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Hands up who’s thinking about...

the menopauseEco tampons, leakproof pants and cycle-based skincare are all part of life these days,

but when it comes to what happens when menstruation reaches its expiration date, most of us are in the dark. Given it’s the one health issue set to affect every woman, it’s time

to read up on menopause and what you can do now to future-proof your bodywords LAUREN SAMS and GEMMA ASKHAM

W o m e n ’ s H e a l t h D E C E M B E R 2 0 1 9 | 1 1 7 W o m e n ’ s H e a l t h1 1 6 | D E C E M B E R 2 0 1 9

here’s no need to download a period-tracking app to keep a log of when you last thought about the menopause. The likelihood is it wasn’t yesterday, nor last month, but never. It’s the stuff of old lady memes, scenes from Coronation Street and the crass punchlines of mother-in-law jokes: a furious woman with a flannel on her face or a chin hair sturdier than Donald Trump’s ego. So when you’re elbow deep in the Jenga towers of the supermarket sanitary shelf, the menopause feels as generation-relevant to you as writing a cheque. Besides, what else is there to it beyond feeling a bit hot?

Bloody hell, you’re in for a shock. Because menopause is not as simple as your body deleting an app. Symptoms can begin years before your last period, have ramifications long after, and there’s no set age at which you’ll experience them. ‘Menopause is the date of your last period when you subsequently don’t have one for a year,’ explains consultant gynaecologist Dr Kate Panter, a member of the British Menopause Society’s medical advisory council. ‘You’re born with a finite number of eggs, which declines throughout your life. When they run out, you don’t develop and release another egg or produce oestrogen, the hormone that stimulates female development during puberty and controls your reproductive cycle subsequently.’

Menopause typically occurs between the ages of 45 and 55, but it could happen in your thirties – one in 100 women has her last period before 40 – or, for one in 1,000, as early as your twenties. Nine in 10 instances of early menopause occur completely

The average woman doesn’t discuss menopause – until she thinks it might have hit

spontaneously without any root cause. Before menopause itself, you’ll experience the lesser-known perimenopause (the transition period where your body makes less oestrogen), which lasts four years on average, but can continue for anywhere from a matter of months to a decade, despite your last tampon purchase still being years away.

HOT SHAMEDr Nicola Gates, a clinical neuropsychologist and author of The Feel Good Guide To Menopause, wants to demystify the menopause conversation and believes that the stigma is happily easing off, thanks to the more public lives women live. ‘My grandmother went through menopause in the privacy of her own home. But my mother went through it as a chairperson on

a board and I’m going through menopause in the workforce,’ she says. In 2017, the 90s Britpop guru-turned-menopause activist Meg Mathews launched megsmenopause.com, a medically backed information resource that hosts taboo-busting conferences, after being shocked by the difficulty she had finding information when she started having menopausal symptoms. Earlier this year, TV presenter Louise Minchin described how the temperature in the BBC News studio was dropped to accommodate her hot flushes, and Kim Cattrall has spoken openly about her own experiences. Last year, Gwyneth Paltrow announced her intention to ‘rebrand’ menopause.

It’s a welcome change, as the average woman doesn’t discuss menopause at all – until she thinks it might have hit. For something that everyone who’s had a period is set to go through, talk is stifled. Why the menopause stigma in the first place? Part of it is because women’s health, in general, has historically been shrouded in mystery. As far back as the ancient Greeks, angry women were said to have ‘wandering wombs’ (the cure: vigorous sex) and in the Victorian era, those same angry women were diagnosed with ‘hysteria’, a word derived from the Greek for uterus. ‘The menopause is often thought of as the last taboo,’ explains Dr Louise Newson†, GP and menopause specialist at Newson Health Menopause & Wellbeing Centre. ‘All women, if they live long enough, will go through it, yet so many don’t understand when they start experiencing symptoms such as low mood, reduced motivation, anxiety and low energy levels. Many women also don’t realise that, when they’re menopausal, they have an increased risk of conditions such as osteoporosis and heart disease.’

There’s also the fact that, by its very nature, menopause is linked to the ageing process – something society tells women they should fight against, or at the very least deal with in private. ‘The menopause is often thought of negatively because fertility gradually declines as we age,’ explains Dr Newson. ‘But given the national average age at which it hits is 51, it shouldn’t be thought of as affecting “old” women.’

