Facts And Definitions
Menopause marks the end of the reproductive stage of a woman’s life. There are many signs and symptoms associated with menopause, majority of which can be associated with the reduction of levels of circulating oestrogen. While some of these symptoms will subside once a woman is post menopausal, some of the changes that occur during menopause need to be considered and managed long term.
Definitions:
Perimenopause – from when the cycle starts changing until 12months after the final menstrual period. Can last 1-3 years – commonly lasts 4-6yrs.
Menopause transition – from when cycle starts changing, until final menstrual period.
Post Menopause – When a woman has had no periods for 12 consecutive months she is considered to be “postmenopausal”. Most women become menopausal naturally between the ages of 45 and 55 years, with the average age of onset at around 50 years. At this stage, there is no production of oestrogen and progesterone and the ovaries no longer release eggs.
Menopause facts:
- 20% of women will have no symptoms, 20% will have severe symptoms and everyone else will be somewhere in between.
- Oestrogen has been proven to be important with brain function, so the ‘brain fog’ some women describe is secondary to the hormone change! More research is needed in this area to fully understand exactly how oestrogen impacts cognition.
- Weight increase is not completely contributable to menopause – age and lifestyle factors also contribute. Menopause is, however, associated with an increase in total body fat and abdominal fat.
- The stage of menopause is generally diagnosed based on symptom profile rather than blood tests measuring actual hormone level. This is because hormone levels tend to fluctuate during perimenopause as opposed to a steady decline. This means a blood test doesn’t hold any value, it will merely highlight what is happening at that moment in time.
Why is oestrogen important?
We have identified that post menopausal women will have a reduction in oestrogen. Research is still lacking, and we still don’t have a thorough understanding of what some oestrogen receptors are responsible for, however, we do know that:
- Oestrogen may be directly involved in muscle metabolism and may also play a role in regulating carbohydrate and lipid metabolism, which may influence skeletal muscle composition in postmenopausal women.
- Therefore, the decrease in oestrogen levels with menopause may play a potential role in the muscle mass decline observed after the 5th decade of life.
- Loss of muscle mass begins substantially at the age of 50, and there seems to be a link between sarcopenia (loss of muscle mass) and osteoporosis.
- Women suffering from sarcopenia have more than double higher risk factors for fractures and falls in comparison to those without.
- Oestrogen promotes osteoblasts (bone forming cells) and increases calcium absorption from the blood, therefore the decrease in oestrogen in menopause marks an increase in bone reabsorption or a loss of bone mineral density.
- Peak mineral bone density is achieved around 30 and progressively declines at a rate of ~0.7% per year. This can be as high as 5% per year following the final menstrual period and can persist for up to 3years following at this rate before it returns to normal.
- Vasomotor changes (hot flushes and night sweats) are not completely understood but are related to oestrogen withdrawal. It is thought that the reduction of oestrogen can impact the brain temperature regulatory centre making sweating and shivering more common.
Menopausal Hormone Therapy
Menopausal hormone therapy (MHT) involves the prescription of oestrogen and progesterone (if appropriate) to help manage the signs and symptoms associated with the decline of oestrogen production. It is important to note:
- Symptoms don’t have to be extreme or severe, the principal indication of MHT is to alleviate vasomotor symptoms (hot flushes).
- Women don’t need to wait until they are menopausal before starting MHT, it can be initiated as soon as they start to notice symptoms.
- MHT should be a part of an overall strategy aimed at improving midlife women’s health.
- MHT can reduce the risk of osteoporosis and post-menopausal bone fractures.
- Risks associated with MHT are small in most women when initiated within 10years of the last menstrual period.
- Progesterone and oestrogen must both be prescribed to protect the endometrial lining and reduce the risk of endometrial cancer. Oestrogen only is therefore appropriate following a hysterectomy
- Non-oral routes have fewer risks than oral preparations
Risks
- Unexpected bleeding/spotting, breast tenderness and bloating.
- This can be minimised by appropriate dosage.
- Likely and normal to occur. Can persist for up to 6months.
- Increased risk of thrombosis (blood clots) with oral but not transdermal hormone therapy.
- In women less than 60 the risk is low. In those over 60, other risk factors for thrombosis increase and therefore the overall risk increases.
- Endometrial cancer is increased with unopposed oestrogens or inappropriately opposed oestrogen. This means women will also need to take progesterone to minimise this risk. Women who have had a hysterectomy will only need to take oestrogen.
- Breast cancer risk is small (<1 : 1000) and appears to be associated with duration of use (>5years) and choice of progesterone.
- Modifiable lifestyle factors are going to be far higher risk of contributing to the development of breast cancer.
- Those who did develop breast cancer had a low risk of mortality.
- Reduced risk of breast cancer in oestrogen only, and reduced risk of mortality in these women.
Non-hormonal treatments
- Most non-hormonal medications have been designed for other purposes, so use of these should be well discussed with your doctor.
- They generally only aim to treat hot flushes and night sweats.
A note on testosterone in women…
It is believed there is a decline in testosterone of about 25% during a woman’s reproductive years. While we know this, the physiology of testosterone is complex and not well understood how it impacts women during menopause. As with oestrogen and progesterone, the blood hormone levels are a poor guide to what is actually happening at a tissue level, which makes measuring testosterone in women very difficult.
The only evidence based indication for testosterone therapy in women is for the treatment of postmenopausal women with low sexual desire with associated distress. There is insufficient data to support the use of testosterone for the treatment of any other clinical symptom or clinical condition, or for disease prevention.
In Summary
Menopause marks the end of a women’s reproductive stage of life, and is caused by the reduction of circulating oestrogen. The decrease in oestrogen is responsible for the common symptoms experienced by women transitioning to post-menopause, and also for some physiological changes that can’t be seen (ie. bone mineral density). MHT can be used (under appropriate guidance) to help combat these menopause-related changes.
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