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"What is the menopause?  The menopause, also called the change of life, is defined as the end of the last menstrual period.  In Western women, it occurs on average at 51 years, but there&amp;#039;s a wide range extending from your 30s to 60s.  Going through the menopause before the age of 40 is known as &amp;#039;premature menopause&amp;#039; and between 41 and 45 as &amp;#039;early menopause&amp;#039;.  What is the menopause like?  The menopause occurs when the ovaries no longer respond to the controlling hormones released by the pituitary gland of the brain.  As a result, the ovaries fail to release an egg each month and to produce the female sex hormones oestrogen and progesterone.  It is the fall in the levels of these hormones in the bloodstream that gives rise to the symptoms of menopause.  Research into the menopause is relatively recent. One hundred years ago, when life expectancy was shorter, most women did not live long after the menopause and so little was known about it. How does the menopause start?  Many women experience symptoms of the menopause and irregular periods for several years up to the menopause itself.  This is called the climacteric, or &amp;#039;perimenopause&amp;#039;, and represents the gradual decline in the normal function of the ovaries.  One of the common problems of the climacteric is that periods become erratic both in spacing and amount. Until the periods peter out altogether, heavy bleeding can cause plenty of problems. Treatments for heavy bleeding are listed below.  NSAIDs   Non-steroidal anti-inflammatory drugs (NSAIDs) are medicines, such as ibuprofen (eg Nurofen), that are used as painkillers and to lower a raised temperature.  They reduce the amount of blood lost in a period and help reduce pain.  Mefenamic acid (eg Ponstan) is an NSAID prescribed almost exclusively for heavy painful periods within the UK.  Tranexamic acid  Tranexamic acid (Cyklokapron) is a drug that encourages blood to clot on a bleeding surface, which can reduce heavy menstrual bleeding. It is only used for the heaviest three or four days of each period.  It&amp;#039;s not suitable for women with a previous history of clots in the veins (thrombosis). Nausea, vomiting and diarrhoea are the likeliest side-effects from this drug. Progestogen tablets  Oral progestogen tablets will cut menstrual flow when given for long enough (21 days each cycle), as will the progestogen released from the Mirena intra-uterine system (coil). Mirena is currently the most effective non-surgical way of dealing with excessive vaginal bleeding.  There are other drug options that can be used by specialists, if necessary, but these can be accompanied by significant side-effects.  Hysterectomy Heavy menstrual bleeding is the most common reason for having a hysterectomy.  Around 30 000 hysterectomies are carried out in the UK each year, although this figure is falling due to an increasing number of women undergoing endometrial ablation instead.  Complete removal of the uterus is a relatively major operation. This means it is accompanied by risks such as the standard risk of using an anaesthetic, surgical bleeding, wound infection and vein clots after the procedure itself, etc.  However, these are risks that apply to any operation.  In practice, hysterectomy is a successful and well-tolerated procedure and increasingly carried out vaginally rather than through an open wound in the abdomen, resulting in a quicker recovery time. Endometrial ablation Surgical procedures other than hysterectomy to treat heavy bleeding are now possible using fibre-optic instruments that can destroy the lining of the uterus (endometrial ablation).  This works because it is only the inner lining of the uterus that is hormone-sensitive and responsible for menstruation. The procedure does not completely remove every piece of the uterine lining, and 30 to 90 per cent of women still get some menstrual bleeding afterwards, but usually it is light.  If you later take HRT after an endometrial ablation, you will still need to use a combined HRT preparation and not just oestrogen alone.  What is the menopause like?  Every woman experiences the menopause differently.  Many hardly notice &amp;#039;the change&amp;#039;, apart frin their periods becoming irregular.  Others suffer many symptoms and find their lives are severely affected.  The transition into the menopause is usually gradual and is accompanied by a range of symptoms.  Hot flushes and sweating The most common symptoms by far are &amp;#039;hot flushes&amp;#039; and sweating attacks. These episodes can happen at any time, as often as several times an hour.  Each hot flush usually lasts for three to six minutes. Exactly why flushes and sweats occur is not fully understood, but we do know that the mechanics behind it involve the automatic controls of the nervous system becoming erratic and the tissues becoming more sensitive to oestrogen levels in the blood. This triggers the skin blood vessels to open and signals the sweat glands to become active at any time. Usually, this would only happen if you were too hot and needed to lose heat.  Sleep disturbance Sleeping difficulties can occur in menopausal women due to problems falling asleep, restlessness or night-time sweats.  You may find that you sweat heavily and have to get up to change the sheets several times a night.  Psychological changes  Depression, mood swings, tiredness and headaches are all possible symptoms.  Forgetfulness or irritability may occur and can be distressing for both you and the rest of the family.  Physical changes   During the menopause your skin becomes thinner. A lack of oestrogen often means the glands in the vagina don&amp;#039;t produce as much lubrication as before and this may cause stinging around the vagina during sex.  