Menopause and Perimenopause

The current average life expectancy of a woman in the UK is 81.

Women now often live 30 years after their menopause; this period of their lives is extremely important.

The average age of menopause all over the world is about 51 years.

What is meant by perimenopause?

Perimenopause is the transition from a normal ovulatory menstrual cycle to cessation of ovulation and menstruation. This is the time when a woman moves from ovulating most months and having normal monthly periods (menstruation) up to the time when periods stop.

During the perimenopause, women may notice hormonal fluctuations, skip menstrual cycles and may have menstrual irregularities.

The ovaries start to fail, periods become irregular as the oestrogen hormones fall and this is usually a gradual change unless it is a surgical or medical menopause. During this time, the number of ovarian follicles becomes less, and this results in low oestrogen levels and high FSH (Follicular Stimulating Hormone) levels. This is what is thought to cause the symptoms of menopause.

The perimenopause usually lasts around 4 years (2-8 years)

It usually commences around the age of 47 years (39 – 51 years)

What is meant by menopause?

A woman is called “menopausal or post-menopausal” when she has not had any periods or bleeding for one year. The average age is 51 years all over the world, although some women can still have regular periods even after this age. It is uncommon to have periods after the age of 55 years.

Any bleeding after one year of no bleeding is known as Post-Menopausal bleeding and must be taken seriously. Medical advice should be sought as cancer needs to be ruled out urgently, even though in most women, the underlying cause is thinning of the vagina or thinning of lining of the womb due to lack of oestrogen.

Because of timing, the menopause often coincides with other life changes such as unwell relatives or parents, children moving out and relationship problems.

What are the common symptoms of the perimenopause and menopause?

8 out of 10 women experience the following symptoms but only 3 in 10 women seek help.

• Hot flushes
• Night sweats
• Mood swings/tiredness
• Sleep disturbance
• Lack of concentration
• Depression/anxiety/stress
• Urinary symptoms
• Osteoporosis
• Loss of libido (loss of interest in sex)
• Reduced sex drive 
• Vaginal Dryness
• Joint and muscle pain
• Dementia Risk

Do women always have to have tests to diagnose menopause?

After the age of 45, a diagnosis made on symptoms alone (clinical diagnosis) is often enough, unless there are also other health problems which may cloud the picture. Your GP will make that decision.

Between 40-45 years, diagnosis is based on clinical symptoms (hot flushes, no periods) and some blood tests.

Under 40 years (diagnosis is “premature menopause” or “primary ovarian insufficiency”). Your doctor should ideally refer you to a gynaecologist, as this needs specialist input and tests.

When should a woman stop using reliable contraception?

It is recommended that women should use effective contraception each time she has sex with a man to avoid unwanted pregnancy (condoms/coil/sterilisation/Pill) for at least two years after their last period if the periods have stopped before the age of 50.

If above the age of 50 years, it is recommended to use reliable contraception every time for one year after the last menstrual period.

This is also the advice if on Hormone Replacement Treatment. Consult your doctor for further advice.

Hot flushes:

Hot flushes are thought to be due to rapid falling levels of oestrogen in the menopause. Menopausal symptoms appear to be significantly less common in Asia, compared with western countries, a difference that is likely attributed to lifestyle factors, especially a high fat, animal based diet in the West that affects hormone levels rapidly and strongly. The drop in the oestrogen levels from high baseline oestrogen levels to very low levels in the menopause on a standard western diet is thought to be partly responsible for the more acute symptoms suffered by women in the western world.  Being overweight (oestrogen is produced in the body fat) is also associated with more severe symptoms.

Hot flushes have been reported by only about 10 – 20 percent of women in China and Japan. In contrast, it is estimated that hot flushes are experienced by 75 percent of women over the age of 50 in the West. Whether these differences might be partly due to reluctance in reporting symptoms among Asians is not entirely clear but as Asia’s diets gradually westernise, these differences are likely to disappear anyway

Western women consume much more meat throughout their lives and about four times as much fat, as women on traditional Asian rice-based diets, with only one-quarter to one-half the fibre. Japanese and Mayan women on the other hand, have lower starting oestrogen levels in their urine, have an earlier menopause and have mainly plant based diets. African-American women report more frequent hot flushes compared with Caucasian women

Risk factors that predict severity of menopausal symptoms include smoking, lower socioeconomic status, low calcium intake, and BMI (Body Mass Index), with higher BMIs correlating with more severe symptoms.

What can a woman do to help herself avoid or reduce the frequency of hot flushes?

Diet (see menopause nutrition leaflet)

It is important to eat low down in the food chain, which means plenty of vegetables, fruit, intact wholegrains, berries, minimally processed soya, beans, peas, lentils, nuts and seeds and water. Many of these foods are excellent sources of natural phytoestrogens (lignans and isoflavones). This will not only help with hot flushes, but also with reduced heart disease and cancer risk and improves general overall health and wellbeing.

