The menopause

The menopause simply means the time when a woman stops having her periods, but as any woman who has been through it will know, the change of life doesn’t usually only involve this. There is awhole range of physical symptoms and emotional upheavals which may occur before, during and after her periods finally stop. It’s for this reason that the menopause is more accurately known as the climacteric, which is derived from a word meaning the rung of a ladder. This word embraces all the changes, both physical and psychological, which a woman may be heir to once her ovaries stop releasing eggs and which eventually lead to a new hormonal balance.

By the time you reach the age of 50 you’ll probably be aware of certain outward signs of ageing; your hair may be going grey and your skin may have lost some of its suppleness. And, although you won’t be aware of it, the same process will be making the internal organs, and in particular the ovaries, age and degenerate.

Ageing causes the ovaries to stop releasing their eggs. This is something which happens to even’woman in middle age- sometimes as early as 45, sometimes around 50 and occasionally as late as The age at which it occurs varies with each individual, and there are normal cases beyond these two figures.

There seems to be no truth in the idea that the earlier a woman starts her periods the earlier she’ll experience her menopause. A study carried out some vcars ago compared women who had started menstruating at 13 with those who had started at 18; in both groups there was no difference in the average age at which the women experienced the menopause.

At birth the ovaries contain millions of poten-tial egg cells. Some die off, but thousands more become surrounded by cells to form During the fertile years only about 500 of these egg follicles will be used up-one for each month that a woman menstruates. The rest will simply degenerate. When this finally happens it will mean the end of a woman’s periods and with it her ability to have children.

Not only does the degeneration of egg follicles mean the end of menstruation, it has repercussions on other parts of the body, too, most notably on hormone levels. It’s the changes in the various hormone levels which account for most of the unpleasant symptoms of the menopause. But it’s important to realize that after two years or so your body will have learnt to adjust to these new fluctuations – the symptoms don’t last forever.

During the time of the climacteric, and in the years following it, there will be larger amounts of (FSH) in the bloodstream. This hormone, as the name implies, sets the follicles in action. Each month, combined with another hormone known as (LH), it stimulates one follicle to release an egg into the Fallopian tubes. Providing fertilization doesn’t take place, menstruation results. During the climacteric, however, the few remaining follicles become increasingly less sensitive to FSH. In response, the pituitary gland then steps up production of this hormone in an attempt to stimulate the follicles into releasing their eggs.

Similarly, the degeneration of the follicles means that there will be lower levels of the hormones and circulating in the bloodstream. Your body tries to compensate for this by stepping up production of oestrogen from other sources. The adrenal glands make more oestrogen, as well as (the male hormone), which is converted into oestrogen in the liver and adipose tissues. But a majority of women aren’t able to recreate the old balance.

The most obvious indication is when your periods cease, although, of course, this has to be coupled with your age. For most women the cessation of their periods is a gradual process and not something which happens abruptly overnight. Many women find the time between each period simply becomes longer and longer, while the periods themselves may last the usual four or five days, or perhaps less. Others may experience the usual monthly cycle but with a scantier flow of blood each time, until the periods peter out altogether and finally cease.

Although the body is in a similar state of flux during this time as during puberty, any other menstrual pattern should be mentioned to a doctor. This is particularly important if the periods reappear after an absence of a year or if, after a year to 18 months of being fairly scanty, they suddenly become much heavier and last longer. Either pattern could indicate an underlying condition which requires medical attention. Talk things over with your GP who will be able to establish whether or not your particular men-strual pattern is normal.

For some women the end of her periods may be the only outward sign of the climacteric. The other body changes, spread over several years, may be so gradual as to be barely perceptible. Such good fortune depends on your body’s ability to convert large amounts of androgen into oestrogen.

A majority of women, however, will experience hot flushes at some time. These are sudden feelings of heat, often followed by cold, and sometimes accompanied by profuse sweating, particularly at night The flushes usually start at the chest and spread upwards. Their actual cause is uncertain, but it would seem that the nervous control of blood vessels in the skin is disturbed either by the increase in FSH or by the reduction in oestrogen levels.

Another symptom which is caused by lower levels of oestrogen is the thinning of the vaginal lining. This lining, made up of 10 to 12 layers of mucous membrane may, during the climacteric, dwindle to as little as two or three layers. And since the thickness of the lining is a measure of its ability to protect the vagina from infection, many women find themselves more prone to infection after the menopause. Even without an infection, some women do encounter vaginal dryness and the effect of oestrogen decline on the breast soreness or discomfort during intercourse.

