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The menopause: a time of transition |
Key words: climacteric, mid-life, hormone replacement therapy
(Aust Prescr 1994;17:2-4)
Menopause is a life event which usually occurs during the mid-life years. It is recognised as an important developmental phase influenced by specific socio-cultural factors.1 The menopause may be accompanied by distressing symptoms and is implicated increasingly in some major age-related diseases in women, particularly cardiovascular disease and osteoporosis. Most women, aware of the controversies through media attention, seek a balanced discussion, an acknowledgement that there is hot debate and an explanation of the issues. Australian Prescriber has published articles on some of these contentious issues2,3,4 and, in this issue, current treatment regimens for hormone replacement therapy are discussed.5
Many women seek information about what changes are usually associated with menopause. At the time of the consultation, the woman may be asymptomatic and wonder what she may experience with menopause.
Before the population-based studies, knowledge of menopause was based on a small proportion of self-selecting, predominantly ill women. Prospective data6 show that menopause itself does not cause poorer health (either physical or psychological). Women can be informed reliably that very few symptoms appear to be related to the endocrine changes of the menopause.6 The symptoms related most often and consistently to the underlying endocrine changes are the vasomotor symptoms of hot flushes and night sweats. Hot flushes are not troubling for the majority of menopausal women. In a recent population study of 2000 Australian-born women aged 45-55 years7, only 39% reported hot flushes as bothersome.
Negative stereotypes of women in mid-life abound, suggesting that middle-aged women tend to be depressed and irritable. However, our population-based study found that the majority of Australian middle-aged women report positive moods most of the time.8 Moods (positive and negative) are influenced profoundly by social factors (such as marital status, employment, education, stress, and attitudes to menopause and ageing), lifestyle factors (such as exercise and smoking) and health status.8 Some minor changes in moods do occur just before menopause, but these are transitory.
Sexual enjoyment may be affected if menopause results in reduced vaginal lubrication during sexual arousal. Problems with the urinary tract may also increase after menopause. The association of menopause with longer term problems, e.g. cardiovascular disease and osteoporosis, should be discussed, with particular reference to the patient's individual history and an assessment of her risk for these problems.2,3
An Australian population study found that women also consult a doctor for relief of troubling symptoms. A doctor was consulted by 63% of the Australian women who suffered from bothersome hot flushes, while 46% of the sample had consulted a doctor about menstrual and menopausal problems in the previous 12 months. The reporting of bothersome symptoms was associated with similar factors to those affecting mood.7 When symptoms are reported, the consultation should be directed towards establishing their aetiology and the relative contributions of psychological, social, cultural and physical (including endocrinological) factors.
Assessment
Each woman needs to be assessed in the context of the social reality of her life. This involves taking a comprehensive history which should include:
- reasons for presentation
- current health status (physical, psychological and sexual)
- past personal and family histories of relevant disorders
- current family and social situation and current stressors
- lifestyle behaviours including diet, exercise, smoking
- medication and use of alcohol and other non-prescription substances.
Much of this information may already be known to the woman's general practitioner. The consultation is also an opportunity for preventive measures if these have not been carried out recently e.g. breast and gynaecological examinations including pap smear. Advice on breast self-examination can be given and mammography recommended to women in the appropriate age range.
Non-pharmacological treatments
Non-pharmacological approaches are an essential part of management. In addition to supplying information, they should include:
Attitudinal change. In a number of studies, negative attitudes to menopause predict the later occurrence of symptoms.9 The majority of women report feelings of relief or neutral feelings about the cessation of menses and attitudes to menopause become more positive as women pass through the transition.9 The consultation may be used to effect positive change in attitudes to menopause and ageing.
