The two great transitions in a woman’s life – puberty and menopause – are fraught times when our bodies do strange and unpredictable things and our moods can take us completely by surprise. But unlike puberty, menopause is often regarded as somehow unsavoury – an issue best kept under wraps. The taboo surrounding menopause means many of us are woefully ill-informed about an unavoidable phase in our lives.
Not only do women not talk about the more difficult aspects of the menopause amongst themselves, but it’s 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 25% 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.
That wall of silence is starting to crack though. Celebrities and TV personalities are opening up about their experiences of the menopause, how it is affecting their lives, and their challenges in getting treatment. And that is sparking a wider conversation and reassuring women all over the world that there is no shame in talking about this common 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, periods will stop suddenly, but 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 the perimenopause and is often accompanied by menopausal symptoms. Perimenopause usually begins in your 40s, although occasionally it can start in your 30s, and lasts several years. The distinction is not particularly important though, says Dr. Richter, OB/GYN and certified menopause practitioner at NovoClinic, as any treatment seeks to manage the symptoms, rather than the stage a woman is in.
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 – are the hot flushes. These tend to affect the upper part of the body and usually occur later in the day, but can also occur during sleep (night sweats) which then cause fatigue and can 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.
Set up a support group with friends so that you can share symptoms and grumbles about the menopause. There is also a Facebook group called 'Cayman Hot Flush Menopause Support' which is a kind and friendly support group for women wanting to know or share information about menopause. Being able share your frustrations with others who are going through the same experience is great for your mental health.
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 – and bear in mind that only 20% of US gynaecologists have training in menopause, and even fewer GPs – seek out a medical professional who specialises in this aspect of women’s health.
GPs may hear 'insomnia, low mood, weight gain, anxiety and irritability' and assume they are dealing with depression, rather than menopause. Equally, Dr. Richter points out that, perspiration, hot flushes, low mood and depression can also be a sign of thyroid issues, so it’s 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 UK menopause expert Dr. Louise Newson 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 Alzheimer’s.
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 it’s 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 menopause experts like Dr. Louise Newson advocate taking HRT even if you have no symptoms and in some cases staying on it long-term, to reduce your future risk of osteoporosis, heart disease and Alzheimer’s.
Risks of HRT
Available since the 1960s, HRT was widely prescribed until the early 2000s. Then, in 2002, a large-scale study by the Women’s 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 people’s 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. Richter says, "is that there might be a slightly increased risk, but it’s definitely not as much of a concern as it’s made out to be. It’s been blown out of proportion by the media."
For the majority of women, HRT is safe and effective. 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.
Women on combined HRT have a slightly higher (0.4%) chance of developing breast cancer – but this should be viewed in context: drinking two units of alcohol per day increases your risk by 0.5% and obesity by 2.4%.
Starting HRT before age 60/within 10 years of the onset of menopause is preferable. Starting at age 70+ carries more risk.
The increased risk of breast cancer is related to how long you take HRT and falls when you stop.
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
Body-identical hormones have the same molecular structure as the hormones in your body and are derived from yams or soy. This is the type of HRT usually available on the NHS, for example. Estradiol and micronised progesterone are body-identical hormones commonly prescribed by doctors, including Dr. Richter, and are available in standard off-the-shelf formulations. Bioidentical hormones – marketed as more natural and tailored to the individual – are essentially the same plant-derived hormones but are compounded in pharmacies into 'bespoke' doses, according to doctor’s orders. These are only available through private clinics, often at great expense, but as they are not produced in labs and are not regulated, their quality, safety and purity are not guaranteed. There is no evidence to show bioidentical hormones are more effective and in some cases the side effects are worse.
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: It’s 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 women’s 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.
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. The fact that we so often don’t talk about it 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.
TOP TIP: Managing Hot Flushes in the Cayman Heat
Keep hydrated, wear loose layers, and keep a towel in the freezer. When you feel a hot flush coming on turn the air con down, put your cold towel on your face, position yourself in front of a standing fan – or get a hand-held fan – and if all else fails, put your head in the fridge!
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.