Take into account, too, that while puberty and pregnancy, for example, are fairly similar for most women, menopause symptoms can run a wild gamut. ‘One woman’s experience of perimenopause and menopause is very different from another’s, not only

in symptoms, but how those might vary over months and years,’ explains Dr Newson. ‘Talking about it more is so important to normalise the whole spectrum of experiences; I’ve had women come to me who think they’re struggling with depression, when in reality their symptoms are linked with a change in hormone levels, but they don’t realise there could be this association. And even though some women don’t have overt symptoms, low hormone levels in the body still leave you at increased risk of conditions such as diabetes, heart disease and dementia.’ COOLING-OFF PERIODIt’s important to get the lowdown on the biology behind the symptoms. ‘If you’ve had regular periods – say, a 28-day cycle with a four-day bleed – the clockwork nature of your cycle goes first,’ explains Dr Panter. The variation will be erratic: some months your period might be longer or shorter, heavy then light. It’s common to

have what Dr Panter calls ‘good egg months’ – three months of periods with no signs of the menopause at all, for instance, followed by ‘three bad egg months’, where your cycle stops and the perimenopause cranks up. Well, heats up. Hot flushes and night sweats, known collectively as vasomotor symptoms because they result from changes in the diameter of blood vessels, occur during the early dip in oestrogen that scientists believe narrows your thermoregulatory veins – which means you feel hotter, way hotter, easier. Then there’s oestrogen’s mood-meddling impact on the brain’s messenger system, affecting hormones such as dopamine (involved in motivation – see ya, 6am workouts), glutamate (crucial in learning and memory formation – where did you put your phone again?), oxytocin (for trust and bonding – cue fights with your partner) and serotonin (key to a balanced mood).

Searching for a silver womb lining in all this? We’re not there yet. Because oestrogen, like a disgruntled ex, creates more havoc before it slams the door on the way out. The female skeleton relies on oestrogen to stay strong and non-porous;

once your ovaries press stop, there’s a dramatic drop in bone mineral density (see page 37 for how to deal with that), increasing the risk of osteoporosis, a bone- thinning that’s symptomless… until you trip while running. Wait, there’s more: low levels of oestrogen make skin thinner, drier and itchier. ‘There are oestrogen receptors in tissues all over the body, but they’re more sensitive in some areas than others – namely, the vagina, vulva and bladder,’ says Dr Panter. This leads to vaginal dryness, which starts during menopause and gets worse after it (oh, joy), as well as urinary tract infections. A fragile bladder, plus changes to the biome of the vagina (it’s less acidic sans oestrogen), is basically an invitation for bowel germs to enter, bed in and cause an infection.

In short, your body’s way of saying, ‘Thanks for the fertile years, we’re good now,’ is far more complicated than you’d think. But, armed with fresh know-how, it’s possible to take back control of some of the symptoms.

ONE FOR THE AGESOnce you’ve accepted that the menopause is inevitable, your homework is to make symptoms more manageable, and that starts now – beginning in the gym. ‘We know there’s a synergistic effect with weight-bearing exercise on bones,’ explains Dr Panter. ‘The jerkiness of cardiovascular exercise, like running, in conjunction with resistance training at 75% of your maximum heart rate a couple of times a week, is optimal.’ This tugging

and stress on bones can nudge bone-forming cells into action. ‘After menopause, your bone mineral density deteriorates from the level you established in your twenties, so it’s really important to have a good peak bone mass – by exercising, but not to extremes (never to the point where your periods stop), avoiding being underweight or obese, eating a diet rich in calcium and vitamin D and not smoking.’ Thanks to the menopause being, frankly, an arse, there are two other reasons why it’s crucial to set a strong exercise routine, stat. First, because you naturally lose sensitivity to insulin around menopause and become susceptible to weight gain around your stomach. Second, your endorphin reward hit from exercise dwindles. Meaning the deeper you embed a workout habit now, the more likely you are to keep it up even when your hormones have gone haywire.

Talking about menopause with the women in your life, just as you might any other health concern or transition, is key. ‘I speak to so many young women who can’t tell me what age their mother went through menopause,’ shares Dr Therese Foran, a sexual health physician who specialises in women’s health, who encourages you to speak to all your older female relatives. Why? Because shared familial characteristics or traits, such as a smoking habit or similar BMIs, can give an indication of when you can expect the menopause to hit. And, increasingly, researchers believe it’s largely down to genetics, with your mum’s menopause age being a significant predictor of your own.

