by Professor Lynn Basford
What is the Menopause?
Clinically, the menopause is defined as the cessation of the monthly flow of blood (menses) from the uterus (womb) via the vagina for more than a period of twelve months.
Commonly known as the ‘period’, this flow of blood occurs each monthly (Lunar Cycle) throughout a woman’s reproductive period and is stimulated through complex hormonal influences.
The menopause quite literally means the end of her monthly periodic cycle and, as a consequence, the end of her reproductive ability.
It is a simple definition that belies its complexity given that the physiological, psychological and emotional elements are influenced through a complex interplay of hormones that ultimately bring about the cessation of ovarian function and a woman’s natural biological reproductive life span. 1,2,
At This Juncture Menopause Has Definitely Arrived
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But, The Journey Can Be Looooooong!
The menopausal journey is different for each woman depending on her culture, dietary and environmental factors, genetic disposition, and personal coping strategies.
Each factor can influence the balance and interplay of complex hormones that may affect her wellbeing.2,3,4,
A Biological Perspective
At the point of fertilisation, when the mature ripened egg is released from the ovaries and fertilised by a single sperm, the sex is determined. If the sperm carries an X chromosome it will be a girl, however, if it carries a Y chromosome it will be a boy .
Throughout foetal development the ovaries will amass a predetermined amount of ova (eggs) cocooned in follicles. This can be as many as one to two million immature eggs, a staggering amount! But don’t worry, not all of these eggs will continue to maturity, but will die through a process that is known as atresia (i.e. natural degeneration of follicles and the ova contained within).7
The atresia process begins at birth and continues throughout a woman’s reproductive years. For example, it is estimated that when a woman starts her periods (menses) roughly 400,000 follicles remain. Out of these 400,000 only about 400 will ripen and mature in readiness for fertilisation to take place. 7
As you will now understand, there is a finite number of follicles and eggs. When this supply is exhausted, menopause occurs (cessation of Menses/Blood flow). This marks a turning point and the ‘change of life’ whereby the woman is now unable to reproduce.
A Natural Biological Process. Menopause has Arrived At last!
In normal circumstances, menopause does not occur as a sudden instantaneous event unless there are other complicated medical conditions/ surgical interventions or pharmaceutical treatments. Natural menopause is a process that can take several years.
More often this process begins around the age of 45 years and is completed in the early fifties. (UK statistical evidence suggest that menopause can occur between 45-55years with a mean average of 51years). 1,2,6, It is truly a remarkable and highly complex phenomenon.
Menopausal Terminology Explained
The medical literature breaks down segments of the whole transitional period into pre- menopausal, peri-menopausal, menopausal, and post menopausal. Many women ask the question:
“ How do I know when I am going through each , or any, of these stages? And, what does it mean for me as an individual”
This is a term used for woman who may have peri-menopausal symptoms, but are considered to be too young to be entering menopause. Usually, if they are under 40 years of age and displaying some form of hormonal imbalance associated with their reproductive cycle they are medically considered to be pre-menopausal.
NB. The underlying reason should be investigated to rule out other conditions. Not everything is menopausal related!
This is a term used for the period of menopausal transition, accounting for the period of menopausal symptoms, or, if asymptomatic, the time leading up to the last period.
Usually, it is a time when the hormone levels are fluctuating causing numerous physiological and emotional effects.
At the end of the peri-menopausal phase there may be skipped menstrual cycles that can lead to the false notion that menopause has arrived. This is why the medical profession make the point that menopause has arrived after the twelve month period cessation.
NB. Such period irregularity is normal, so there is really no need to worry. Nonetheless, not every symptom a woman presents with should be overshadowed with the notion that, “it is only the menopause”. It is a time for women to be more vigilant about their health and to ensure they have regular health checks.
This is defined to have occurred when monthly periods have ceased for more than twelve months.
When a woman has had twelve months without a period, then menopause has arrived and she enters the post menopausal phase.1,2
Biological Menopausal Age
- UK average menopausal age is 51 ( range 48-55)
- Peri-menopausal period relates to symptoms such as irregular periods, hot flushes, mood swings, etc and has a mean duration of 4-10 years.
- depending on life expectancy a woman can be post menopausal for more than 30 years.
- Environmental factors and biological markers can influence the onset and duration of peri-menopause.
Signs and Symptoms of Peri-Menopause
Without a doubt it is this period that is most distressing for lots of women. The peri-menopausal changes that occur are greatly influenced by hormonal imbalances and fluctuations.
For some woman the onset is swift, seemingly overnight, (clearly not), while others seem to smoothly flow into and through the menopause without any problems. And yet there are other women whose peri-menopausal phase is like riding a juggernaut, sometimes smooth, and at other times like being tossed around and crushed in a sea of emotions.
Please note not all women will have the full range of symptoms identified below
The key noticeable transition symptom is menstrual irregularity, a consequence of diminished ovarian function. It affects a large percentage of women and is characterised by increased menstrual flow that can look dark and sticky. In addition, for some woman there is an increase of large clots and an overall reduction in cycle length. This can also be augmented with in between cycle spotting – meaning bleeding that occurs in between the normal cycle. The in between bleed times can vary as can the lightness or heaviness of the bleed.
