At 47, sweating through the night like a boiled potato, I now get why, in House of Cards, Claire Underwood regularly cools herself in front of an open fridge. But when I whisper the word ‘peri-menopause’ to a friend my age, she denies all knowledge and goads me for details.
Not wishing to play the wizened crone to her dewy youth, I say I was asking for research purposes. Our shame about ageing makes it worse. Admitting you’re menopausal is to admit, a friend says, that you’re ‘a dried-up witch; there is no hot-flush camaraderie’.
As a result, many women manage the change alone and flounder. We don’t recognise that anxiety, edginess and low mood are classic peri-menopausal symptoms. And nor do some doctors – who, as one 41-year-old wrote on Mumsnet, ‘prescribe antidepressants, diazepam and sleeping tablets but not HRT’. And we’re confused.
Many women believe there’s a ‘one size fits all’ hormone replacement therapy (HRT) made of pregnant mare’s urine (Premarin), available on the NHS, while those who can pay do so privately for more expensive, individually tailored hormones.
The truth is more complex: body-identical oestrogen and progesterone, derived from yams, are actually available, for the price of a prescription, on the NHS, and are a form of HRT. They have the same molecular structure as the hormones produced by the body, unlike Premarin, which contains different types of oestrogen, some of which we don’t need in our bodies.
Many women do well on older-style HRT, but newer, purer forms of progestogen – the synthetic version of the hormone progesterone – are increasingly prescribed. Other concerns include an increased risk of cancer.
Evidence suggests that HRT does not cause cancer, although in rare cases it can accelerate the growth of cancer cells already present. And yet 90 per cent of women avoid HRT: some for medical reasons; others because headlines have convinced them it’s a death sentence.
My social circle reflects this ratio. One friend, 55, decided against it as she hasn’t had kids, which slightly raises her breast cancer risk. A cousin, 53, took black cohosh – a herbal remedy available in health food stores – to combat mild hot flushes, but puts up with ‘terrible insomnia’ as she’s wary of HRT. She exercises, eats well and ‘can cope’.
Meanwhile, a colleague – Rachel, 55 –takes HRT unwillingly, after ‘violent, brain-melting’ hot flushes gave her months of one and a half hours’ sleep ‘in five-minute chunks’. She’d tried a LadyCare menopause magnet, which claims to balance the autonomic nervous system (which controls our heart and glands).
Many say the magnet relieves symptoms, although doctors don’t discount a placebo effect and, after two weeks, it hadn’t worked for Rachel – although she did spend a day walking around the office with a large paper clip stuck to her skirt.
A quarter of women breeze through the change with merely a few hot flushes. But most of us stumble through our 40s and 50s feeling like medieval peasants watching a thunderstorm: what the hell is happening?
So, to help answer that question, here’s Stella’s guide to everything you wanted to know but were too afraid to ask…
What is the Menopause?
The menopause occurs after your periods cease. When your ovaries stop producing eggs, your oestrogen levels fall. However, the symptoms can present up to five years beforehand, as the oestrogen gradually declines. This is known as peri-menopause.
Among its many functions, oestrogen is thought to aid cognition and memory. It also affects collagen in the skin, maintains bone density and keeps blood vessels clear of the sticky deposits that cause damage and can lead to cardiovascular disease.
It maintains the pH balance in the vagina, reducing the likelihood of infections, prevents the vaginal wall from thinning and keeps the area moist. In short, a decline in oestrogen can wreak mental and physical havoc, with symptoms often worsening over time.
The psychological symptoms
This year, my brain turned to sponge. I lost my wedding ring and, eight months later, found it in an Ocado bag I happened not to have recycled. I turned up Kate Bush on the car stereo and reversed into a tree. Such psychological symptoms – memory lapses or an inability to multitask – may result from decreasing oestrogen.
‘I feel like I’ve got Alzheimer’s,’ I bleat to GP and menopause expert Dr Louise Newson of Spire Parkway Hospital, Solihull. ‘Many women say that,’ she says.
‘The most common psychological symptoms are a loss of self-esteem and confidence, anxiety and panic attacks. Lots of people have depressive symptoms but they’re not actually depressed. They’re short-tempered, irrational. The psychological symptoms are the ones that floor people – and they don’t realise they’re related to the menopause.’
Physical symptoms
Lesser-known physical effects, such as ‘not being able to hold on to urine’, as Dr Newson puts it, will resonate with women who dread the third sneeze. This usually isn’t because you skipped your pelvic floor exercises but because the tissues of your bladder and its supporting structures are affected by oestrogen.
‘Loads of people also have vaginal dryness,’ adds Dr Newson, ‘but it’s one of those hidden taboos.’ (An oestrogen tablet or pessary, applied locally, can help.) The most common physical symptoms of the menopause and peri-menopause are hot flushes and night sweats.
‘I have patients who have them every two, three minutes,’ says Dr Newson, ‘and other people who have them occasionally – but you can’t predict when. It’s the lawyer in court, having them when she’s doing a difficult case, or the teacher standing up in class.’
Some people, Newson notes, ‘get dizzy episodes, or palpitations. Then there are the dry eyes; itchy, dry skin; lank hair; and brittle nails. It’s all related to collagen. Even people who don’t have night sweats can have patchy sleep. And some suffer from fatigue, even if they’re sleeping well.’
HRT: What it does
Hormone replacement therapy (HRT) replaces oestrogen and progesterone (though if you’ve had a hysterectomy you need only oestrogen). Progesterone is taken, usually as a pill, for two of every four weeks, or daily if you no longer have periods. Oestrogen is taken daily, often as a patch or gel.
Taken alone, oestrogen builds up the womb lining. ‘If you carry on and carry on,’ says Dr Newson, ‘there’s a small chance of it changing to cancer.’ However, taking progesterone too ‘stops the womb lining building up, so there’s no increased risk’.
If you’re still having periods when you start HRT, you take progesterone cyclically for a year, so you continue having periods. This is to give your body time to adjust.
Then you start taking it daily, at which point your periods stop. HRT does not postpone the menopause – it simply replaces the depleted hormones. And it’s best not to wait for your symptoms to worsen.
‘The earlier you take it, the better,’ explains Dr Newson. ‘When you’re peri-menopausal, rather than waiting till you’re post-menopausal.’ Even if it’s just one symptom – ‘say, hot flushes, making you not sleep and not function, and interfering with your quality of life, or loss of drive’ – HRT might benefit you.
Some symptoms vanish after menopause. But some women suffer hot flushes into their 80s. Dr Newson says, ‘To take HRT for the shortest length of time, I would just reduce my dose and stop after three to five years, and see if I still had any symptoms. The majority of women will probably be fine, but some women take it for decades.’
The risks of HRT
There are different brands and strengths of HRT. It can be taken in tablet, gel or patch form. Some women choose combined HRT, in which doses of oestrogen and progesterone are pre-prepared in a single tablet or patch. Others take oestrogen as a gel, and progesterone as a tablet.
Some women are fitted with a Mirena coil – a contraceptive that releases a synthetic form of progesterone into the womb – so they just need oestrogen. Taking HRT orally carries a small risk of a blood clot or stroke. Dr Newson explains: ‘Oestrogen as a tablet is digested and activates your liver, producing clotting factors. So you have a very small increased risk of a clot in the leg, or a stroke.’
But, she stresses, ‘Most people’s risk is very small. The risks increase if you’re overweight, you smoke, or have a family history of clots.’ An increased risk of breast cancer is most people’s fear. However, as Dr Heather Currie – gynaecologist and founder of Menopause Matters – notes, ‘Being overweight after the menopause is a far greater risk factor for breast cancer than use of HRT.’
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