Some women don&amp;#039;t feel like having sex, whereas others find their orgasms become less intense.  The lack of oestrogen also affects the bladder and you may find you need to pass water more often.  There is a gradual rise in the risk of heart disease and stroke after the menopause.  Falling oestrogen levels lead to unfavourable changes in cholesterol and fat levels in the blood, resulting in a predisposition to these problems.  Osteoporosis  In recent years there has been a lot of interest in osteoporosis (thinning of the bones) in connection with the menopause.  Oestrogen normally stimulates the activity of bone-building cells in the body. As a result of the drop in oestrogen, women tend to lose bone mass and strength for several years following the menopause. Ultimately, this can make the bones more likely to collapse or fracture.  What can make the menopause easier? Medical treatment is available for women who are troubled by symptoms of the menopause, but most women will manage their menopause without needing to consult a doctor or nurse. Hormone replacement therapy Hormone replacement therapy (HRT) alleviates the symptoms of the menopause by adjusting hormone levels.  It involves receiving a small daily dose of oestrogen. Women who have not had a hysterectomy are also given a progesterone-like drug as part of the HRT. This is called combined HRT. Combined HRT can be described as either sequential or continuous.  Sequential combined HRT is suitable for women who are perimenopausal, ie still experiencing erratic menstrual bleeding.  Most preparations are designed to mimic the menstrual cycle and result in monthly periods. They are based around a 28-day cycle in which oestrogen is taken every day and a progesterone is added for the last 12 to 14 days of the cycle. For women who are borderline postmenopausal and have very infrequent bleeds, there&amp;#039;s also a sequential preparation available that results in three-monthly bleeds, although this is used less often in the UK. Once a woman has not had a natural period for a year and is described as postmenopausal, continuous combined HRT is more suitable. This form of HRT does not produce periods and involves taking a daily dose of oestrogen and progesterone.  Occasionally, women aged less than 54 years old do experience some irregular vaginal bleeding with these medications. How is HRT taken?  There are many ways of taking HRT, with the most usual being a daily tablet.  Alternatives include skin patches, a gel applied daily to the skin, a ring inserted into the vagina or a nasal spray. What are the side-effects of HRT? The majority of women have no side-effects, but the following are fairly common:   nausea breast tenderness  weight gain fluid retention.  These symptoms often settle after the first few months of treatment. If they don&amp;#039;t, it&amp;#039;s worth consulting your doctor or gynaecologist to adjust the medication.  How effective is HRT?  HRT is effective in relieving hot flushes (&amp;#039;vasomotor symptoms&amp;#039;) and vaginal dryness. Many women also report an improvement in their general sense of wellbeing.  However, HRT will not help the mood swings and resultant depression that occurs around the time of the menopause.  HRT is often taken for a short spell of six months to a year to relieve hot flushes, but it can be taken for much longer in the case of an early or premature menopause.  The long-term benefits of HRT have recently been brought into question. However, the current thinking is that HRT has more benefits than risks if used carefully and not for prolonged periods of time.  HRT can help reduce the risk of blood clots in the leg (&amp;#039;DVT&amp;#039;) and stroke if taken shortly after the menopause, but the risks recur if being used after the age of 60.  The possibility that HRT users are less likely to develop Alzheimer&amp;#039;s disease is still to be confirmed. Studies suggest that HRT may offer some protection against developing bowel cancer.  It has been confirmed that HRT increases the risk of developing breast cancer and endometrial cancer (cancer of the lining of the womb).  It can also increase the risk of stroke (in women over 60) and ovarian cancer.  Breast cancer and HRT  HRT has been known for years to increase the risk of breast cancer. The risk increases with the length of time HRT is used and becomes detectable after about one to two years of treatment.  The risk falls once HRT is stopped, and takes about five years to drop back to the population average.  The best evidence available at present tells us that breast cancers that occur in women taking HRT are smaller, less advanced and of a more treatable type than breast cancers occurring in women not taking HRT.  This accounts for the fact that despite the increased numbers of cancers arising due to HRT, the actual mortality of women from breast cancer is the same in the HRT and non-HRT populations.  However, experts now feel the balance of risk has swung against HRT given for longer than five years. Certainly, in women over the age of 60, the risks of HRT start to outweigh the benefits and are significant by the age of 70. It&amp;#039;s recommended that HRT is only used as a short-term treatment to relieve menopausal symptoms and that treatment is reviewed at least annually.  Any woman considering HRT should discuss the risks and benefits for her individual circumstances with her doctor before making a decision about treatment. Other breast problems related to HRT  Women in the pre-menopause who take HRT often get breast pain and benign breast lumps, including cysts (fluid-filled lumps).  HRT may cause benign breast lumps that are already present to get bigger.  