Types of plant oestrogens:

• Avoiding alcohol and smoking will reduce menopausal symptoms and help in reducing breast cancer and heart disease risk.
• Caffeine containing drinks can make hot flushes worse.
• Being overweight or obese increases the severity of hot flushes because of the bigger drop in oestrogen levels. Being of a normal weight is important as obesity is directly linked to lifestyle cancers (breast, bowel, ovarian and womb cancers)

Regular Sustained Exercise: walking, running, swimming, yoga and other low impact exercises have shown to help with hot flushes. Aerobic exercise can improve psychological health and quality of life (mood, insomnia).

Hypnosis: has shown to be effective for some women in reducing hot flushes.

How should sleep disturbance and mood disturbances be addressed?

It is important to get good quality sleep of 7-9 hours at night. This sleep may be disturbed in the perimenopause and menopause. Sleep is needed for DNA cell repair and to normalise cortisol and other hormone levels. It also improves mood, lowers tiredness and stress levels.

How can a woman reduce her risk of osteoporosis?

• Weight resistance exercises twice a week working all groups of muscles is key to strengthen muscles and bones. Perform under supervision if beginner
• Yoga and Tai Chi improves mood, posture and balance
• Regular exercise aiming for a total of 150-300 minutes per week is recommended. This translates to 30-60 min of any exercise including walking/day.
• Walking, with arms, legs and back of neck exposed to the sun especially while sunny helps to maximise Vitamin D production in the skin. Duration of sun exposure varies from 15-45 min depending on skin pigmentation. Put sunscreen on after 15 min if pale skin to avoid sun damage. Avoid exposing your face to the sun.
• Supplement with Vit D3 1000-2000 IU per day especially in the winter months.
• Adopt a high fibre whole food plant based diet (minimally processed soya products such as edamame beans, tempeh and tofu, green leafy vegetables, beans and seeds) can help with bone protection
• HRT prevents osteoporotic fractures, but benefit declines soon after stopping, hence not recommended for this alone.
• Consult your GP or specialist for further medical options if indicated (for example strong personal or family history)

How can an individual help to reduce their risk of dementia and Alzheimer’s disease?

• Eating a fibre rich whole food plant based anti-inflammatory diet rich in fruits and vegetables is highly recommended for brain health. 
• Fresh fruit/vegetables/nuts/turmeric
• Spinach and berries, especially for helping maintaining vision
• Avoiding trans and saturated fats is particularly important
• Diabetes and heart disease increase the risk of dementia, so avoiding these through diet and lifestyle is important. 
• Yoga/Tai-Chi/Pilates improve tone and balance & also helps pelvic floor and urinary continence
• Encourage to join group activities and maintain social network.
• Encourage new hobbies – Sudoku, crosswords, learning a musical instrument

What are the common urinary problems in the perimenopause/menopause?

Urgency and urge Incontinence – Avoid too much tea/coffee/smoking. 

See a specialist who may recommend lifestyle changes/Bladder Drill/ medication

• Increased frequency or waking up at night to pass urine: This can be a real issue. Avoid drinking fluids for a couple of hours before going to bed. Losing weight and avoiding caffeine containing drinks that irritate the bladder and local vaginal oestrogen can all help with symptoms of cystitis. Cystitis like symptoms are often due to atrophy of genitourinary system as a result of lack of oestrogen rather than a true urinary infection.
• Stress Incontinence (leaking of urine on coughing/sneezing/running etc) 

Yoga/Tai-Chi/Pilates improves tone, balance & helps pelvic floor and continence. See your GP who may recommend Pelvic Floor Exercises/ Physiotherapy/ tablets/referral to a specialist for tests and surgery if indicated.

• Blood in the urine needs urgent attention to rule out serious causes. 
• If you have symptoms of urine infection (burning/increased frequency) this needs to be investigated and treated by your doctor if proven to be an infection. E Coli bacterial urine infection often has same genetic makeup found in chicken and can be a source of infection
• Maintain hydration with water
• Urgency/Urge Incontinence:
• Avoid tea/coffee/caffeine drinks
• Avoid smoking
• Avoid fluids at least 2 hours before bedtime

Are there some common gynaecological problems a woman may suffer during the perimenopause/menopause?

• Heavy Periods
• Post-menopausal Bleeding
• Uterine Prolapse
• Vulval soreness and itching. See general vulval and vaginal care leaflet.
• Vaginal dryness and soreness and often painful sex. See painful sex leaflet.

What are possible tests that the doctor may recommend?

• Depending on the condition, the following tests may be suggested:
• Blood Tests
• Cervical smear
• Pelvic Ultrasound Scan
• Hysteroscopy (Camera test)

Further information: 

See Menopause nutrition advice, Lifestyle medicine, HRT, Calcium, Vitamin D, Supplements, What should I eat, Soya, nutrition leaflets

Dr Nitu Bajekal FRCOG Dip IBLM

Consultant Gynaecologist and Women’s Health Expert

Lifestyle Medicine Professional

Updated January 2020