Loss of calcium from the bones starts to occur during the menopause, although the effects are cumulative and may not be noticed for several years. This can eventually lead to osteoporosis- the thinning and weakening of the bones. This condition makes the bones, particularly those of the hips, wrists and vertebrae, more vulnerable to fracture. Even though the onset of osteoporosis coincides with the menopause, there is some contention over whether it’s actually caused by reduced oestrogen levels

Is it true that a woman’s breasts get smaller after the menopause? Yes, this does often happen. The main factor in the development of breasts is oestrogen secretion from the ovaries. These become active just before puberty. Oestrogen not only causes the milk-producing duct system to develop, but also causes the number of fat cells between the duct tissues to multiply. It’s these cells which deter-mine the size and shape of a woman’s breasts. The number of fat cells will be pre-determined by her genetic make-up and the size of the cells will depend on how much she tends to eat.

With the fall in oestrogen levels at the meno-pause the duct system within the breasts will decrease in size and the breasts may lose some of their firmness as a consequence. But the duct system only forms a relatively small part of the breasts.

Oestrogen is also necessary to maintain the size of the womb. After the menopause this always gets smaller- sometimes shrinking to as little as a quarter of its former size. In women having regular sexual relations, the vagina itself won’t decrease in size. But in the case of women who don’t have a sexual relationship, the vagina and (the external genital organs) may shrink after the menopause. Once again, it’s important to remember that these changes take place over several years and don’t occur suddenly when a woman reaches a certain age.

Yes, it can be avoided. Weight gain around the time of the menopause has very little to do with changing hormone levels- it’s due simply to the fact that a great many women become less active during this time. There is a tendency to blame die menopause for all sorts of changes, but it’s unwise to put every new feeling or alteration in the body down to this.

If you do become less active but don’t reduce your calorie intake to match, weight gain is inevitable whether you’re going through the menopause or not. You may, however, experience a general alteration in your body’s proportions even without weight gain. This is to do with ageing in general and not solely to the fact that you’re experiencing the menopause.

The familiar’middleage spread’, which tends to creep over the waisdine and bottom but leaves the arms and legs relatively unaffected, is due to fat cells dying off from around the arms and legs. This makes the other parts of the body relatively fatter, even though you may not actually have put on any weight Remember though, that if you do put on weight, it will tend to accumulate round the waist.

You can avoid putting on weight by making-sure that you’re taking as much exercise as you were before the menopause; by reducing the amount of food you eat to match the decrease in physical activity; or by being more careful both to exercise and eat moderately. However, even the most rigorous attempts at keeping your weight constant can’t guarantee that you won’t get middleage spread. The likelihood of this happening is governed by the genetic and consti-tutional make-up of each individual, and there’s very little that can be done to influence it. But any type of exercise, even if it’s only housework, will boost your physical well-being.

Yes, this may happen to some women. Super-fluous hair, which is generally confined to the upper lip, is due to increased levels of androgen being secreted by the adrenal glands. The increase in the levels of androgen has it’s compensations, however. While some will be converted into oestrogen, the remainder, in its unconverted form, acts as a spur to sexuality. After the menopause, many women report an increase in their sex drive, something which is due, in part, to the increase of this hormone in die bloodstream.

If you do feel self1 conscious about facial hair, it can always be removed by electrolysis or can be made less noticeable by bleaching.

As regards the general quality of your skin, it’s almost impossible to tell whether an increase in the number of wrinkles and dry patches is due to the menopause and oestrogen deficiency or to general ageing and weathering. Certainly, if you’ve taken care of your skin all your life such changes will be less noticeable. If, on the other hand, you’ve been haphazard in the way you’ve cared for your skin, then skin problems in later life will be more obvious.

Alterations in feelings and emotions at the climacteric are difficult to generalize about. One woman might not notice any upset in the way she normally feels. She may sail through the meno-pause with only the slightest physical discomfort. Another woman may experience anxiety and depression, or a mixture of the two. She may go through mood swings with feelings of being unable to cope or experience sudden uncontrol-lable urges to cry.

There is no doubt that shifting hormone levels can cause some emotional changes. The in the brain master-controls the endocrine system. But just as it can initiate changes in hormone levels throughout your body, so it can be affected when these levels change. When this happens the hypothalamus can trigger certain emotional reactions such as depression and irritability, and cause rapid changes in mood.

The way you feel about your own fertility will also have a profound effect on your emotional response to the menopause. It can be a tragedy for the woman whose family expectations remain unfulfilled, or a time of relief if she has had the family she desires.

Ifs unfortunate that the menopause coincides with certain of life’s crises. It generally comes at a time when a woman’s children are growing up and perhaps even leaving home – so she can’t help but feel that her role as mother is changing. Her own parents will be ageing and may be declining in health. In this respect decisions may be needed as to who will look after them. Either her husband’s career, or her own, may have reached the stage where on the one hand, success is having a disruptive effect on family life, or, on the other, there may be the realization that ambitions will never be achieved. All these and other related domestic, social, and financial considerations will influence each woman’s overall reaction to the ‘change of life’ apart from any of the physical effects that she may oe experienceing at this time.

