The Menopause: Demystified

Not only do women not talk about the more difficult aspects of the menopause amongst themselves, but its so overlooked, that medical practitioners in the US and UK receive no mandatory training in it, and employers often offer no support to women going through it.

Granted, some women will sail through the menopause with no adverse effects, but at least 30% suffer debilitating symptoms — both physical and mental — that seriously impact their quality of life and sometimes their ability to continue working. However, because it’s not talked about, many women don’t know that they can safely get relief from the symptoms and decrease their risk of other diseases at the same time. Dr Pooja Monteiro, a consultant OB/GYN at Total Health, spends a significant amount of time helping and advising women with their menopause symptoms and is often surprised at how little women know about menopause. She notes that many aren’t aware of the wide variety of symptoms that can occur when their hormone levels start to change.

Thankfully, that wall of silence is starting to crack. Celebrities and TV personalities are opening up about their experiences of the menopause, how it affects their lives and the challenges in getting treatment. This is also sparking a wider conversation and reassuring women all over the world that there is no shame in talking about this inevitable experience.

What is the Menopause?

Quite simply, the menopause refers to the end of a woman's menstrual cycle. A woman is considered menopausal when she has not had a period for more than 12 months. The average age for this is 51, although it can vary by several years either side of that. Menopause usually lasts between five and seven years, but again, it can be longer or shorter. Once menopause symptoms stop, a woman is considered post-menopausal.

For some women, their periods will stop suddenly. Many others will experience irregular periods that may be heavier or lighter than normal, some years before they stop completely. This phase, when hormone levels are fluctuating, is perimenopause and is often accompanied by menopausal symptoms. Perimenopause usually begins in your 40s.

Symptoms of Menopause

Menopause is driven by hormones. As we approach the end of our fertile years, our ovaries slow down and eventually stop functioning: not only do they stop producing eggs, but they also stop producing the hormone oestrogen. Because there are oestrogen receptors in every tissue and organ in the body, oestrogen affects not only our menstrual cycles and reproductive organs, but also our urinary tracts, heart and blood vessels, bones, breasts, skin, hair, mucous membranes, pelvic muscles, and brains.

So when levels of this vital hormone decrease we feel it in a perplexing variety of ways so much so that many women fail to connect the symptoms they are experiencing with the menopause.

The most recognised physical symptom — and for many, the most debilitating — is the hot flushes. Dr Pooja estimates that 8 in 10 women experience these, describing them as if feeling like they are “being set on fire”. Hot flushes tend to affect the upper part of the body and usually occur later in the day, but they can also occur during sleep as night sweats. This can end up causing fatigue and, in turn, lead to a low mood and irritability.

However, the symptoms women experience vary widely and present in different combinations. Other physical symptoms include aching joints, weight gain, tingling skin, headaches and heart palpitations. Because the tissue of the bladder thins during menopause, symptoms can also include frequent UTIs, overactive bladder, and incontinence. More difficult for many to talk about is the loss of libido and the vaginal dryness, which is also caused by thinning tissue and, if not treated, can make sex painful and day to day life uncomfortable.

In addition to these unquestionably unpleasant physical symptoms, are the severe mental and psychological symptoms that can accompany this time. An estimated 40% of women do not even know about these, so that when gripped by extreme mood swings, anxiety, anger, poor memory and mental fog, they think they are losing their minds. These symptoms don't only impact relationships, but also leave some women feeling unable to continue in their jobs, or to pursue more senior career roles.

When To See a Doctor

Too many women soldier on, ignoring the symptoms as best they can, looking forward to the calm after the storm. However, by not seeing a medical professional, we are not doing ourselves any favours, as treatments can dramatically improve one's quality of life.

The best time to see someone is as soon as you start to feel symptoms, but if your doctor is not knowledgeable about menopause seek out a medical professional who specialises in women's health (for example an OB/GYN).

GPs may hear 'insomnia, low mood, weight gain, anxiety and irritability' and assume they are dealing with depression, rather than menopause. Equally, perspiration, hot flushes, low mood and depression can also be a sign of thyroid issues, so its essential to rule out other conditions.

