MENOPAUSE: THEORIES

The hormonal theory

Changes in hormones do affect the emotions; in some women this is pronounced, and in others it is hardly noticeable. This depends to some extent on how rapidly the hormone levels change and also of course on the general make up of the woman and how she reacts to it, but the menopause may be a time of instability. The actual level of circulating hormones also has an effect. The depression associated with hormonal changes at the menopause is similar to the emotional instability at puberty and postpartum depression which often occurs after delivery of a child. During pregnancy there are high levels of circulating oestrogens followed by a sudden drop at delivery; at puberty also there are changes in hormone levels.

The involutional theory

If her periods have gone it is thought that a woman feels that death is around the corner. I think that women who are well don’t feel like this. Death is something that ‘happens to someone else’ if you are on top of things. But, admittedly, in this youth-oriented society, depending on what you have valued in the past, changes at this time do perhaps suggest a loss of youth. Fortunately, more and more women realise that there is more in life than youth, and I feel that with the increase in the interests of women this will be less of a problem in the future.

The empty nest syndrome

I also feel that the ‘empty nest syndrome’ has been overplayed, although it is, of course, also a factor. But numerous women sit in front of me telling me that the last thing they want is another baby. Others tell me that they are fed up with waiting on a bunch of young adults who can well look after themselves. They want time to pursue their own interests. Those who don’t have these feelings and feel a loss at this time should view this period of their lives just as people view retirement, and prepare for new interests in their lives.

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MENOPAUSE PROBLEMS: VAGINITIS PROBLEMS

Vaginal infections are more common after menopause, probably due to the alteration in acidity of the vagina. Before the menopause the vagina is more acid than alkaline although this varies during menstrual cycle to some degree. When oestrogen levels are high the vagina is more acid, and after the menopause the alkalinity therefore increases. With high oestrogen levels the lining of the vagina is also thick and moist, and this, plus the acidity, protects the vagina from harmful bacteria. Bacteria may migrate from surrounding areas, such as the rectum or bladder, or may be introduced during intercourse. Most women at some time in their lives before menopause have had a vaginal infection. Particularly, these occur during or after a course of antibiotics, because the antibiotics alter the normal bacterial inhabitants of the vagina, and make foreign bacteria happier there, and they multiply. After the menopause some women get one infection after another due to the low oestrogen levels, and also the thinning of the vaginal mucosa.

Prevention The genital region should be kept as dry and well-aired as possible, therefore cotton pants should be worn. Synthetics keep the area moist and warm and should not be worn. Tight jeans should be avoided particularly in hot weather, as also should pantyhose. Wiping yourself from front to back after urinating and bowel movements, or simply dabbing to dry oneself and avoiding courses of antibiotics – these are preven-’ tive measures to keep in mind. Do not douche as this destroys the normal bacteria and makes the vagina more prone to infection.

Oestrogens are useful as the vaginal wall becomes thicker, moister and more acid when they are present. They may be given orally or locally as a cream or pessary.

Medication If you have an infection and medication is prescribed by your doctor, it is important to complete the whole course as prescribed, or the infection may recur and become chronic.

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ROUTINE TREATMENT FOR MENOPAUSAL PROBLEMS

There is a mistaken impression in the community that women are psychologically unstable at menopause, facing sociological changes that they cannot cope with. But this applies equally to both sexes. The difference for women is that they suffer a hormonal imbalance as well. Adjust this and the rest usually falls into the place.

We see no point in our clinics in running group therapy sessions. This is not done for any other hormone deficiency condition such as diabetes or thyroid deficiency. We stabilise the women’s hormones, and if following relief of their oestrogen dependent symptoms, they still need help, we refer them to psychiatrists or other expert professionals. Those who still need help after their hormones are stabilised are shown to be unable to cope with the stresses of mid-life which are common to both men and women.

In any medical interview the doctor looks into the workload and stresses of the patient. It is not uncommon to find women in this age group working full time, running a home, coping with a partner facing increased stress at work or retirement, coping with teenagers with their problems, as well as often being a major source of support for old people who may live in the home. It is impossible to assess the problems of menopausal women without taking all this into account.

