Menopause literally means the end of menstruation. This occurs when the supply of eggs that the women is born with runs out. At the same time, there is a decreased level of hormones that had been released as the eggs matured. This process begins several years before the final menstrual period.

As sex hormones decrease, fertility declines. Periods become less predictable and the short term effects such as hot flashes can be a nuisance. The possible long term problems involve bones, the heart and other organs of the body.

What problems with periods occur before menopause?

Few women just stop having periods. More that 80 percent begin to have irregular periods as the ovaries produce fewer sex hormones. Some women fear these are a sign of some disease, particularly cancer. A family doctor or gynaecologist can usually put these fears to rest and no treatment is needed.

For a few women, bleeding may be heavy enough to cause anemia and undermine their health. The bleeding can also be embarrassing if, for example, they bleed through their clothing. The problem generally goes away as menopause approaches but it can make life difficult. In the past, hysterectomy was the solution but now new methods can be used. One way is to destroy the lining of the uterus by balloon therapy. That and other simple day surgery procedures can end the problem or reduce the bleeding to tolerable levels. Hormone medications are effective treatment for abnormal bleeding but some women do not want to take the medication for a long time. A quick surgical “fix” is often seen as the answer.

What hormone replacement and other drugs are used in menopause?

The most effective way to control the problems of menopause is through estrogen. Most studies show that hormone replacement therapy (estrogen together with progesterone for those women who have a uterus) gives women a better quality of life. The chances of heart disease and osteoporosis at an early age are reduced. Hormone replacement also appears to decrease the risk of colon cancer.

For some women, use of hormone replacement is not advised because of a family history of breast cancer. For others, fears and uncertainties about the hormones make them hesitant to use them. Many women prefer to put up with the hot flashes rather than risk the perceived dangers of treatment. In Western Canada, only about 15 per cent of women take estrogen and the average length of treatment is about two years. This is too short to gain any long term benefit.

The reasons behind this reluctance are complex. For some women, breast cancer is a major concern. For others, taking hormone replacement is seen as not natural. There may be some unpleasant side effects and often the return of periods.

Women do not find it easy to make a decision about long term hormone replacement and the decision need not be hurried. For many women the process is not a weighing of risks and benefits, it is a balance of hopes and fears. The woman's decision should be made consciously and not by default. Not knowing or understanding the benefits and risks of medications remain major problems.

To provide reassurance, a doctor can monitor health and other worries that the woman may have. Medications can be adapted to her needs (not the other way around). The range of pills, patches, gels and creams means there should be something for everyone. Some non-estrogen drugs (Dixarit™, Provera™, Megace™ and Aldomet™) can reduce the frequency of hot flashes but often cause side effects.

Doctors know about prescription medications but not necessarily about health food store remedies. These remedies vary in quality. They may have unknown ingredients and often little information is known about their effects or their dangers. This lack of data often makes their use difficult to support. When doctors do not recommend such a treatment it is usually because they do not see enough evidence that it works. When shown to be effective, some herbal remedies may be recommended.

What are hot flashes and related changes?

More than 85 per cent of women have hot flashes and night sweats around menopause. These can begin before the final period and often continue for up to two years after menopause. One quarter of women have hot flashes for five years or more.

When the hot flashes occur at night, sleep is disturbed. Even without hot flashes, changing hormone levels interfere with a woman's sleep. The restlessness of a sweaty, sleepless partner can interfere with the man's ability to sleep. This in turn can make both partners irritable and insensitive. By knowing this, they can both try to be more understanding when tensions arise.

Hot flashes are a natural event over which a woman has little control. However, there are a few things she can do to ease them. They are made worse by hot environments, alcohol, spicy food, hot drinks and anxiety. A woman who knows this can try to avoid these situations.

Plant extracts that contain substances called isoflavones, soy for example, can reduce hot flashes. The difficulty is that their use requires a major change in eating patterns and less is known about potential side effects.
Plant estrogens are usually called "phytoestrogens" and their use is increasing. A common misconception is that if the substance is natural it is safe. Most of the knowledge about soy, ginseng and other substances that contain estrogen is not scientific. Increased research will help determine their safety and effectiveness, and set quality controls. If you want to take them it would be prudent to discuss their use with your family doctor or pharmacist.

What sexual difficulties may develop?

There is no reason why sex should not continue many years beyond menopause. This includes both vaginal intercourse and other sexual activity. A common cause of change in intercourse in a relationship is the male partner's loss of interest or his ability to obtain and maintain an erection. The recent success of Viagra™, used to improve erections, provides clear evidence about the high frequency of male sexual dysfunction.

This does not mean women don't have difficulties. When the ovaries stop producing hormones, the lining of the vagina becomes dry. It is more likely to be injured during intercourse, causing pain. Lubrication in response to sexual stimulation is slower and less certain than in younger women. Just when men have an erection that may not last long, their wives need more time to respond. Vaginal dryness is a common problem that can usually be solved by a partner's patience and use of lubricants such as Replens™. Hormone replacement, including locally in the vagina, can help.