The other reason to see a doctor, whatever your symptoms, is because certain health risks increase post-menopause.

After the symptoms abate, low oestrogen levels stay with women for the rest of their lives. As Dr. Reeves emphasises, post-menopausal women are in effect living with a hormone deficiency. That deficiency can affect their health in multiple ways: most importantly, it dramatically increases women's risk of osteoporosis, heart disease and Alzheimers.

Up until a century or so ago, when life expectancy was much lower and women tended not to live long beyond the menopause, this hormone deficiency was not particularly significant. These days, however, many women will live up to a third of their lives after the menopause, so its essential to consider the long-term health impacts of low oestrogen.

Scroll to the bottom of this article for a list of doctors and clinics in Cayman that specialise in women's health.

Hormone Replacement Therapy (HRT)

The single most effective treatment available for menopausal symptoms is Hormone Replacement Therapy. The aim of HRT is not to delay or stop the menopause but rather to manage the symptoms by topping up hormone levels.

There are two main types of HRT: oestrogen-only and combined oestrogen and progestogen (a synthetic form of progesterone). Women who have had a hysterectomy can take oestrogen-only HRT, but because oestrogen can cause a thickening of the uterus and increase the risk of endometrial cancer, women who still have their wombs are also given progestogen to reverse that risk. Occasionally, testosterone is prescribed for sexual issues.

Oestrogen is best delivered through the skin so that it is not metabolised by the liver; this can be in the form of patches, gels or sprays. Progestogen is usually taken as a capsule whereas testosterone mainly comes in gel-form.

There is no one-size-fits-all HRT treatment: every case is treated individually and it may require trying different formulations to find the right dose and combination for the individual.

HRT is best started at the onset of symptoms. While the standard recommendation is to administer the lowest dose for the shortest possible time (not more than five years), a growing number of women's health experts like Dr. Reeves advocate taking HRT even if you have mild symptoms and, in some cases, staying on it long-term, to reduce your future risk of osteoporosis, heart disease and Alzheimers.

Risks of HRT

Available since the 1960s, HRT was widely prescribed until the early 2000s. Then, in 2002, a large-scale study by the Womens Health Initiative, which evaluated the effect of HRT on health in postmenopausal women, published its preliminary findings. These showed a link between HRT and increased risk of breast cancer, stroke, heart disease and clots although it was the breast cancer link that made headlines. Almost overnight millions of women stopped taking HRT and doctors around the world stopped prescribing it.

Those initial findings have been widely discredited, and investigators involved in the study now emphasise that it was poorly designed and that the risk identified was not statistically significant. But it is the sensational headlines that have stuck in peoples memories and kept women in fear of HRT. Twenty years on, only a minority of menopausal women now take HRT.

There have been several studies since, some of which show an increased risk of disease, and others that do not but that should not be cause for alarm. "The worst-case scenario," Dr. Reeves says, "is that there might be a slightly increased risk, but its definitely not as much of a concern as its made out to be. Its been blown out of proportion by the media."

She states that the benefits of HRT in healthy women with symptoms of menopause generally outweigh the risks when started before age 60 and within 10 years of menopause. The key points to bear in mind regarding the risks are:

• Women on oestrogen-only HRT do not have an increased risk of breast cancer.
• Starting HRT before age 60/within 10 years of the onset of menopause is preferable. Starting at age 70+ carries more risk.
• HRT does not increase your risk of cardiovascular disease and oestrogen-only HRT may offer protection.
• There is a very small increased risk of stroke associated with oral oestrogen but most doctors now prescribe transdermal oestrogen.
• HRT is widely accepted as protecting against osteoporosis.
• Menopause specialists agree that the benefits of HRT far outweigh the risks.

Stopping HRT can cause menopause symptoms to return, particularly if you do so suddenly. It may be best to reduce the dosage gradually. If you're on HRT and want to stop, discuss it with your doctor first and decide on the best approach.

