What is menopause and perimenopause? – The Age

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You have to surrender to it, British comedian Dawn French proclaimed last year of menopause. "I promise that, afterwards, theres life."

Disturbed sleep. Thinning hair. Anxiety. Mood swings. Memory loss. Weight gain. Or, for some women, nothing much at all.

Despite being a fundamental biological transition affecting half the world's population, the symptoms of menopause have been deemed, traditionally, "secret" women's business. Now it's starting to become more a part of the conversation.

In Britain, women are gathering at pop-up "menopause cafes" to swap notes on their experiences. Workplace policies to cater for menopausal employees are up for discussion too: Britain's Labour Party wants to mandate them for large organisations, and a major media company introduced one in October.

What is menopause and what is it with a "peri" in front? What happens to women experiencing it? What happens afterwards? And is there a male equivalent?

On average, a woman in Australia will have 400 to 500 periods in her lifetime. Menopause is when the periods stop. The word itself stems from the Greek pausis ("pause") and men ("month"), meaning the "end of monthly cycles".

Women are on a path to menopause from birth. A baby girl has more than a million eggs in her ovaries. Steadily, as she ages, they deplete. By the time puberty hits, only about 300,000 remain, and so it goes, through her adult life.

[Menopause] represents the end of a womans reproductive life, says Martha Hickey, professor of obstetrics and gynaecology at the University of Melbourne. Specifically, menopause is the final menstrual period a woman experiences it is a one-off event. All women will go through menopause. It is inevitable."

(In a reproductive life spanning decades, the average Australian woman will have two or fewer babies.)

Menopause is considered a normal part of ageing when it happens after the age of 40. But some women can go through menopause early, either as a result of surgery such as hysterectomy, or damage to the ovaries such as from chemotherapy. When menopause happens before 40, regardless of the cause, it is called premature menopause.

The average age of menopause is about 51 but it can happen sooner, with most women experiencing symptoms in the lead-up which brings us to perimenopause.

Comparing notes on perimenopause: there's a lot to talk about. Credit:Illustration: Dionne Gain

Technically speaking, the symptoms women experience in the lead-up to menopause are actually perimenopausal. Peri, a Greek word for "around" or "near" menopause refers to this transitional state.

Perimenopause is when a woman's ovaries begin to make less oestrogen and the body responds. It's a phase that lasts until menopause and, on average, begins when a woman is 47, although it can last from a year to a decade.

As the body makes less oestrogen, the pituitary gland produces higher levels of signalling hormones follicle-stimulating and luteinising hormones in an effort to keep the ovaries producing eggs and to make oestrogen and progesterone levels "normal".

This can lead to ovulation occurring twice in a cycle, the second time during a period, which can lead to high hormone levels. In other cycles, ovulation might not occur at all.

Some women describe perimenopause as a time of hormonal chaos akin to a second-wave puberty. Symptoms also include hot flushes, changes in libido, mood swings, memory problems, vaginal dryness and a higher risk of osteoporosis. Periods can be less regular, lighter or heavier, last longer or be briefer.Womens' experiences vary greatly some barely register anything.

"It's what's called the menopause transition when those symptoms start," Professor Hickey says. "That can go on for a number of years and the end of that transitional period is a year after the final menstrual period."

Genetic factors play some role in timing. If your mother and other close female relatives had an early or late perimenopause, it's likely you will too. But various studies also point to lifestyle factors, such as smoking, being linked to early onset while other studies have pointed to alcohol consumption delaying perimenopause.

Credit:IStock

After a woman has had 12 consecutive months of amenorrhea (lack of menstruation) she is said to be postmenopausal.

Perimenopausal symptoms ease but health risks related to the loss of oestrogen rise. This includes a decrease in bone density, which can lead to osteoporosis, where bones become thin and fragile. It also includes weight gain, which can increase the risk of obesity, diabetes and cardiovascular disease. Women are advised to keep active, which also releases endorphins that improve mood, and to do strength training to increase blood flow and strengthen the heart.

Hormone replacement therapy (HRT), or menopausal hormone therapy (MHT) as it's now known, is currently the most effective type of treatment available for perimenopause symptoms; more than 300,000 Australian women and about 12 million women in Western countries are using it. But it has been linked with breast and ovarian cancers.

