events during short-term use were not apparent but data on long-term administration were missing.
Link to Abstract
35. Yoga for menopausal symptoms: A systematic review.
Lee M.S., Kim J.-I., Ha J.Y., Boddy K., Ernst E.
Menopause. 16 (3) (pp 602-608), 2009.
SR of 7 studies. Conclusions: The evidence is insufficient to suggest that yoga is an effective intervention for menopause.
Link to Abstract