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We all react differently to problems at any time in our lives; there is an old saying that at the menopause we are what we are only more so, but this really only describes our reaction to any change or phase in our lives. For example some women notice pain more than others. It also depends on what else is going on at the same time.
It is suggested that women who have interesting and fulfilled lives notice the menopause less, but I do not find this in our clinic. I have patients who say they cannot carry on their busy involved lives with their hot flushes and emotional disturbances. Among these are a top accountant, an opera singer, and an executive in a business organisation. Some women, on the other hand, cannot do housework because of their menopausal symptoms. It all depends on your make up. There is no need to feel ashamed or apologetic, and there is no sense in not seeking help.
You may find that generally tidying up your physical habits is all that is needed. It is well known that tension, excess weight and alcohol consumption, to mention just a few examples, all increase the severity of some symptoms. Maybe you can adjust this yourself. Some believe in natural foods and increases in vitamins; others in hormone replacement. Find a sympathetic doctor you can talk to. I feel that if you know the facts, you can sort it out with him or her and in any case will be more relaxed about approaching and experiencing this phase in your life.
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Treatment of uncomfortable intercourse is to my mind one of the most important uses for oestrogen replacement. Women must be given oestrogen replacement long-term after the menopause if they are having painful intercourse and discomfort so severe it cannot be relieved by other measures. These women, from then on, will only get drier and drier if the discomfort is due to oestrogen lack, and the process will not be reversed unless treatment is given. Marriages have been ruined and family life disrupted when this simple treatment has been withheld. There is no doubt that this symptom is interrelated with libido after the menopause, but as explained later, other factors are also important.
In all the discussion about increased desire, or loss of it, there are two main points, that libido is maintained by regular sexual activity, and that sexual activity actually keeps the vagina more flexible. There is no doubt that sexual activity within a relationship gives a new meaning to it, and in most instances it is well worth maintaining. It is a fact that in both men and women, regular sexual activity in later life not only improves the performance but also the desire.
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As I have said already, if the uterus is removed periods cease, but, if the ovaries are left, hormones are still produced and menopausal symptoms should not occur. However, in patients attending our clinics, and it is reported elsewhere as well, a large number of hysterectomised patients do have menopausal symptoms earlier than expected. This is thought to be due to the fact that the blood supply to the ovaries is interfered with, and they atrophy or shrink following operation.
Oestrogen replacement after oophorectomy Unless it is con-traindicated, oestrogen therapy should be given after an oophorectomy. It is routinely done in most cases, particularly with younger women. Oestrogen replacement should be continued at least until after the woman would have normally had her menopause in her fifties as this prevents thinning of the bones or osteoporosis (see chapter 5).
7 thought I could not become menopausal if I had had a hysterectomy’ This is a common statement. If ovaries are present menopause will, in many cases, occur at about the same age as you would have it normally. If ovaries are removed it follows soon after operation.
Hysterectomies do not affect your sex life at all. If ovarian production is also interfered with but the symptoms are removed with replacement therapy, this should not affect your sexual life either.
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This is up to you, and may depend on the severity of your symptoms. As far as I am concerned I am neither of the group that says ‘It is best for everyone’ nor am I against it. I prescribe oestrogens for those whom, after full examination, I feel it will benefit, and for whom I believe it is safe. Oestrogen therapy should not be refused, nor should women worry about taking it, but like any therapy it should be used with caution and administered in the safest possible way. After all, this applies to any therapy.
If you are in doubt If you have symptoms, try replacement therapy. You can stop at any time; you will know in a short time if the symptoms are relieved and you feel better for it.
What is the safest possible way?
The safest course of replacement therapy is the method outlined in the guidelines of our clinic. We see patients six to twelve months after they are stabilised on treatment, examining their blood pressure and their breasts and looking for any untoward side-effects. We give them a full examination and pelvic examination yearly, and we do a smear test yearly for two normal smears, then every alternate year.
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SHOULD UNUSUAL BLEEDING BE REPORTED?
It is important to know about bleeding, when it is abnormal, and when to report to your doctor.
Heavy periods Around the menopause, women often experience heavy bleeding. This should not be ignored. In almost all cases it is due to hormonal changes, but, in a small number of cases, there may be something abnormal producing this, and a dilatation and curettage should be performed. This is not only for diagnosis, but is often curative.
Prolonged periods Any period that lasts longer than seven or eight days, or, if your periods are usually long, if there is a pronounced increase in length, should be reported.
Bleeding between periods This should be investigated; it may be due to a polyp or local build-up of tissues in the uterus or cervix, but it may be due to something more severe. It may also be due to oestrogen lack, due to an atrophic vagina, and in these cases it may also occur after intercourse. This should also be reported. Other bleeding that should be reported is bleeding that is more frequent, and bleeding that occurs twelve months after the last menstrual period.
Missed periods Although missed periods are very common during the menopause, you will probably want to consult your doctor to ensure you are not pregnant. If you are pregnant, and wish to carry on with the pregnancy, tests can be done to determine whether the baby has abnormalities. This should be considered as there is a relatively high degree of abnormality in babies of older women.
With oestrogen therapy, what bleeding should be reported?
1 Bleeding while the tablets are being taken unless progestogen tablets have been taken in the preceding week.
2 Any bleeding which is heavy or prolonged at any time, even if it is at an expected time, that is following progestogens.
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