The simple answer is to regard the menopause not as a disease or an illness but to accept it as simply another aspect of maturity. It’s important to remember, too, that a considerable number of women (one estimate puts it as high as 40 per cent) maintain similar levels of oestrogen after the climacteric as they had before it So if you haven’t been through the menopause already, don’t automatically expect the worst.

Certain things can be a genuine help to a woman trying to cope. An understanding and sympathetic family, for example, can make a lot of difference. So, too, can a doctor who is willing to offer a listening ear and explanations of what’s going on in your body rather than giving you a bottle of tranquillizers to ‘calm you down’. Hormone replacement therapy (HRT) helps when there are upsetting oestrogen deficiency symptoms.

A job- part-time, full-time or voluntary- can give a purpose to life as well as giving a boost to morale. In this respect, one survey found that women who were employed full-time complained less of experiencing serious or unpleasant meno-pause symptoms. Boredom can be a terribly destructive state, especially to someone who is getting older.

As Far as sexual activity goes, the menopause needn’t signal any changes. Apart from possible vaginal dryness – and this can be temporarily improved by applying a lubricant before making love, or by treatments prescribed by your GP -you can continue to have sexual relationships well into old age. Your ability to enjoy sexual activity is not dependent on your ability to reproduce and, in fact, many women find that their enjoyment is actually increased once the fear of pregnancy has been removed.

Finally, it may help to remember that the climacteric doesn’t go on indefinitely. Your body may be in a state of flux for two or three years. After this time it will have adjusted to the changing hormone levels, which themselves will also have settled into a more stable state.

Although no one really knows the answer to this, scientists have managed to isolate a number of different processes that contribute to ageing.

Our bodies are maintained by hundreds of millions of cells constantly dividing and repro-ducing exact copies of themselves. However, it seems that certain cells can only divide a certain number of times, after which they cease to do so. These cells have a genetically determined life span and die out when they have completed their total number of divisions. This happens even in a foetus. Early in its life, the foetus has webbing between its fingers and toes, but the cells of the skin web die out after a certain number of divisions, so that by the time the foetus is born the toes and fingers move as independent units.

One very obvious example of cells reaching the end of their life span is baldness. It seems that baldness is genetically predetermined and that the cells which make hair protein can only divide a certain number of times. In some people they die out much sooner than in others. The menopause provides another example of cell death: there is evidence that the reproductive cells of women can only divide a certain number of times and reach the end of their life span between the ages of 45 and 65.

A second process that contributes to ageing is the accumulation of cell ‘mistakes’. It isn’t sur-prising that out of the hundreds of millions of cells copied in the body each year, mistakes are occasionally made and some of them are flawed. If a mistake is very bad the cell will die, but in many cases it survives and goes on to make copies of itself, all showing the same flaw – rather like the scratch on a negative which is reproduced even- time a print is made. An example of this is white hair: a stage is reached when, because of an accumulation of’mistakes’, the hair cells alter and no longer distribute pigment in the hair follicle in the same way, and so white hairs begin to be produced.

The third aspect of growing older involves a change in the chemical structure of the body -particularly in the elastic tissues under the skin. The proteins that make up this elastic tissue alter, becoming more rigid and making the elastic fibres stiffer and slower to return to their normal shape. In youth, skin is held tight to the underlying tissues by elastic fibres, but as these fibres lengthen with age, so the skin becomes slack, just as when guy ropes on a tent come adrift, the tent itself sags. The chemical changes in the body mean also that the ratio of fat to protein increases, so that although a person may stay the same weight, he has more fat and less muscle.

Although the protein which makes up muscles continues throughout life to be broken down and rebuilt, with age, muscles tend to waste at a faster rate than they are remade – so that by about the age of 70 muscle accounts for 12 rather than 19 per cent of body weight. Apart from muscle shrinkage, the organs of the body lose some of their bulk in varying degrees – including the brain, kidneys, liver, uterus and pancreas.

No. Many people apply oils and chemicals to their skin in the attempt to prevent ageing, but this is largely both time and money wasted, as nothing can reverse the process. Several important changes take place in the skin as a result of ageing. First, the skin becomes less elastic, which can easily be seen by taking a pinch of skin from the back of the hand, releasing it, and comparing how long it takes to return to normal with the skin of both a child and a much older person. At the same time, there is a decline in the amount of fat underlying the skin. This, together with the loss of elasticity, contributes to producing wrinkles.

Secondly, the sebaceous glands which secrete oils that keep the skin moist and soft emit less natural oil in old age, and the skin becomes drier.

Thirdly, the cells deep down in the layer of skin, which constantly divide and provide new skin cells, are prone to the types of error mentioned earlier. The mistakes lead to a change in appearance of the cells which come to the surface of the skin. For instance, the brown spots often seen on the skin of elderly people (especially on the backs of the hands) are due to errors in the distribution of pigment.