Navigating Menopause

Approx. reading time - 12 min.

What is menopause?

Although menopause is often thought of as the time around the age of 50 when women’s periods become irregular or when symptoms begin signalling that their periods will soon be stopping, natural menopause is actually defined as the final period a woman or person assigned female at birth (AFAB) experiences. So, it may only last 3-14 days, depending on the person, and it’s permanent. 

Menopause isn’t usually diagnosed until twelve months have passed with no periods at all. At this point a “postmenopausal” diagnosis is usually given. The months and often years associated with irregular periods and other symptoms in the lead up to that last period are termed the perimenopause. Peri being a Greek word meaning “around” or “about”, mēn meaning “month”, and pausis, “a cessation” or “pause”. Natural menopause usually happens between the ages of 45 and 55. In Australia and the U.S. the average is 51-52, with perimenopause taking anywhere from 2-14 years.^1-3

Early menopause and premature menopause

Sometimes, menopause occurs earlier than the age of 45. When this happens, it is termed early menopause. If menopause occurs even earlier, before the age of 40, it’s called premature menopause.^{4, 5} The reasons for early and premature menopause vary. If you look around on the internet, you’ll notice that premature ovarian failure, now known as primary ovarian insufficiency (POI), is often lumped in with premature or early menopause, even on reputable sites and in peer-reviewed articles, but they are actually very different.^{6, 7} With POI, periods stop suddenly and spontaneously, either early or prematurely, just like menopause. BUT the difference is that with POI, ovulation and menstruation may still be occurring occasionally, and may even return to normal after a time. Women with POI can become pregnant. After premature, early or normal menopause, ovulation, menstruation and pregnancy are no longer possible.^{6, 7}

Causes of early and premature menopause include chemotherapy or radiation to treat cancer,8, 9 surgical removal of the ovaries or uterus,¹⁰ family history^11-13 and chromosomal abnormalities,^{11, 14} auto-immune disorders,¹⁵ smoking,^{16, 17} ME/CFS,¹⁸ HIV/AIDS^{19, 20} and infections such as mumps.^{21, 22} Sometimes the cause is unknown. Some of these may also cause POI, but the difference between POI and menopause is that with POI there is the possibility of periods and fertility returning.

Early and premature menopause are not uncommon. Statistics suggest that around 5-8% of women or people AFAB experience menopause before 45 and about 1% before 40 years old. Menopause can happen in a woman’s 20s, but rarely – only 0.1%, or 1 in 1000.^{23, 24}

What causes menopause?

The current consensus is that eggs, also known as oocytes, are not made fresh throughout a woman’s life. All the eggs ever released during a woman’s life are stored inside her ovaries from birth – around 1-2 million oocytes. This number declines with age, and by puberty, may already have reduced to less than 300,000.^25-27

Recent understanding tells us that eggs are not stored in their final developed form, and don’t take just one month to fully develop but instead are stored in ovarian follicles as immature eggs. These eggs develop in stages. The first three stages start before a woman is even born and then pause, or rest, until puberty when hormones trigger the fourth stage to begin. The final stage of egg development occurs, perhaps surprisingly, in the minutes after fertilisation by sperm.²⁸ Before puberty, approximately 10,000 eggs die per month in a process known as apoptosis.²⁹ From the age of menarche, when a young woman has her first period, a proportion of around 1000 eggs of the remaining oocyte pool begin their final maturation over around 90 days in a continuous process that results in the release of one dominant egg each month. For the first 70 days of this process, the growing follicles are unaffected by the major follicle development hormone, follicle-stimulating hormone (FSH), but once they reach about 2 mm in size, they become sensitive to FSH, which then begins to drive their development.^{30, 31} The remaining eggs that start the final stages of development but do not fully mature also die off. Over a period of around forty years, the number of egg follicles continues to dwindle. Menopause occurs when the ovaries are completely depleted and virtually no eggs remain.²⁹ It is the changing levels of hormones that effectively detect the remaining reserve of eggs and ultimately drive menopause.³²