Even when sex has been a healthy part of the relationship, a woman's sexual enjoyment depends on many factors. If physical pleasure has decreased or intercourse is painful, it is not surprising that her enthusiasm for sex and ability to have an orgasm begin to fade. Hormones have less effect on sex drive in women than in men but if the small amount of male hormone in her body falls too low, she may lose interest in sex. Treatment with testosterone can improve a woman's desire and her sense of general well being also.

What about mood changes?

An unkind portrait of women at menopause shows them with mood swings out of control. They go from angry to happy to sad without obvious reason. Lack of estrogen, hot flashes and difficulty sleeping all have some effect on mood but there are other factors.

The loss of reproductive function is a major life change. For some women, this is a symbol of the end of a useful life as wife and mother. For some it seems to herald the inevitable decline into old age. Other factors that can influence mood include children leaving home, aging parents making demands, or a spouse's attitude. Often middle-age men can be grumpy because they are losing their own dreams for success or have physical failings. The physical and emotional stresses of this time may well be reflected in a change in mood.

Hormones help to some degree but practical and emotional support help much more. If the problem is a long standing psychiatric one, hormones probably will not help much and other treatment is indicated. In these cases, the male partner can be a great source of support as a woman seeks appropriate care.

Can bladder control be a problem?

Bladder control in women is less reliable than in men. In women, bladder control often depends on the balance of pressures inside and outside the belly cavity. Muscles and supports that control the bladder may have been stretched and damaged during pregnancy giving problems even before menopause. Decreased sex hormone levels make matters worse. The supports can stretch further thus causing major problems with bladder control.
The nature of the bladder problem must be determined before treatment is attempted. It is clear from surveys that many, perhaps most, women with these problems do not discuss them with their doctors.

What are the long-term consequences of menopause?

Low levels of sex hormones after menopause are linked with an increased risk of heart disease, osteoporosis and perhaps Alzheimer's Disease. For women who do not use estrogen replacement, other drugs are now available to decrease some of the risks.

Didrocal™ and Fosamax™ act on bones to prevent osteoporosis and reverse bone loss. Evista™ is a new drug that prevents osteoporosis. It does not help with hot flashes or vaginal health. Perhaps the most interesting feature of Evista™ is its ability to reduce the risk of breast and uterine cancer.

What is the risk of breast cancer?

The most frequently voiced concern that women have as they grow older is breast cancer. About one woman in nine will develop breast cancer and one woman in 25 will die from the disease. Heart disease causes 10 times more deaths than breast cancer but women don't fear it as they fear breast cancer.

Many women believe surgical disfigurement, medical and radiation treatments and a painful death are inevitable consequences of this cancer. A quick heart attack death seems merciful by comparison. Neither picture is totally accurate but it does make it easier to understand some of the concerns of women about menopause.

Although breast cancer increases in frequency as women age it is not caused by menopause. Long term estrogen replacement therapy may have a small effect on the frequency of diagnosis of breast cancer. The decision to take or not take hormone replacement therapy is very much an individual one and one which most women do not take lightly.

A man can encourage his partner to express her fears and confusion but finally the decision to take or not take estrogen for its longterm benefits is the woman's alone. A woman will need respect and support for her decision; it is not an easy one.

How can men help?

Where do male partners fit in this great debate? They may have their own fears of health problems, of growing older and less effective, and of difficulties with sexual performance. Sometimes they may be too preoccupied to be supportive. Also they may feel they lack the knowledge to be helpful. Knowledge and communication are the keys. An understanding of the mutual needs of each partner at this time should return matters closer to normal.

A man who learns as much as he can about the changes of menopause will be more effective in understanding, supporting and empathizing with his partner's experience. If he knows about medication choices he can act as a sounding board for a woman making a decision about their use. An understanding man can help his partner overcome the embarrassment of loss of bladder control and seek help.

Open discussions are not easy about subjects where men have traditionally not been invited to be involved. Social conventions have meant that men and women often find the topic of menstrual periods embarrassing to discuss even within a stable relationship. Men should not dismiss the situation as "women's troubles." They should seek to become involved and encourage their partners to become active participants as they review the evidence as partners in problem solving. They can support by listening to their partners and helping them think through the best decision. However, most women need to be free to make their own decisions about easing symptoms and choosing medications.

A woman has control over what happens to her body. The decision is her own and a man should respect this. He should support her decision, even if it changes over time. A man will hopefully share much of the final third of a woman's life - that portion beyond menopause. If both partners can discuss and have a positive approach to health, this time together can be more fulfilling.

FAMILY HEALTH is written with the assistance of

While effort is made to reflect accepted medical knowledge and practice, articles in Family Health Online should not be relied upon for the treatment or management of any specified medical problem or concern and Family Health accepts no liability for reliance on the articles. For proper diagnosis and care, you should always consult your family physician promptly. © Copyright 2019, Family Health Magazine, a special publication of the Edmonton Journal, a division of Postmedia Network Inc., 10006 - 101 Street, Edmonton, AB T5J 0S1 [WH_FH]

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