Plus, there’s nothing like the unknown to put the fear into you, so, when it comes to a biological phase known to affect mental health, it’s all the more crucial to start prepping your mind now, not just your body. ‘We know that how you think about your symptoms will definitely affect how badly (or not) they impact your quality of life,’ confirms Dr Panter. For example, if you get a hot flush at work and think, ‘Oh my god, everyone’s looking at me,’ you’ll get a longer, deeper hot flush because you add in social anxiety, stress and embarrassment. Whereas thinking, ‘Eff it, no one cares,’ reduces the physiological response. Do the prep work now and you’re much more likely to swerve shame later. Myra Hunter, professor of clinical health psychology at King’s College London, found that when women rationalised hot flushes and night sweats in a kinder way, they didn’t bother them as much. In one

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THE MENOPAUSE IN NUMBERS

The number of years you’ll typically experience perimenopause, when the familiar

symptoms begin to occur as the levels of oestrogen in your body start to decline.

The percentage risk of developing depression during perimenopause and menopause for

women who have never experienced it before, according to a study published in the journal Psychological Medicine. For those who have

had depression before, the risk was 59%.

The estimated percentage of women who experience hot flushes during menopause.

Studies* have shown that Japanese women are much less likely to suffer them, reportedly due

to the amount of soya-based foods in their diet.

The proportion of women who hit the menopause before the age of 40. For one in

1,000, it can happen as early as your twenties. At the other end of the scale, five in 100 women

will menstruate up to their 60th birthday. That’s a whole lot of tampons.

The average age when the menopause occurs for women in the UK. It usually takes

place between the ages of 45 and 55, according to data from the NHS.

example, she asked 20-somethings what they would think if they saw a 50-year-old woman red-faced. They replied that they’d think she’d been to the gym or had just run up the stairs. The menopause – and any judgement associated with it – just didn’t figure. ‘It’s like when you have a spot and you think everyone’s looking at it, but no one else notices,’ says Dr Panter.

YOUR HRT’S DESIREWhen the time does come for symptoms, what does the standard treatment, hormone replacement therapy (HRT), actually mean for your menopause? ‘HRT replaces, at a very low level, the hormones that a woman is no longer producing,’ Dr Panter explains. That means either applying an oestrogen gel to your inner thigh or wearing an oestrogen-releasing patch on your stomach or bum, as well as taking an oral progesterone tablet. ‘In terms of hot flushes and night sweats, HRT usually gets rid of those completely and, psychologically and cognitively, people feel much more themselves again.’

That said, taking HRT isn’t a one-size-fits-all-ovaries miracle, either: doses and types of HRT vary, so it’s crucial that you receive personal advice. If you have a no-sweat resistance to hot sweats, but find yourself plagued by vaginal itchiness, for example, you may be better suited to a topical treatment, such as a low-dose oestrogen tablet called Vagifem that you insert into your vagina twice a week. If your periods stop early or your quality of life has noticeably deteriorated, however, you’d be encouraged to take full HRT as early as possible to safeguard your bone and heart health. What makes HRT less desirable is its reported link to an increased risk of breast cancer. However, many types of HRT have never been associated with any heightened risk and, even in the ones that have been, the risk is very low. Indeed, the average woman is far more at risk of developing breast cancer by being overweight; a BMI over 30 pretty much doubles the probability.

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HARD GRAFTIn August, Professor Simon Fishel, one of the pioneers behind IVF, revealed that his fertility company ProFaM is now offering women under 40 the option to remove a tiny slice of ovary, freeze it and graft it back on to their body (likely in the armpit because of its strong blood supply) when their oestrogen supply starts declining – ergo delaying the menopause. How long that delay will last is almost as TBC as how long your Ryanair flight will be delayed for. Tissue taken from a 25-year-old might postpone the menopause for 20 years; that from a 40-year-old might only delay it for five. The surgery costs between £7,000 and £11,000, and Dr Panter is wary. ‘It’s been used as a fertility treatment for women with cancer: you remove their ovaries before they have chemotherapy (which can destroy them) and then put them back in. But it’s completely untested in clinical trials to delay the menopause,’ she explains. ‘By reintroducing an ovary, you’re exposing women to much higher oestrogen levels than a low dose of HRT. My feeling is that it needs to be measured – the risks and the benefits – and then evaluated. After all, menopause is a natural process – it isn’t necessarily a damaging health condition that needs to be treated like a disease.’

What’s more important for you right now is to break open the conversation and arm yourself with the best indicator of what menopause might look like for you. That is, ask your mum, your grandmother, your aunts about what happened to their bodies at what age. Wise up on how to build bone strength as well as ab strength to future-proof your body. Attempt to reframe your mind to see menopause as a biological process you can control, rather than one you simply have to live with. When it comes to menopause, even more than most things, knowledge is power.

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