Lifestyle modification. Many of the risk factors identified for later events (e.g. osteoporotic fracture, cardiovascular disease) are common to other diseases, so their elimination may carry many benefits.10 Women should be encouraged to stop smoking, drink minimal alcohol, improve their diet and exercise more. Dietary improvements include reducing salt, animal protein, fat and caffeine. An adequate amount of calcium and more fruit and vegetables should be eaten. Calcium supplementation of an additional 1000 mg/day (see 'Dietary sources of essential minerals' Aust Prescr 1992; 15:36-8) in postmenopausal women with mean dietary intakes of 750 mg/day significantly slows bone loss.'11 One hour, twice a week, of weight-bearing low-impact aerobic exercise designed for 'seniors' had a significant protective effect on bone density (and well-being).12
Stress reduction. As interpersonal stress is associated with many negative health outcomes7, there is a role for examining sources of stress in the woman's life. Stress management techniques should be discussed including cognitive strategies as well as those techniques which will lower the level of stress arousal (relaxation techniques, self-hypnosis, yoga, meditation).
Marital counselling. Where the source of stress relates to ongoing marital or sexual problems, specific counselling, often with the partner, may be needed.
The role of hormone replacement therapy
In addition to the non-pharmacological approaches discussed above, hormone replacement therapy (HRT) may be considered. HRT has an important role to play in the alleviation of bothersome symptoms due to vasomotor instability and urogenital atrophy. These include distressing symptoms of hot flushes, sweats, vaginal dryness, dyspareunia and urinary frequency. Therapy should be short-term (up to 5 years) and, when the woman has an intact uterus, must include a progestogen to counteract the oestrogenic effects on the uterus.
It is not yet possible to recommend indefinite HRT purely for the prevention of cardiovascular disease and osteoporosis. However, when there is an increased risk of these disorders, the clinician should discuss the potential benefits and risks of HRT together with the other lifestyle modifications needed. For example, a woman at particular risk of osteoporosis may be offered long-term (greater than 5 years) HRT, together with attention to nutrition and adequate exercise. In doing so, she must be informed that there appears to be an increased risk of breast cancer from such long-term use and be advised of the need for self-examination, annual examinations and repeated mammography. The potential benefits and risks must be explained clearly to enable the woman to make an informed choice.
References
1. Lock M. Ambiguities of ageing: Japanese experience and perceptions of menopause. Cult Med Psychiatry 1986; 10:23-46.
2. Newnham HH, Burger HG. Cardiovascular issues in the menopause. Aust Prescr 1993;15:60-2.
3. Wark JD. Osteoporosis and the menopause. Aust Prescr 1993;16.16-9.
4. Khoo SK. Cancer, the menopause and hormone replacement therapy. Aust Prescr 1993;16:66-8.
5. Palmer D. Regimens for hormone replacement therapy. Aust Prescr 1994;17:13-6.
6. McKinlay JB, McKinlay SM, Brambilla DJ. Health status and utilization behavior associated with menopause. Am J Epidemiol 1987; 125:110-21.
7. Dennerstein L, Smith AM, Morse C, Burger H, Green A, Hopper J, et al. Menopausal symptoms in Australian women. Med J Aust 1993;l59:232-6.
8. Dennerstein L. In pursuit of happiness - wellbeing during the menopausal transition. In: Proceedings of the International Congress on Menopause, Stockholm 1993. von Schultz B, Landgren B, editors. Lancaster: Parthenon Publishing. In press.
9. Avis NE, McKinlay SM. A longitudinal analysis of women's attitudes toward the menopause: results from the Massachusetts Women's Health Study. Maturitas 1991;13:65-79.
10. Lindsay R. Prevention and treatment of osteoporosis. Lancet 1993;341:801-5.
11. Reid IR, Ames RW, Evans MC, Gamble GD, Sharpe SJ. Effect of calcium supplementation on bone loss in postmenopausal women [see comments]. N Engl J Med 1993;328:460-4. Comment in: N Engl J Med 1993; 328:503-5.
12. Caplan GA, Ward JA, Lord SR. The benefits of exercise in postmenopausal women. Aust J Public Health 1993; 17:23-6.
| Editor's note |
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Each piece of the eye symbol represents a fraction. These pieces were used when specifying the quantities of ingredients in a prescription. The complete symbol may have evolved into the prescribing sign Rx which is still used today. |
The new cover of Australian Prescriber features the Eye of Horus. Horus was the falcon god of Lower Egypt who had his eyes torn out in a dispute.