For those women suffering from heavy prolonged periods ( i.e. heavy bleeds – known as menorrhagia), it may appear they are always on a period throughout their monthly cycle. In its extreme, it is draining physically and emotionally. But, more importantly, over time the woman may suffer from iron deficiency anaemia that may compromise her health further including extreme feelings of tiredness, sleep deprivation, irritability, depression.
For some women premenstrual tension and associated cramps can increase in severity and duration. for others, the problem is lessened.1,2,3
Some women notice irregularities with their bowels., i.e. Increased gas, bloating, constipation followed by bouts of loose stools. 1
Most women’s breasts are affected by her monthly cycles, some more than others. The result is often acute tenderness and engorgement. Pain on touch is often an associated issue. During the peri-menopausal phase hormonal fluctuations can exacerbate this situation. The breasts became enlarged with a feeling of heaviness. Whilst not empirically proven it is generally thought that when progesterone rises and oestrogen decreases breast pain and tenderness can result.1,2,3,
Apart from the hot flush effects on the skin, menopause brings a host of issues that are skin related, from excessive dryness, itchy skin, age spots, wrinkles, and facial acne. Chiefly, it is to do with diminishing oestrogen levels slowing down the body’s oil production and the body’s ability to retain moisture.1
This is associated with a slowing down of the metabolism, a factor of biological ageing. During the peri-menopausal and post menopausal phases it is important for women to re adjust their calorific intake to prevent unnecessary weight gain and associated health issues. 1,2
This concept will be surprising to women as it is a little known menopausal symptom. However, hormonal differences affect every cell of our body, including those in the mouth. Fluctuating hormonal changes affects the build up of plaque and increases the risk of gum disease. Some women are also known to have increasing number of mouth ulcers, dental caries and changes in sense of taste throughout this period.
Tension headaches and cyclical migraine attacks seem to have a correlation with a women’s menses. The exact cause is unknown but scholars believe the fall in oestrogen levels during this cycle has a direct effect. In Peri-menopausal women the fall in oestrogen can be significant and trigger increasing migraine attacks. 1,2
The fall in oestrogen levels can have an affect on bone density within the skeletal system. Physiologically speaking, falls in oestrogen levels facilitate more reabsorption of bone osteoclasts than new formation of osteoblasts.
In other words, bone regeneration is slowed down affecting bone density. If this process continues a women is more prone to fractures and skeletal deformities. 1,2,4
Scientists have confirmed that oestrogen acts as a cardio protector including favourable effects on blood lipid levels. Upon reaching the menopausal transition period and beyond, hormonal cardio protection is diminished and therefore leaves the woman prone to increasing risks of myocardial infarction ( heart attack) and stroke.2
For a variety of reasons peri-menopausal women experience insomnia, fatigue and/or extreme tiredness. Such women have a sense of exhaustion, everything is a great effort, they have no energy and everything seems so overwhelming.
Menopausal fatigue is different from that due to normal exercise or everyday high level of activity. It comes on anytime, even after a good nights sleep with the result the woman longs for her bed, or a lie down.1
And getting a good nights sleep can be difficult. Night sweats can interrupt sleep. Sleep disturbance can occur such as difficulty going to sleep or waking in the middle of the night and fining it hard to get back to sleep.
Vaso-Motor Symptoms – Hot flushes, flashes and night sweats
The most talked about peri-menopausal symptom is the hot flush syndrome. It is an experience like nothing else. The suddenness of its occurrence and frequency of episodes causes much distress. Yes, to the observer it can be seen as a humorous episode, or to others, such as partners, an irritating activity that is an excuse not to engage in sexual intercourse.
The hot flush syndrome includes rising intense heat that most often starts at the heart centre and proceeds up the neck towards the head . During this phase there is increased perspiration that can drench women in minutes. If it occurs also at night (night sweats) it can cause sleep deprivation and a reluctance to engage in sexual activities with one’s partner. The tendency to have a hot flush is exacerbated during sexual arousal and if the missionary position is adopted it heightens the women’s heat control mechanism and so increase the tendency to have a hot flush.1,2
The reason for hot flushes to occur is thought to be the lowering of oestrogen levels ( not altogether conclusive), and can be precipitated by stress, local heat, stews, alcohol, and spicy foods, and sex. Hot flush episodes can occur throughout the day and night, but more often they occur during the night, Hence, the caricature of, “ bed clothes on , bed clothes off” – even in winter!
Psychological and Emotional Effects
Along with the Hot Flush Syndrome, comedians thrive on the notion of peri-menopausal women having significant mood swings, regularly forgetting where things are, and having behavioural changes that do not relate to the woman’s norm. The image of the cool, calm, demure, woman changing to the monster, is a classical caricature. Such mood swings are often attributed to a woman’s hormone fluctuation, but what is not always understood is the inherent psychological distress that can also be associated with the knowledge that her reproductive ability ( i.e. femininity and youthfulness) is finally over.
