Effective treatment is available for menopause symptoms, including sleep problems, joint pain and hot flushes. But first the symptoms must be identified. University of Helsinki researchers answer questions about menopause.
When does menopause start?
Menopause is a transition that happens as the ovaries gradually stop functioning, and the production of oestrogen declines and eventually ceases.
The average age when menopause starts is 51. However, the first symptoms can occur up to 10 years earlier, as the functioning of the ovaries changes even before menstruation stops.
The diagnosis is based on the symptoms. If the person affected has reached the age when menopause typically starts, no laboratory tests are required.
What is perimenopause?
Perimenopause is a stage when ovarian ageing results in decreased ovarian function, which manifests itself in, for example, a shorter or irregular menstrual cycle. Some experience symptoms of menopause at this point, but for others, symptoms may be milder and appear only occasionally.
The terms pre- and perimenopause may be used almost interchangeably to refer to the time before menopause, or the last natural menstrual period.
Everyone has probably heard of hot flushes and sweating. What are other typical symptoms of menopause?
Symptoms are highly individual. As women have oestrogen receptors in almost all tissue, symptoms too can occur almost anywhere. Common symptoms associated with menopause include joint and muscle pains, fatigue, irritability and mood changes.
Sleep issues are very common and may even be debilitating. Sleep deprivation is harmful to physical and mental health and performance.
Although hormonal migraines are not actually caused by menopause, they may worsen during perimenopause when hormone levels fluctuate more.
Depleted oestrogen levels make mucous membranes thinner and drier, which may cause pain during intercourse and increase the risk of urinary tract infections.
During the menopausal transition, many put on weight. The average weight gain is half a kilogram per year. Researchers disagree about whether this is caused by hormones or ageing and lifestyle changes. All of these factors are likely to play a role.
However, oestrogen is known to encourage fat to accumulate around the buttocks and thighs. When oestrogen production falls, fat begins to centre around the waist and the abdominal cavity.
Muscle strength starts to deteriorate even before menopause. Maintaining muscle fitness is important for metabolism and functional capacity.
When does menstruation stop?
This too is individual, but most commonly the menstrual cycle first becomes irregular and unpredictable. This usually happens five to 10 years before the last period. Menstruation may go from heavy to light, and the flow may last from just a few days to over a week.
If the flow is very light, menstrual blood takes longer to leave the body, which means it becomes, as it were, older and may have a brownish colour.
About a year or two before menstruation ceases, intervals between periods may reach up to several months. It is difficult to tell which period will be the last.
A person using a hormonal IUD (coil) or a progestogen-only pill (mini pill) and whose period has been absent may recognise the onset of menopause from other symptoms.
How can symptoms of menopause be treated?
Symptoms are usually treated with hormone replacement therapy (HRT). As menopause is due to a lack of oestrogen, it is logical to replace it in the form of HRT. For those with an intact uterus, the hormone progesterone (or the synthetic version progestogen) is taken along with oestrogen to protect the lining of the uterus.
Hormone therapies can be administered in different ways: through the skin as a gel, patch or spray or as an oral tablet. The best option for each person depends on individual risk factors and preferences.
HRT cannot be prescribed, for example, to those with a history of breast cancer, deep vein thrombosis, pulmonary embolism, heart attack or stroke. If a person has had one of the above, HRT may exceptionally be considered if menopausal symptoms are severe and cannot otherwise be controlled.
The use of HRT is not automatically precluded by a family history of disease, as it may indicate hereditary risks, but may equally as well be associated with lifestyle factors. For example, although a close relative's diagnosis of deep vein thrombosis may be a sign of a genetic predisposition, it may also have been caused by prolonged bed rest or surgery, in which case the risk is not genetic. If necessary, a potential predisposition can be investigated.
If a person is unable to take or use oestrogen, they may turn to non-hormonal options, such as SSRIs, which are used to treat, for example, depression. However, they may be less effective than HRT in treating menopausal symptoms.
A new drug for treating hot flushes has recently become available: fezolinetant acts on the neurokinin receptors in the brain that regulate core body temperature and sweating. It cannot treat other symptoms.
Some prefer non-medical products, although studies have shown that they are no more effective than placebos.
What are the risks of HRT?
Oral oestrogen therapy is associated with a risk of deep vein thrombosis (DVT). It is recommended that persons with risk factors of DVT use oestrogen applied to the skin.
Similarly, patches, gel or spray is recommended for those who have migraines or epilepsy, as, for example, the transdermal route produces more stable oestrogen levels in the blood and does not affect the concentrations of other drugs.
The risk of breast cancer begins to increase if HRT is taken for over five years. This requires a comprehensive assessment of factors, including the severity of symptoms.
However, the risk of breast cancer is not so high as to necessitate more frequent breast examination. A breast screening (mammogram) performed every two years suffices.
What are the benefits of HRT?
The elimination or alleviation of difficult symptoms improves the quality of life. Other significant benefits include the protection provided by oestrogen against osteoporosis and some intestinal cancers. In addition, HRT helps stave off coronary heart disease and reduces the risk of developing type 2 diabetes.
When should treatment begin?
Treatment should begin when symptoms start to interfere with daily life.
Under current recommendations, treatment should begin under the age of 60 or within 10 years of menopause, that is, the last period. If initiated later, HRT will provide no benefit, or its risks may increase. The most common age for starting HRT ranges from 45 to 55.
How long should treatment continue?
This is highly individual. For most people, symptoms last at least five years, often longer.
At some stage, HRT users must simply try to reduce the dose or stop taking HRT to find out whether their symptoms have disappeared.
However, it is not a good idea to stop and start HRT treatment repeatedly. This is because of the small risk of blood clots associated with starting treatment. If a person discovers they need to continue taking HRT, they should do so and try stopping two or three years later.
What should you do if you suspect your symptoms are related to menopause but your doctor does not take them seriously?
The easy answer is to switch to another doctor. This may be fairly straightforward for a well-to-do person living in a city. If symptoms are typical and no help is available, it is a good idea to contact a patient ombudsman at the local health centre or a medical centre.
Not all doctors recognise even the most common symptoms of menopause. Fortunately, current medical students are taught to identify and treat menopausal symptoms. However, identifying atypical symptoms may be difficult even for a gynaecologist.
Why should we talk about menopausal symptoms?
Although menopause affects half the population, it is only in recent years that it has been given the attention it deserves and been spoken about more. We should reframe our ideas of menopause.
Some still see menopause as an 'old lady thing', and articles on menopause may contain pictures of grey-haired women - this despite the fact that people going through menopause are of working age, and many are at the top of their careers. Society cannot afford to let them spend their nights sleepless and sweating.
By talking more about the symptoms, people will learn more, and an increasing number will seek and find relief. This is important for not only individuals but society as a whole.
The questions were answered by Hanna Savolainen-Peltonen , Specialist in and Docent of Obstetrics and Gynaecology, and Kaisu Luiro-Helve , Specialist in Obstetrics and Gynaecology and Clinical Instructor at the University of Helsinki.