From menarche onwards, women experience a roughly monthly cycle (averaging 28 days) of rising and falling hormones coordinated in a delicate balance of signals by the hypothalamus and pituitary gland of the brain, and the ovaries.³² These hormones include the FSH mentioned above, oestrogen, progesterone, and Luteinising Hormone (LH). FSH is produced in the pituitary gland of the brain during the first half of the menstrual cycle and is responsible for driving the ovaries to develop the immature egg follicles every month, hence the name “follicle-stimulating” hormone.³³ When a solitary egg approaches full maturity in its follicle each month, a surge of LH from the pituitary gland causes the follicle to burst, releasing the egg into the fallopian tube for fertilisation.³³

This monthly cycle continues happily until around the age of thirty-five to thirty-seven. With advancing age, the reserve of available eggs dwindles, especially as females enter their 40s.²⁹ The quality of the remaining eggs’ development also declines, which leads to the release of fluctuating oestrogen levels, and reduced inhibin B, another hormone, from the developing egg follicles. In younger women, oestrogen and inhibin B normally inhibit the production of FSH³⁴, but with the age-related fluctuations and decrease in oestrogen and inhibin B, inhibition of FSH production is reduced, meaning fluctuating levels of gradually higher and higher FSH.^35-37 These greater levels of FSH then drive the ovaries harder to force the development of their remaining eggs. In practical terms for fertility, this is a good thing, as without the higher levels of FSH, even fewer eggs might mature. However, even though more egg follicles are stimulated to mature than in younger women, which is thought to be the reason for more non-identical twins born to older women,³⁸ the egg follicle sizes decrease.³⁷ Eventually there are no eggs left that are capable of fully maturing, oestrogen levels have critically dropped, and FSH, for want of a better description, has gone through the roof.

Before puberty, normal female (yes, men do produce FSH as well!) circulating blood levels of FSH are 0-5.0 mIU/mL, increasing to 0.3-10.0 mIU/mL during puberty. For the majority of menstruating people, FSH ranges from 4.7-21.5 mIU/mL. After menopause, this increases to 25.8-134.8 mIU/mL,³⁹ which is why many self-tests intended to assist with menopause, early menopause and premature menopause detection, have a cut-off at 25 mIU/mL. Australian guidelines recommend that when menopausal symptoms are experienced by women under 45 years old, two FSH measurements are taken 4-6 weeks apart, to diagnose early or premature menopause, but not normal menopause.⁴⁰ FSH and oestrogen tests are not advised to be used to diagnose menopause over the age of 45 years because levels of both fluctuate, sometimes significantly, from day to day, although two measurements of FSH with a suitable gap between can still be helpful for women wanting to better understand symptoms they may be experiencing and manage their health in consultation with their doctor. Supporting this, the Mayo Clinic says that blood tests aren’t needed to diagnose menopause, but they may still be recommended by doctors to check levels of FSH, oestrogen, hCG (the pregnancy hormone) and TSH (a thyroid hormone) in certain circumstances, and to exclude other health conditions.⁴¹

Symptoms of menopause

The first and most obvious sign of pending menopause that many women notice, is that their previously regular periods become less regular, even intermittent. Spotting between periods and changes in vaginal bleeding may also occur. Stage 2 of the STRAW + 10 system (Stages of Reproductive Ageing Workshop) criteria defines perimenopause as having begun when there are persistent differences in cycle length of seven or more days between consecutive cycles that continues until twelve months after the previous Stage + 1a.⁴² Other symptoms associated with oestrogen excess and oestrogen deficiency as levels fluctuate in the years before menopause, whether normal, early or premature menopause, include^{6, 32, 41}:

• Hot flushes (also known as hot flashes)
• Night sweats/chills
• Vaginal dryness and discomfort or pain during sex
• Sleep disturbances (insomnia)
• Fatigue
• Irritability, mood swings, anxiety, depression
• Dry skin, mouth and/or eyes
• Headaches and migraines
• Aching joints and muscles
• Memory and concentration issues
• Weight changes – often weight gain due to slowed metabolism but sometimes unexpected weight loss
• Hair loss
• More frequent urge to urinate and more frequent urinary tract infections (UTIs)
• Low libido

Permienopause vs. Premenstrual Symptoms (PMS)

With the same female hormones fluctuating through the monthly cycle when everything is working as it’s supposed to, much of the symptom list above is also experienced by women with PMS in the one to two weeks before a period.⁴³ This overlap in similar symptoms between perimenopause and PMS can make it challenging to determine whether the symptoms are being caused by PMS or perimenopause.

