Menopause and the Transition

by Dr. Marilena Quadrio


This is a question often asked by women in their 40’s, and less commonly even younger than this. The reality is that many of us notice a change in our periods by

the mid 30’s to early 40’s, with periods sometimes becoming heavier and less predictable and not on time! Breasts may become tender in the 1-2 weeks before our period and this may be associated with fluid retention, mood changes

and sleep disturbances, along with other symptoms commonly referred to as PMS or Premenstrual Syndrome. While this can occur at any age it can become more severe

for some women in this Pre -menopause phase. This is due the two main hormones, Oestrogen and Progesterone not being as well balanced in the second half of the cycle. While the production of Oestrogen is still very normal, Progesterone is often reduced. So there is an osetrogen dominance effect. This leads to the bleeding changes, and you may notice periods getting heavier, as well as the increased PMS symptoms felt by some women.

Bleeding or spotting between periods should never be ignored. This should always be reported to your doctor who will assess the circumstances and investigate accordingly. New onset of very heavy periods should also be reported to your doctor.

We progress from Pre- menopause to Peri-menopause, usually sometime in our 40’s, when our oestrogen levels drop significantly and this may be associated with less frequent periods, or more irregular periods, generally feeling hotter, having hot flushes or flashes, night sweats and sleep disturbances. Anxiety and other mood changes may also occur at these times. You may also begin to notice some memory and cognition changes; increased joint and muscle pains; an itch or crawling sensation on the skin; tiredness, and increased discomfort with intercourse. So women often wonder if they are now in Menopause. But this time of transition referred to as the peri-menopause can last on average between 4-8 years, with fluctuating oestrogen levels which can be very high sometimes as well as very low at other times. This leads to many women feeling very confused about where they are at and don’t know what to expect from one day to the next! Don’t sweat it out! There is help available in this peri-menopasual phase and you can discuss the best treatment option with one of our doctors once you have been fully assessed. You do not have to wait until periods cease and you are in menopause.

If you have a past history of depression or anxiety then your risk of recurrence at the time of peri-menopause and menopause is much higher. A first presentation of either depression or anxiety at this stage of life may also be related to the changing oestrogen or complete loss of oestrogen at menopause. Best management requires a full assessment of the individual and past medical history.

Menopause has officially been reached when you have had your last period. But we only know when you have had your last period when you have had no bleeding for 12 months, then we can say your are menopausal. After 12 months of no bleeding your are referred to as Post –menopause. Any bleeding after 12 months since your last period, which we refer to as postmenopausal bleeding, must be reported to your doctor and investigated, even if it seems like a normal period. While, occasionally, this could be case, it is important to exclude other more sinister reasons for postmenopausal bleeding.

Contraception during the peri- menopause is very important. Pregnancy can and does happen! Appropriate contraception needs to be continued until 12months after your last period. The Mirena IUCD is very useful in the peri-menopause for both heavy periods and contraception if there are no contraindications. If there are no contraindications to the use of the pill, this can often be helpful in peri-menopause for management of symptoms as well as contraception

In the post menopause, vaginal dryness and urinary symptoms can worsen and interfere with your sexual life. It is not time to give it up! Come and discuss this with us so that you can continue to enjoy a positive sex life. If this is the main symptom, without flushes and sweats, then a local vaginal pessary or cream can be very useful to alleviate symptoms and restore pain free intercourse and improved bladder functioning. This is a very small dose of local oestrogen which is not absorbed into the body and has its affects only on the vagina and bladder.

It is important to remember that it is not always menopause! Many symptoms of menopause are present with other conditions, some of which can also present more commonly during the peri-menopause or in menopause. These include conditions such as anxiety, depression, thyroid problems, anaemia, arthritis, and side effects of medications, just to name a few. So it is important that you are fully assessed. We also take the opportunity to do a full assessment of your risk factors, before tailoring the most appropriate treatment for you specifically. No two women experience menopause in the same way, and everyone has a different medical history, so management has to be tailored to suit the individual. It is not a one size fits all.

Once fully assessed and menopause symptom management is required, we can fully discuss with you your treatment options according to your medical circumstances and preferences. There are a fortunate few who have a trouble free menopause transition and need no specific treatment. Everyone can benefit from positive lifestyle changes, such as exercise, weight loss (when needed), and stress management, which can help mild flushes. Avoidance of spicy food and alcohol and other triggers can also be helpful. There are many herbals on the market aimed at the menopausal woman, but few have strong medical evidence to support their claims. Also, there can be safety issues and interaction with medications you take, so beware and make sure you get appropriate professional information, rather than buying something over the counter.

A good proportion of women get significant flushes and sweats, which can lead to major sleep disruption, or significant cognitive or mood changes, which needs more active management with hormone treatment. Unfortunately there has been a lot of inappropriate negative publicity over the years, which has not presented the facts in a balanced way, creating fear amongst those who need it and have been suffering unnecessarily. We do have much more information and positive information, which does not make the headlines! While I am not proposing that everyone needs hormone therapy, for those that do, it is important to be assessed early rather than later. For those that have significant symptoms and need relief, replacing oestrogen is what is required. There are cardiac benefits in starting closer to the time of menopause, rather than many years after the menopause. So once fully assessed, the treatment is tailored to your specific circumstances. For example, if you have had a hysterectomy you only require oestrogen. But for all women with a uterus you must have micronized progesterone or a progestagin with the oestrogen to protect the endometrial lining. Hormone therapy comes in many forms – tablets, combined oestrogen and progeastagen tablets, patches and gels. What is prescribed will take into account your medical circumstances as well as your preference. With the introduction of micronized progesterone to Australia in the last 12 months, (after extensive research and use in Europe in the last 20 years) we can now truly offer evidence based hormone therapy which has the same biological structure as the body had prior to menopause in the form of oestradiol and progesterone.

Hormone Therapy can be given safely in the appropriate woman, who has been fully assessed and does not have any contraindications, who is monitored regularly. There are women who can’t have hormone therapy, such as those who have had a breast cancer in the past, especially a hormone positive breast cancer. There are also some other medical conditions, which need to be excluded or taken into consideration, before prescribing hormone therapy.

Our practice has very experienced female GP’s who are very happy to help you navigate through this stage of life and offer you a full assessment and individual mid life management.

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