What happens at menopause

• hot flushes • night sweating • anxiety, depression and irritability • sexual difficulties due to changes in vagina • skin ‘ages’ as it loses elasticity • bones weaken as calcium is lost

By alleviating the physical changes, hormone replacement therapy can lift the mind and help women to come to terms with the change of life.

How does hormone therapy affect your sex life?

The reduction of oestrogen can make the lining of the vagina become thinner and less elastic -making sex uncomfortable or even painful. (This is known as ‘vaginal atrophy’). Couples can find it very distressing when a previously enjoyable sex life becomes painful, and it can be a cause of great unhappiness and tension between them. Treatment with oestrogen soon restores elasticity to the vaginal wall and reduces discomfort, so that intercourse becomes a pleasure again.

On the other hand, difficulties that relate to feelings about sex, lack of enjoyment, not being ‘bothered’, are more often concerned with a woman’s ideas about herself at this age. Her resentment at the inevitable signs of ageing is sometimes made worse by comparing herself with attractive daughters. Some older women begin to equate themselves with their own mothers, whom they never imagined enjoying intercourse, and feel that sex is inappropriate -’I’m too old for that sort of thing.

Each woman will have an individual reason for her sexual difficulty and only treatment which aims to help reach and understand the source of anxiety is really effective. If your own doctor does not know where you can find help, contact the Institute of Psychosexual Medicine who will be able to advise you.

Is it true that taking these hormones keeps you young? Oestrogen does have a marked effect on the condition of the skin and connective tissues-just think about how the skin changes at puberty when oestrogen levels rise. When it is reduced during the menopause the skin becomes thinner and less elastic. This loss of elasticity may also mean that the breasts lose their shape. So the effect of oestrogen on the skin and connective tissue can help to keep a more youthful appearance.

However, it’s worth bearing in mind that, until recendy, most of the women who had HRT were those who had enough money to pay for it. They would also have had more money to spend on clothes, make-up, hair-care, etc., and have been more cushioned from the hard economic pressures of work and family raising which can contribute a lot to ‘ageing5. Certainly the way a woman feels about herselfis as important as her hormone status.

Decrease in oestrogen levels is also related to the gradual thinning of the bones which affects women as they get older; after the menopause calcium is lost from the bones at the rate of 1 per cent a year. This does not cause any immediate difficulty, but gradually makes women more likely to have fractures; which becomes more common around the age of 70.

HRT will stop the loss of calcium but only during the period of therapy. In fact, there can be an increased loss when treatment is stopped, so that the risk of fractures can only be reduced by prolonged therapy.

Can you get pregnant while you are having HRT?

It is possible to conceive while having hormone therapy. While a woman’s oestrogen production may be sufficiently erratic to produce such symptoms as hot flushes, there may still be an occasional ovulation, which makes pregnancy possible. HRT does not suppress this. The oldest age of conception in the Guinness book of Records is 57 years. It is always advisable to continue contraception until two years after the last period when this occurs before the age of 50, and one year when it is over 50 years.

There is no reason why an IUD cannot be left in the womb until contraception is no longer needed, provided there is no irregular or heavy bleeding, but it should then be removed. If a progestogen-only pill is used as a contraceptive, the doctor has to take this into account in HRT, because the therapy may contain a dose of progestogen in the second half of the cycle.

How safe is hormone therapy?

A doctor has to bear in mind some possible risks when prescribing oestrogen treatment- although in some areas the evidence is still rather confused.

Oestrogens are thought to affect the rate of growth of breast cancer, which is why the ovaries are often removed in those who suffer from this disease. HRT must never be given to a woman who has had breast cancer before the menopause, but there is no suggestion that HRT causes cancer of the breast in women.

There has been anxiety about the effect of giving oestrogen on the lining of the womb, especially when it is no longer shed at regular intervals during menstruation. This is why oestrogens are now usually given combined with progestogens for part of the cycle, to encourage a regular monthly bleeding from the womb. Any woman taking hormones should have tests to check that there is no abnormal thickening of the cells of the womb lining, which could later develop into cancer.

The connection between oestrogen and heart attacks is confused. Studies of patients taking oral contraceptives, containing synthetic oestrogens, have shown that they increase the risk of a coronary thrombosis, especially in the over-weight woman, who is already liable to attacks.

On the other hand, women during the re-productive years, when oestrogens are naturally present, show a lower incidence of coronary heart attacks compared with men of the same age. After the menopause the rate rises to become equal, suggesting that natural oestrogens do protect against heart attacks.

For this reason it may be that HRT, in which natural oestrogens are used, protects against coronary riirombosis, because it restores a woman to herpre-menopausal state.

Does hormone therapy make the change of life easier, or does it only put it off? Because hormone therapy can alleviate some of the acute symptoms of the menopause, it will help to restore a woman’s confidence and prevent her from feeling at the mercy of her hormones. By gradually reducing the dosage, the treatment can often be stopped without the symptoms returning. But the caring attention that a woman receives during the treatment can often play just as vital a role, helping her to come to terms with die fact that some changes are inevitable as we grow older – and that, however regrettable, ageing cannot be put off forever.

So, although HRT can relieve the bodily symptoms, she may well need sympathetic coun-selling help with the more emotional causes of distress. It’s interesting that studies have shown that single ‘full-time’ working women suffer from fewer complaints during the menopause, so it seems important for a woman to develop some new worthwhile occupations to hold her interest during these years.