The main difference between perimenopause and PMS symptoms is that the latter are more regular and predictable. As mentioned, PMS usually occurs in the second half of the menstrual cycle, and especially the week before a period. The symptoms of perimenopause can fluctuate daily due to the daily hormone fluctuations,³² are much less predictable and are usually associated with the increasingly irregular periods as described above. Perimenopause symptoms can also persist for much longer than would have been expected when younger and can feel unrelated to the menstrual cycle.

Importance of perimenopause and menopause diagnosis

Due to the decline of hormones such as progesterone, and oestrogen, which provides a protective effect on many of a woman’s biological systems throughout the first half of her life, it is essential to be aware of when these hormones are declining to manage and mitigate the detrimental health effects.

With the loss of oestrogen during perimenopause and menopause, the risks of the following chronic health conditions increase^{32, 44}:

• Cardiovascular disease
• Altered glucose metabolism and diabetes
• Altered fat metabolism and weight gain
• Increased mood disorders, anxiety, and depression
• Increased risk of cancers including but not limited to breast, bowel, and cervical cancer
• Loss of bone density and osteoporosis
• Loss of muscle mass (sarcopenia)
• Increased risk of dementia

 

Being aware of when perimenopause and menopause are occurring enables women and people AFAB to consult with their doctor or other appropriate health practitioner to take the necessary steps to optimise their health both during the transition from menstruating to non-menstruating, and to maintain the best possible health into a hopefully long and enjoyable old age. Taking these important steps to manage their health with a health professional’s guidance early in the perimenopause to postmenopausal transition can also help reduce or even eliminate the discomfort of any symptoms. Prompt care can minimise, or possibly prevent, some health conditions that would otherwise occur another 10-20 years down the track. At worst, appropriate early intervention can help delay ageing-associated diseases and help women continue to do the things they love doing for longer. At best, 60 is the new 40, or 30!

It is also important to have a health professional exclude the possibility of other health conditions that may share similar characteristics with perimenopause and menopause, for example, elevated hCG levels may indicate pregnancy, or Thyroid Stimulating Hormone (TSH) may be checked by your doctor to ensure that an underactive thyroid (hypothyroidism) is not causing the similar symptoms.⁴⁵

Treatment

Menopause itself doesn’t require medical treatment. However, the symptoms can be alleviated and potential chronic conditions can be prevented or managed. Treatments that may be prescribed by a doctor include:^{41, 46, 47}

Hormone therapy (HRT) – Considered the most effective option for relieving hot flushes and preventing bone loss, oestrogen therapy (and progesterone if a uterus is still present) at the lowest dose and shortest timeframe may be recommended. For women experiencing early or premature menopause, oestrogen therapy is strongly recommended until the age that menopause would normally occur, to reduce even greater risks of osteoporosis and chronic health conditions. Long term use and late start of hormone therapy, particularly if started more than 10 years after menopause, has been suggested to have some cardiovascular and breast cancer risks. Concerns regarding study design and control group characteristics in conflicting reports argue that if hormone therapy is started early, this may not be the case, and that there may be significantly greater health benefits. 

Low-dose antidepressants – Selective serotonin reuptake inhibitor (SSRI) antidepressants may be prescribed to alleviate depression and mood difficulties. SSRIs may also be helpful for reducing menopausal hot flushes, especially for those who can’t take oestrogen, for example, women who have been diagnosed with oestrogen sensitive cancer.  

Vaginal oestrogen – An oestrogen cream, tablet or ring may be applied directly to vaginal tissues to relieve vaginal dryness and discomfort during sex. Urinary symptoms may also be helped. 

Other medications to treat hot flushes – For women who are unable to use oestrogen therapy, gabapentin, clonidine, fezolinetant and others may be used to treat hot flushes.

Osteoporosis medication – These may be prescribed to prevent or treat osteoporosis on an individual basis, to reduces bone loss and decrease the risk of fractures. A Vitamin D supplement may also be recommended to support calcium absorption and bone strengthening.