"All medications carry risk and benefits," Professor Hickey says. "A benefit of HRT is that it's really good for symptoms. A risk is that it does increase the risk of cancer. I don't think we should beat around the bush about that. But it varies by the type of hormone therapy you take and it might vary depending on how long you take it for."

The risks are greater, for example, for users of oestrogen-progestagen hormone therapy than for oestrogen-only therapy. A large study by the Institute of Cancer Research in London found that women who took hormone therapy for five years were 2.7 times more likely to develop breast cancer than those who did not. Recent research also suggests that, in some cases, the danger can persist for more than a decade after treatment stops.

Another study found that women using hormone therapy for between one and four years have a 60 per cent higher chance of developing breast cancer compared with those who have never used it.

The report's authors, who examined 58 studies across the world, found that of 108,647 women who developed breast cancer at an average age of 65, almost half had used hormone therapy.

When asked if women should avoid hormone therapy due to the increased risk of cancer, Professor Kelly-Anne Phillips, the founder of the Peter MacCallum Breast and Ovarian Cancer Risk Management Clinic, has said the decision should be made on a case-by-case basis.

"Some women will find, short-term, it can help relieve their symptoms," she saidearlier this year.

Professor Phillips warned, however, that women who had been on hormone therapy for a year should have their treatment reviewed, adding there were alternatives for treating symptoms including weight loss, moisturisers for vaginal dryness and avoiding caffeine or alcohol.

The 'grandmother theory" is one explanation for menopause in humans.

Apart from humans, most mammals stay fertile until the ends of their lives. There are a few exceptions: killer whales, short-finned pilot whales, belugas and narwhals can live for decades beyond their reproductive years. Guppies also appear to go through a fish version of menopause.

But long postmenopausal lifespans are an aspect of biology that appears to be at odds with natural selection. Why do women suddenly stop having periods when they still have at least a third of their lives to live, during which they could be producing offspring?

Some experts, including Professor Hickey, believe high death rates of mothers during childbirth throughout history emphasised the importance of grandmothers in rearing future generations, unhindered by more children of their own. This is known as the grandmother theory.

Not really but andropause can affect men older than 40. Andropause is the gradual reduction of the male sex hormone (testosterone) with increasing age. Its symptoms include sexual dysfunction, weakness, fatigue, insomnia, loss of motivation, mood disorders and reduction of bone density. Though the symptoms aren't as severe as those of menopause, they can last for as long as 15 to 20 years.

An egg surrounded by sperm.Credit:Alamy

Although eggs succumb to menopause, pregnancy is still possible using a donor egg. During perimenopause, ovulation can occur, meaning a woman can conceive naturally, even if she is using hormone therapy.

When UK based former magazine editor Lynnette Peck and her friend Paula Fry first began to experience symptoms of perimenopause they found they had no safe space to share their feelings on the matter. In a bid to open up dialogue, they started a secret Facebook page in 2017.

Word got around quickly. Soon they had more than 700 members and then Feeling Flush was born; a public online community for women across the world to connect.

"We wanted women, including ourselves, to have places to share information and educate each other and have a moan," Ms Peck says.

"Women mostly ask us about hormone replacement therapy and the pros and cons. We are not medical experts so we point them to people who are. There is now a conversation. It was hidden before. Here in the UK, even political parties and huge brands are getting involved."

Professor Hickey notes that women make up almost half of the workforce in Australia and two-thirds of the voluntary sector. They continue to look after children across generations and are often the primary carer for parents.

Our society has a big a focus on youth and the preservation of youth and menopause is a maker of age in women and ageing in women is not a topic we still have very much discussion about," Professor Hickey says.

"It's quite likely that women who experience menopause may not have been informed fully about what to expect. It's quite possible a lot of men don't know very much about menopause at all."

Last week, British free-to-air television Channel 4 launched a menopause policy to support women experiencing perimenopausal symptoms such as hot flushes, anxiety and fatigue by giving them access to flexible working arrangements and paid leave if they feel unwell.

It's a shift Professor Hickey wants in Australia. She would like to see menopause treated as a "diversity issue" with workplaces actively supporting women experiencing it.

"Pregnancy would be a similar example: only women get pregnant, and we've learnt to adapt, and I think we need to take a similar perspective to menopause."

Melissa Cunningham is The Age's health reporter.

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What is menopause and perimenopause? - The Age