Body-Identical vs Bio-Identical HRT

Dr Pooja says that to reduce the risk of negative effects, the most preferred forms of HRT are the body-identical hormones (BHRT). These have the same molecular structure as the hormones in your body and mimic your body’s natural hormones. These are not to be confused with natural plant-based supplements derived from yams or soy.

Lifestyle Changes

Whether you choose to take medication to assist you through the menopause or not, certain lifestyle changes will also help to manage the symptoms.

Exercise: At a time when low mood and depression can be a daily battle, physical activity is a great way to release endorphins and can also be a great sleep aid for those struggling with insomnia. Weight-bearing exercise strengthens bones and protects against osteoporosis and any aerobic exercise will help to protect against heart disease.

Diet: Its important to support your body through this change by giving it the nutrients it needs. Eat plenty of plant-based foods for fibre and lean proteins. Avoid excessive salt, which can adversely affect bone density, and make sure you eat calcium-rich foods to keep your bones strong. To keep your heart healthy, avoid saturated fats.

Pelvic Floor Health: Keeping your pelvic floor muscles strong is the best way to prevent or control urinary incontinence and pelvic prolapse, which can be a distressing effect of menopause. The womens health physiotherapists at Cayman Physiotherapy and Elevation Health & Physiotherapy both create individualised treatment plans to help women in this stage of life.

Caffeine and Alcohol: Both of these can contribute to hot flushes, mood changes, interrupted sleep and the need to urinate more frequently, so are best consumed in moderation.

Supplements: To keep your bones strong, it may be a good idea to up your calcium and vitamin D intake with supplements once you enter menopause.

For those who prefer natural alternatives to HRT, there is a huge choice of supplements that claim to relieve mild menopause symptoms, particularly hot flushes. Black cohosh, red clover, soy, flax seeds and ginseng are some of the most popular ones. However, there is no solid evidence to support the claims. In fact, black cohosh is not recommended for anyone with liver issues, and phytoestrogens, such as soy, may be risky for women who still have their uterus. Remember, herbal supplements can interact negatively with other medications or cause side effects, so consult your healthcare provider before using supplements. You can also consult with HSAs Complementary and Alternative Physician, Dr. Irka Ebanks about other available natural remedies.

Menopause can be a messy, confusing and unpredictable time. The fact that it often coincides with a phase in women's lives when they are also dealing with grouchy teenage children, ageing parents, marriage breakdowns and reaching the peak of their careers, makes it all the more stressful. And the lack of conversation surrounding the topic also adds an unnecessary extra burden. But this transition isnt one we have to grin and bear alone and in silence: we can and should be more open about it, both at home and at work. And rather than enduring it in ignorance, we should seek out medical professionals who are knowledgeable about menopause, and do our own research, so that we are armed with facts, not fiction.

Final Word

Menopause can be a messy, confusing and unpredictable time. The fact that it often coincides with a phase in women’s lives when they may also be dealing with grouchy teenage children, ageing parents, marriage breakdowns and reaching the peak of their careers, makes it all the more stressful. And the lack of conversation surrounding the topic also adds an unnecessary extra burden. But this transition isn’t one we have to grin and bear alone and in silence. We can — and should — be more open about it, both at home and at work. And rather than enduring it in ignorance, we should seek out medical professionals who are knowledgeable about menopause, and do our own research, so that we are armed with facts, not fiction.

Dr Pooja notes that she sees many women coming into her clinic suffering from menopause without realising it, and they are enduring symptoms that affect both their home and work lives. With the right care, symptoms can be controlled and women can get their lives back. “Menopause is not an end. Think of it as a new beginning, a reinvention of yourself!”

Further Reading

Megs Menopause www.megsmenopause.com

Menopause Matters www.menopausematters.co.uk

My Menopause Doctor www.menopausedoctor.co.uk

Women's Health Clinics

There are several high qualified and experienced women's health experts on- Island which we have listed below. You can also speak to your family doctor for help and advice.