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What is menopause?

The menopause is the point in a woman’s life when her periods stop. The mean age of menopause in Indian women is 49.5 years with a normal range from 45 to 56. Conventionally a woman has to stop menstruating for 12 months before she is considered to be menopause. The time preceding and following the last menstrual period is called the “climacteric”.


What happens to my body during the climacteric?

At puberty, two types of sex hormones are produced by the body; oestrogen and progesterone. Oestrogen is important as it gives a woman all the secondary sexual characteristics such as stimulation of breast development and creating a fertile environment in the womb. This hormone will also provide the correct environment for the fertilized egg, while progesterone sustains and supports the pregnancy.

During a normal menstrual cycle, the two hormones rise and fall and if a pregnancy does not occur at the end of the cycle, a period results. However, when a woman reaches the climacteric, the production of these hormones is reduced and stops. When the ovaries stop producing these hormones, the periods stop.


What will I experience during the climacteric?

The periods become irregular. Women may have a number of symptoms including night sweats, hot flushes, anxiety and fatigue. Many women will complain of the inability to concentrate and problems with memory. They may also complain of aches and pains in the body. At a later stage, vaginal dryness or vaginal atrophy may cause itching and pain during sexual intercourse.


What are the common symptoms of the menopause?


Physical Emotional
Hot flushes Mood swings
Night sweats Irritation
Sleepless nights Anxiety
Lack of concentration Depression
Vaginal dryness & painful sex Loss of sexual desire


How frequent are the menopausal symptoms? Will this happen to me?

About 25% of women do not have any problems or at most, have minor symptoms. One third of women, however experience severe symptoms which will disrupt the quality of life. You should seek medical help should the symptoms interfere with your daily life or if you like to know more. Symptoms are found more commonly in women who had premenstrual syndrome or painful periods. The symptoms are found less frequently in Asian and Negro women.


How long would these symptoms last?

This is very variable. In some individuals, the symptoms may subside after several months. For some they may even last for several years. On average the symptoms lasts about 3 to 5 years.


What are the long term consequences of menopause?

Low oestrogen levels lead to thinning of the bones and eventually osteoporosis. This result in an increased risk of fractures of the hip, wrist and compression fractures of the vertebrae resulting in a Dowagers hump (humped back). In reproductive life, women are protected from coronary heart disease. Ten years after menopause, the rate of coronary thrombosis is as high in women as men. Recent research, however, does not support the cardio-protective effects of HRT.


What is HRT? And what is the purpose of HRT?

HRT or hormone replacement therapy is made from the hormones similar to those produced in the body before the menopause. They include oestrogen only or oestrogen combined with progestogen.

HRT restores the levels of sex hormones in the body to its premenopausal level. It has 2 consequences:

  1. Alleviates symptoms of the menopausal especially hot flushes and night sweats
  2. Prevention of osteoporosis on the long-term


Is HRT for all women?

HRT will definitely alleviate all the menopausal symptoms and will prevent osteoporosis. However, you should discuss this with your gynaecologist before starting on HRT. A complete physical and gynaecological examination is necessary before starting on HRT. It is also advisable to have a pap smear and a mammogram done before. A bone density scan is recommended as a baseline study.


Is there a risk of cancer?

Cancer of the endometrium (lining of the womb) may follow unopposed oestrogen (i.e. if you take oestrogens alone). The risk depends on the duration of use and increases 3-6 times after 5 years of use, 10 times after 10 years. Adding cyclical progestogens will eliminate this risk.

The relative risk of breast cancers is about 1.3 times up to ten years of HRT.

  • Background risk- 45 per 1000 women
  • 5 years of HRT use- 47 per 1000 women (i.e. 2 per 1000 increased risk)
  • 10 years of HRT use- 52 per 1000 women (i.e. 7 per 1000 increased risk)
  • This small increase in breast cancer risk is associated with a more favourable prognosis than in those who have breast cancer without HRT. There is no evidence of any increase in cancer of the cervix or ovary.


Will I have period if I do go on HRT?

A combined oestrogen/progetogen therapy is usually recommended. The tablets are taken in a cyclical fashion and therefore there is a period at the end of each month. However, the period is usually light.


If I do not want a period, is there an alternative?

A continuous combined oestrogen-progestogen therapy is available to those women who do not wish to have a period. Tibolone (Livial), is another form of HRT, which can also be taken. It is prescribed for hot flushes, psychological and libido problems and is not accompanied by regular withdrawal bleeding. However, it can only be taken after 1 year of stopping periods.


Do I need to be checked by a doctor?

Yes, this is essential, prior to starting HRT. A detailed history will be taken and a physical examination done. This will include particularly blood pressure, weight, breast and bimanual pelvic examination. A pelvic ultrasound will be performed. A cervical smear is taken and blood test is done to check the lipid profile and blood sugar to exclude diabetes. A mammogram and bone density scan will be advised.


What about follow-up visits?

You should have a yearly check-up to include the following:

  • Weight and blood pressure measurement
  • Breast examination and mammogram
  • Pelvic examination and ultrasound scan
  • Cervical smear
  • Lipid profile and blood sugar


What if I had a hysterectomy?

Women who had their womb removed will also experience the menopause, although it occurs a few years earlier. However, women who have their ovaries removed at the same time will experience menopausal symptoms shortly after surgery. Women who have had a hysterectomy do not have to worry about menstrual periods. They do not need to worry about cancer of the lining of the womb. Therefore, oestrogen only therapy is recommended. One tablet is taken everyday.