In the UK, as well as relying on women to check their breasts and report changes to their GP, there is also a national screening service that offers periodic mammograms to women over 47.  HRT is known to increase the density of breast tissue, which makes it harder for the X-rays used in mammography to penetrate the breast.  It is therefore of concern that HRT can make it more difficult to detect breast cancer by mammography.  However, HRT is not the only type of medicine that can be used to relieve menopausal symptoms. Other treatments for the menopause  Tibolone  Tibolone (Livial) is a synthetic steroid hormone that has some oestrogen plus some progesterone effects (and has some testosterone-like effects, too).  In a way it&amp;#039;s a type of combined continuous HRT in a single tablet, which is largely how it&amp;#039;s used. It helps hot flushes and night sweats, vaginal dryness and irritation and also protects against osteoporosis. The benefits of tibolone include much less breast tenderness and little effect on breast tissue density in mammograms.  However, the Million Women study showed that tibolone is associated with a slightly increased risk of breast cancer, of around the same level as that associated with oestrogen-only HRT. Clonidine  Clonidine is a drug originally developed for use as a blood pressure lowering treatment, but at smaller doses (Dixarit) it can relieve hot flushes.  However, it is not effective in most women. Oestrogen creams and pessaries  Vaginal dryness can be relieved by short courses of oestrogen creams or pessaries that are inserted into the vagina.  There is also a special vaginal ring containing oestrogen that can be left in the vagina for three months, where it slowly releases oestrogen into the vaginal tissues. Complementary medicine A range of &amp;#039;complementary&amp;#039; medical treatments are also widely in use to relieve menopausal symptoms.  Although the scientific evidence in favour of complementary medicines is not as good as for conventional treatments, they are generally safe to try.  Black cohosh is the best known of the complementary treatments.  It has its origins among North American Indians, where it has been used as a traditional herbal remedy for a range of gynaecological problems for hundreds of years.  Liver damage may occur in some people taking black cohosh \u2013 although liver injury is rare, it could be serious.  The Medicines and Healthcare products Regulatory Agency (MHRA) have said that all products containing black cohosh should carry a warning.  Are there steps I can take to make the menopause easier?  There has been a tendency to think of the menopause as an illness or a health hazard, which is the wrong way to look at it. It&amp;#039;s a phase of life and we have to live with it.  There is a lot of help and support that can be gained from the medical profession and self-help groups for those women who find it difficult to manage their symptoms alone.  Lifestyle advice is as much part of the discussion about managing the menopause as discussing HRT \u2013 know regular exercise can help to reduce vasomotor symptoms as well as to lose weight.  Being overweight increases the amount of adipose or fatty tissue in the body, which tends to increase the number of hot flushes or night sweats, as well as increasing the risk of breast and ovarian cancer post-menopause.   Regular exercise, such as walking for 20 to 30 minutes three or four times a week, can improve your health and add years to your life. Exercise strengthens your bones, increases wellbeing and can help make sleeping easier.  Eating the right food is also important. For healthy bones, the body needs about 1500mg of calcium each day from dairy products, such as milk and cheese.   Eating plenty of fruit and vegetables provides the necessary minerals and vitamins for good general health and also helps to protect against cancer and heart disease.  There&amp;#039;s some evidence that soy flour (or other foods rich in so-called &amp;#039;plant oestrogen&amp;#039;) can reduce menopausal flushes. Smoking is never good for your health. Stopping smoking is the biggest single move anyone can make to improve their health, whatever their age.  Other people also read: Menstrual cycle: why do women menstruate? Bowel cancer: who does bowel cancer affect? Vitamins and minerals: what do they do? Allergy: does hypersensitivity occur frequently?   References Writing group for the WHI study. Risks and benefits of estrogen plus progestin in healthy postmenopausal women. Principal results from the women&amp;#039;s health initiative randomised controlled trial. Journal of the American Medical Association 2002;288:321-333 http://jama.ama-assn.org/cgi/content/abstract/288/3/321. Dixon JM. Hormone replacement therapy and the breast. British Medical Journal 2001; 323: 1381-1382 http://bmj.com/cgi/content/full/323/7326/1381.  Beral V, et al. Breast cancer and hormone replacement therapy in the Million Women Study. Lancet 2003; 362: 419-427. HRT: Update on the risk of breast cancer and long term safety; MHRA Current problems in pharmacovigilance, Volume 29 Sept 2003. Tanna N. Hormone replacement therapy: risks and benefits. Pharmaceutical Journal 2003; 271: 646-648 Hickey M, Elliot J, Denison SL. Hormone replacement therapy. British Medical Journal 2012; Feb 16 344 Panay N, Hamoda H, Arya R et al. The 2013 British Menopause Society and Women&amp;#039;s Health Concern recommendations on hormone replacement therapy. Menopause Int, 2013; June 19(2); 59-68. .   Based on a text by Niels Lund, specialist gynaecology and obstetrics, Charlotte Floridon, MD, PhD, gynaecology and obstetrics, Christel Bech, nurse  Last updated 25.02.2015 "^^<http://www.w3.org/2001/XMLSchema#string>
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