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12Apr

All women have to go through it eventually – the menopause may be postponed with the help of HRT, but even those still wanting to produce babies in their eighties have one day to accept the fact that their ovaries have called it a day.

Given that everyone bar the occasional male hermit will eventually either experience the menopause or know someone who has, it’s astonishing how little helpful information is easily accessible to menopausal women looking for advice on managing their menopause.

In 2009 a study of women in northeast Scotland looked at the frequency and management of menopausal symptoms. [1]

The study involved 4407 women aged between 45 and 54. Of these, 46% experienced hot flushes and night sweats, and 28% vaginal dryness. Those who had undergone a hysterectomy or removal of ovaries (which induces menopause) had the greatest frequency of symptoms and the most bother from them. Overall, though, two-fifths of the women reported the symptoms as quite or extremely bothersome.

More than 60% of the women managed menopausal symptoms using social support – talking to friends and family. They used herbal remedies more than prescription drugs: in fact, 38% of the post-menopausal women had used herbal remedies. 34% wanted more support from their GP or practice nurse.

Sympathise, however, with the harassed doctor desirous of providing information and support on treatment options to their menopausal patients. What, if anything, do they have to offer? Wouldn’t it be useful if they were at least able to inform women about how long they were likely to suffer certain symptoms, and at what level of intensity?

A recently published study of the symptom patterns experienced by 675 women who had a natural menopause (hadn’t had a hysterectomy or received hormone treatment) holds out hope that such information may eventually be available. [2] This study had two objectives: to disentangle menopausal symptoms from those caused by ageing; and to collate information for health professionals on the duration and variation in severity of symptoms through the menopausal transition.

To start with the first objective: which symptoms are definitely associated with the menopausal transition?

Symptoms showing a correlation with menopause:

• Hot flushes
• Cold or night sweats
• Trouble sleeping
• Anxiety and depression
• Tearfulness
• Irritability
• Feelings of panic
• Forgetfulness
• Vaginal dryness
• Difficulties with sexual intercourse.

Yes, a fairly unpleasant-looking list.

There is, however another list of symptoms that can’t be blamed on the menopause:

• Aches and pains in joints
• Pins and needles in hands and feet
• Dizziness
• Palpitations
• Skin crawling sensations
• Frequent severe headaches
• Breast tenderness
• Increased frequency of passing urine.

Between the ages of 48 and 54 this group of symptoms is likely to decline:
breast tenderness, palpitations, dizziness, skin crawling sensations, irritability, anxiety or depression, tearfulness, forgetfulness, and frequent severe headaches.

These symptoms, however, increase in prevalence: hot flushes, trouble sleeping, aches and pains in joints, vaginal dryness, and difficulties with sexual intercourse.

Moving on to the second objective: what information on the severity and duration of symptoms came out of the study? Interestingly, there was often a correlation between the two: if symptoms were mild then they tended to follow a different timeline than if they were severe.

In these observations, menopause is considered to be the time of the last ever period. Peri-menopause is the time leading up to the last ever period, and post-menopause (you’ve guessed it) is the time after the last ever period.

• Most of the psychological symptoms (trouble sleeping, anxiety and depression, tearfulness, irritability, feelings of panic, and forgetfulness) peaked at or in the year after menopause, if they were severe.

• If vasomotor symptoms (hot flushes and night sweats) started early and were severe, they peaked around early post-menopause and then declined noticeably.

• Severe sweaty symptoms that started later on increased rapidly in perimenopause and peaked in the year after menopause, remaining high over the subsequent 3 years.

• Sweaty symptoms that started later on but were moderate again peaked in the year after the last period, but declined faster from then on than severe symptoms.

• Here’s a strange thing: women were less likely to have a profile for severe vasomotor symptoms if they were from a non-manual social class or had degree level qualifications. Possibly educational level is a predictor of better health awareness and ability to afford a good diet and healthcare. Non-smokers were also less likely to experience severe flushing and sweats.

• Late on-set severe symptoms of sexual discomfort (vaginal dryness and difficulties with intercourse) showed an increase until menopause, with symptoms persisting afterwards.

• Women who have minimal symptoms of flushes, mood change, insomnia and sexual discomfort around their final menstrual period are unlikely to develop severe symptoms later. They are likely to experience a similar level of symptoms throughout their menopausal years, and they are likely to have mild symptoms across the board i.e. if one symptom is mild then the rest are likely to be.

• Women with moderate to severe menopausal symptoms are likely to experience them for several years.

• Early onset of symptoms (up to 3 years before menopause) is more likely to be associated with symptom reduction by the 4th post-menopausal year. If, therefore, a woman knows that she has had at least 3 years of symptoms prior to her last period, she can anticipate no more than 4 years more.

All this may not sound too encouraging, but is helpful for women to know that their symptoms are likely to decline within a roughly accurate timescale. Knowing, for example, that symptoms are likely to have reached a peak and will soon decline, may affect their decision about how to treat them.

There are some problems with the data in this study, as not all women report to their doctor when their symptoms commence, or even at all. And they may not be able to recall accurately when those symptoms did commence.

The researchers conclude that treatment such as hormone therapy should be targeted to vasomotor symptoms (flushes and sweats), which are most strongly associated with menopause, rather than to less specific symptoms related to aging per se.

A review of this study in the BMJ [3] notes that with the increase in numbers of women having children later on, many are experiencing menopausal symptoms (flushes, sweats, insomnia, irritability, anxiety) whilst still looking after young or adolescent children, holding down a job and maintaining a sexual relationship.

So girls: fewer actual physical headaches to look forward to, but just as many intellectual headaches!

[1] Duffy O, Iversen L, Hannaford P. The impact and management of symptoms experienced at midlife: a community-based study of women in northeast Scotland. BJOG 2012; 119: 554–564
[2] Mishra GD, Kuh D. BMJ. 2012 Feb 8; 344: e402. doi: 10.1136/bmj.e402
[3] Davis S. BMJ 2012; 344: d7664

  

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