The Three Stages of that ”Stage of Life”

The word Menopause is actually defined as “the final menstrual period”. In Australia, the average age of natural menopause is 50 years. The Peri-menopause is the time leading up to this. In real life, of course, you cannot know at the time as to which period is going to be your last one! So, menopause cannot definitely be said to have occurred until a woman has gone 12 consecutive months without a period. After the 12 months you are said to be in Post-menopause.

Peri-menopause

As the ovaries age, hormone levels (mainly oestrogen and progesterone) are fluctuating. One month they may be too low, the next too high! Sometimes they will just gradually decrease. Most of us have heard of the “classic” peri-menopause symptoms which include hot flushes, night sweats, muscle/joint aches, mood swings, irritability, insomnia and vaginal dryness. It is hard for anyone to predict who will get significant symptoms and how long they will last for. Only about 20% of women will get few or no symptoms at this stage.

25% of women will get severe hot flushes that considerably impact their daily life About 50% of women will get sleep disturbance About 30% will get significant psychological symptoms

If symptoms are concerning you, it is recommended you see your GP for a full check -up and to discuss management options. Lifestyle, dietary and stress management should be addressed. Becoming an informed patient will empower you to be able to make a decision that considers your individual quality of life benefits and the potential health risks.

Menopause Hormone Therapy (MHT)

MHT works very effectively to control perimenopause symptoms, especially hot flushes. In most women, benefits outweigh risks. MHT also significantly lowers the risk of osteoporosis-related fractures. MHT is usually only needed for less than 5 years as in most cases the hot flushes have subsided by then. Unfortunately there are some women for whom MHT is contraindicated/ dangerous and should not be taken – for example, women with clotting disorders or high thrombosis risk, and women with pre-existing hormone-sensitive cancers (eg breast or uterus)

Recent studies have cleared up some misconceptions about MHT: MHT does NOT cause weight gain There is NO significant increase in breast cancer risk if combined MHT is used for less than 7 years MHT does NOT increase the risk of heart attack in previously healthy women. Oestrogen –only MHT (used in women who have had hysterectomy) does NOT increase risk of breast cancer (even after 20 years)

Body-identical vs Bio-identical

A number of women express an interest in using “natural hormones”, often handmade, compounded products in the form of troches, creams and pessaries. These are typically called “Bio-identical HRT”. However, the lack of quality control and testing has led the International Menopause Society to instruct their members not to recommend these.

On the other hand, “Body-identical” hormones are compounds that have exactly the same structure as hormones that are produced in the human body. They are of pharmaceutical grade quality and safety has been tested in controlled trials.

Up until 2016, no Body-identical progesterone was available in Australia, and all prescribed combined MHT (oestrogen plus progestogen) contained a synthetic progestin. Body-identical (micronized) progesterone is superior to synthetic progestins in terms of safety profile and side-effects (a number of women are sensitive to synthetic progestins). It has been available in this country since 2016 however it is more expensive. Talk to your doctor about your options.

Post-menopause

Over 50% of women will get genitourinary (vaginal, vulval, urine) symptoms. These may not present until later (after the hot flushes have finished), or may present in women who had very mild or even no hot flushes at all.

Low hormone levels can lead to vaginal and vulval dryness and itching, irritation and soreness. Vaginal lubrication takes longer. Sex can become painful. There may be some pelvic organ prolapse, urinary incontinence or recurrent urinary infections.

Studies have shown that only a quarter of women with these symptoms will mention them to their health care provider. This is unfortunate, as there are a number of effective treatments available which relieve discomfort and enable women to continue an active sex life.

Tips for general vulval care

Avoid: 

• soaps (especially perfumed liquid soaps) – use Aqueous cream or QV wash instead
• bubble baths (use dispersible bath oil or salt) 
• wet wipes, perfumed oils, antiseptics and feminine sprays – use hypoallergenic toilet paper
• plastic-backed pads – use breathable panty liners
• nylon underwear, tight pants – use “Icon” “Thinx” or “Modibodi” underwear Use Sudocrem/Zinc and castor oil cream for skin protection if you have urine leakage Some women use a vaginal moisturizer (eg Replens® ) which provides a long-lasting moist film

For sexually active women a lubricant is essential . If there is not enough lubrication, sex will hurt, and that’s not a good thing for any relationship! A number of proprietary lubricants are available, eg KY Jelly. Natural oils such as olive oil, sweet almond oil or coconut oil can be used (do not use natural oils with latex condoms) avoid gels as they may contain antiseptic, which can irritate water-based lubricants can be used with condoms for STI protection Silicone lubricants are absorbed more slowly and remain “slippery” for longer

Oestrogen-only vaginal therapy

Local treatment with hormone (oestrogen) vaginal tablets, pessaries or cream is a highly effective treatment, especially for sexually active women, women with mild prolapse, and those who suffer from recurrent urine infections. These are easily inserted once or twice a week. They are very well tolerated and there are very few risks as only a miniscule amount of oestrogen gets in to the blood stream (vaginal oestrogens are contraindicated if taking Aromatase inhibitors for breast cancer treatment)

Newer treatments include laser treatment to the vaginal walls, which stimulates regeneration of new tissue (very expensive though!) It may also be useful to see a pelvic floor physiotherapist to find out which parts of the pelvic floor to strengthen and which parts to relax.

If you have any questions about menopause and its management, you should consult your GP. A useful website is CareDownThere www.caredownthere.com.au   This is written by a team of Australian health professionals with special expertise in treating vulval disease and is a great resource for women of any age.