To assess this, a full general and gynaecological history is taken. The woman is examined including a smear test for cancer of the cervix and a breast examination. She is also instructed on breast self-examination (figure 4.1). The doctor then explains what treatment is available and in what way it can be expected to help, together with a full explanation of the therapy and why it is necessary.

Oestrogen replacement therapy is offered orally, locally or by implant and if this is contraindicated, or if the woman does not want to take this therapy then alternative therapy is made available to her. Those who are not suitable for treatment must be recognised.

• women with a history of cancer of oestrogen-sensitive tissues, for example cancer of the breast or lining of the uterus. This does not apply to the neck of the uterus or cervix

• women with recent liver disease or defective liver function

tests

• women with a history of thrombosis or clotting. In some instances, if symptoms are incapacitating, small doses of oestrogen may be given, particularly certain oestrogens which are said not to affect the clotting mechanism of the blood.

Other treatment is available if oestrogen is unsuitable.

General treatment

Of course any other medical or gynaecological conditions are treated as well. Advice is given on regular exercise; diet and correction of obesity, if necessary, are discussed. Counselling on general problems is given.

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PREVENTION OSTEOPOROSIS: EXERCISE IS IMPORTANT

Oestrogens can help to prevent osteoporosis, and certainly may provide pain relief once osteoporosis has occurred. It is thought that oestrogen does not actually reverse the changes once they occur, although more recent studies indicate it may to some extent do this.

At this stage, oestrogen cannot be recommended for all women postmenopausally, as benefits must be weighed against side effects, but it would certainly be indicated if there were a strong family history or osteoporosis.

Exercise is important

Every woman should h.ave daily exercise other than, for example housework, driving car and shopping Have a programme of exercises and do them daily. Jog or play tennis. It will certainly benefit your bones as well as any symptoms, and also your general well-being. Bones become denser with the stress of exercise. Astronauts have been found to have softer bones when examined after landing and patients confined to bed for any length of time exhibit the same effect.

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WEIGHT LOSS: WHAT CAN YOU DO?

Simple measures Eat half what you do at the moment. Cut down what you know fattens you – refined carbohydrates such as sugar and starch. Fats too should be reduced.

Simple painless measures first Use non-saccharine artificial sweeteners for stewed fruit and beverages, and avoid sugar

wherever possible.

Skim milk to replace milk, however little milk you use, is beneficial. Skim milk is now available in containers from dairies and food stores in the cities (and in most country areas), and tastes very pleasant for those who dislike the powdered form.

Alcohol This not only supplies masses of calories, but weakens the will in many things, including whether you will stick to your planned diet or not. A good idea, if you can’t cut it out altogether, is to make a compromise: drink alcohol only when you are out, for instance at parties; or take half your usual intake. Better if, for a period, you can remove it altogether. Beware the additions to alcoholics drinks, for example tonic water is full of calories. Whisky and soda, or pink gins, are less calorie filled. Beer is out; it is loaded with calories.

Crash diets These are useful in the short term but only after consulting your doctor. Those which completely remove one element in your diet should be avoided; a balance is much safer. Go out and buy a calorie counter at your chemist so that you can see what you are consuming.

Diuretics ‘I accumulate fluid, doctor.’ Some women have this problem – though it is not as common as some believe – but draining yourself of fluids is not the way to reduce weight. There are certain things known to aggravate fluid retention:

• a high salt intake. Salt should be cut down and should not be added after cooking. Like your appetite for sugar, you develop a taste for it but you can gradually cut it back. You need it less and less, even on eggs. This salt reduction also helps your blood pressure.

• a highly refined carbohydrate diet is known to retain fluid so cut this down as far as possible

• smoking.

Diuretics should only be taken under the close supervision of your doctor. In my opinion diuretics will be needed less frequently if the simple measures above are adhered to.

Natural fibre Plenty of natural fibre in your diet is important, as indicated in the section below on constipation, and becomes more important if food intake is reduced. Those who have not been constipated before in their lives sometimes find constipation a problem if they are on restricted diets.

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