As this phase in life also often coincides with children reaching the teen years, there may be added distress relating to parenting teenage children – mood swings, exam pressures, and ‘empty nest syndrome’ with kids flying the nest to go to University or take up employment. Other factors may be divorce, (increased numbers of partners divorce during the peri-menopausal years 8), or widowhood, career change, or caring for ageing parents that is an increasing factor in modern societies.
The preponderance of modern societies with image and beauty adds to the psychological and emotional pressure. Everywhere a women looks, there are stark reminders that they have to retain their youth at all costs.
Feeling depressed and unsure of the future is a common attribute associated with women during the peri-menopausal phase, but there is a fine line between normal sadness and clinical (morbid) depression that requires therapeutic intervention.
Anxiety and Panic Attacks
Anxiety is also common and is often triggered by hot flushes. Many women don’t know what a hot flush is and so when they begin to experience the first sensations of a hot flush, they can misinterpret them as anxiety or panic attacks. This can lead to a reluctance to be in the middle of a crowd or large enclosed seated areas as, during a hot flush, the woman often feels the need to cool down and the idea of not being near to a door (i.e. air) can in itself cause anxiety and further aggravate the hot flushes.
There are ways to manage hot flushes and we will be dealing with this in a further article.
Genitalia and Sexual Issues
The hormone Oestrogen plays a significant role in a woman’s sexual enjoyment. chiefly, a decline in oestrogen can affect her libido, vaginal lubrication and her ability to have penetrative sex without pain ( dyspareunia).
How does this work?
During peri-menopause there is a natural fall in oestrogen levels. The fact is that nature intends that a woman’s reproductive biology is primarily focused on reproducing more humans! Sexual intercourse is a feature of this process. When the ability to reproduce finishes, natures view is that women’s reproductive biology does not need to be kept in such prime condition.
As a consequence the fall in oestrogen reduces the tension in the vaginal wall and decreases vaginal lubrication. Vaginal lubrication is designed to keep the vaginal lining soft and supple and to make penetrative intercourse pleasurable so any decrease in this will affect vaginal sensations.
The effects of these changes can also cause vaginal irritation, itching and changes in the vaginal pH that keeps the vagina and surrounding tissues healthy. The close proximity of the urethra can lead to increased urinary tract infections occurring, and / or, some element of urinary incontinence due, in part, to the oestrogen receptors in the urethra, bladder and pelvic floor not being stimulated.
Falling oestrogen and testosterone levels also affect a women’s libido (sex drive). Sex drive is often a key factor in maintaining harmonious relationships and reduced libido means the woman is not easily aroused and less sensitive to touching and stroking.
NB. A case in part for maintaining Pelvic Floor Exercises!
We’ll look at more menopause issues in further articles but for now here’s a recap of this
- Menopause is the cessation of (periods/menses) and a woman’s biological capability and capacity to reproduce. Average UK age 51yrs.
- Menopausal arrival is preceded by a transitional process that can last several years. (4-10 years)
- It is a biological event when there are no more follicles (eggs) available to ripen and mature in readiness for fertilisation.
- Hormones greatly affect the maturity of the follicles/ova (eggs) and the whole reproductive process.
- NOT ALL WOMAN have the same experience, but there are some similarities.
- A woman’s culture, diet, environment, genetics and personal coping strategies can have an affect on her well being during the menopausal process.
Do you have a particular menopause issue?
Is there a particular topic you’d like us to deal with?
Please let us know….
- NHS (2014) Menopausal symptoms and conditions, www.nhs.Ukconditions/menopause symptoms. 30-08-14
- Scheid, Volker. “Not Very Traditional, nor Exactly Chinese, So What Kind of Medicine Is It? TCM’s Discourse on Menopause and Its Implications for Practice, Teaching, and Research.” Journal of Chinese Medicine 82 (2006): 5-20.
- Scheid, Volker. “Traditional Chinese Medicine – What Are We Investigating? The Case of Menopause.” Complementary Therapies in Medicine 15, no. 1 (2007): 54-68.
- Scheid, Volker. “Globalising Chinese Medical Understandings of Menopause.” East Asia Science, Technology and Society: An International Journal 2, no. 4 (2009): 485-96.
- Scheid, Volker, Veronica Tuffrey, and Trina Ward. “Comparing TCM Textbook Descriptions of Menopausal Syndrome with the Lived Experience of London Women at Midlife and the Implications for Chinese Medicine Research.” Maturitas 66 (2010): 408-16.
- Ward, Trina, Volker Scheid, and Veronica Tuffrey. “Women’s Mid-Life Health Experiences in Urban Uk: An International Comparison.” Climacteric 13, no. 3 (2010): 278-88 transition from a potentially reproductive to a non-reproductive state is normally not sudden or abrupt, occurs over a number of years, and is a consequence of biological aging. For some women, during the transition years the accompanying signs and effects (including lack of energy, hot flashes, and mood changes) can be powerful enough to significantly disrupt their daily activities and sense of well-being. In those cases various different treatments can be tried.
- www.goaskalice.columbia.edu/women-and-their-eggs-how-many-and-how-long. 2014-30-08.