Lifestyle interventions

While many alternative medicine options don’t yet have solid scientific evidence to support their effectiveness in treating menopausal symptoms, and some herbal remedies commonly recommended on the internet may even cause more problems or interact badly with prescribed medications, there are some lifestyle and home remedies that reputable sources, such as the Mayo Clinic,⁴¹ suggest evidence does support.

Exercise – this one is a biggy. Studies repeatedly show that regular daily physical activity or exercise for 30-60 minutes at an intensity that just about enables conversation, is massively beneficial for improving the symptoms of many health conditions, including menopause.^{48, 49} If 2-3 days a week of the exercise involve lifting some kind of weights, also known as resistance training, even better.⁵⁰

As an added bonus, exercise improves sleep⁵⁰ and mood,⁵¹ reduces symptoms of depression,⁵¹ supports the immune system by upregulating immune cells called Natural Killer cells,⁵² protects against heart disease,⁵³ diabetes,⁵⁴ osteoporosis⁵⁵ and many other conditions associated with ageing.⁵⁶

Diet – the Australian Dietary Guidelines⁵⁷ recommend everyone to “enjoy a wide variety of nutritious foods” while “limit[ing] intake of foods containing saturated fat, added salt, added sugars and alcohol” This especially applies to women experiencing perimenopause and menopause as a healthy balanced diet will support the body during this challenging transition.

Sleep – while it may seem easier said than done, prioritising sleep is a must during menopause. With the hormonal fluctuations already impacting sleep to varying degrees depending on the person, making the best of an often less than ideal situation is key to minimising fatigue, mood disorders, and any cognitive impairment. Good sleep hygiene including regular sleep and wake times, exposure to natural sunlight within an hour of waking, a cool dark room with minimal noise disturbance to sleep in, and exercise during the day but not too close to bedtime (or it may wake you up), are all important. Hopefully it goes without saying that eating⁵⁸ and exposure to screens⁵⁹ in the two to three hours before sleep are not helpful. Even if you have a blue light filter on your phone or other screen, new evidence suggests that sleep is disturbed more by yellow light than blue light anyway,⁶⁰ and the remaining light produced by screens is still sufficient to negatively impact the sleep hormone, melatonin,⁶¹ and disrupt your sleep.

Don’t smoke – smoking has been shown to increase the risk of many health conditions, including those related to menopause, more specifically cardiovascular disease,⁶² osteoporosis,^63-65 stroke,⁶⁶ cancer^67-69 and others. Evidence suggests smoking may also cause earlier menopause^{16, 17} and can increase hot flushes.⁷⁰

The final word

Menopause is a time of transition in the lives of women and people AFAB. It can be a challenging time for many, but with knowledge, and the confidence to take charge of their health with the support of a qualified health professional, women have the ability to negotiate this change and enter a new phase of life gracefully. There is little doubt that our approach to menopause, both physically and psychologically, impacts the experience of menopause. Cultural and social attitudes towards menopause are now known to strongly influence women’s experience of menopause and menopausal symptoms. A recent meta-analysis⁷¹ (a study of many studies) described Western culture’s use and focus on negative disease-associated terminology, such as “fertility failure” and “ovarian failure”, which together with a high value on youthfulness and sexual attractiveness may lead to negative attitudes towards menopause. Diverse other cultures, including Japanese, Chinese, Indian, Native American, and Australian Aboriginal and Torres Strait Islander, alternatively focus on menopause as a natural transition with more positive associations. Although influenced by genetics to some degree, Japanese women report the fewest symptoms of menopause^{71, 72} together with the lowest incidence of breast cancer and menopausal complications.⁷¹

Instead of associating menopause with loss, unpleasant symptoms and fear, as is common in Western culture, the Japanese word used for menopause is “konenki”. Konenki, has no direct translation to English. Instead, it’s a word that reflects the three aspects of energy, regeneration, and renewal, three things that already make menopause feel a bit less intimidating, and maybe even something to look forward to.

In the words of award-winning Australian actress Naomi Watts, who prematurely experienced perimenopause at 36, “It’s been the plan for the body all along. It’s not a failure, it’s not a disease.”⁷³