Your doctor will ask whether you have any menopause-related symptoms, such as hot flushes, irregular periods, headaches or dryness of the vagina. It may also be a good idea to discuss other changes in your life at this time. What are your children up to? How about your parents? Are you content with yourself and your place in the family, at work, in the

community? Are all your important relationships in good-order? How do you see yourself and your future? That sort of thing.

Your doctor will also check your medical history, including any experience of breast disease such as cysts, breast cancer and so on, and diseases of the reproductive system (cancers of the cervix, uterus or ovaries, fibroids, endometriosis, premenstrual syndrome and so on). He or she will also want to know whether you have had any abnormal blood clotting or high blood pressure, including elevated blood pressure during pregnancy (pre-eclampsia).

Your menstrual history is also of interest, and so are any experiences of anorexia, menstrual periods disappearing for longer than six months, and long-term use of steroids — for example, for the treatment of asthma or thyroid disease.

*118\38\8*

- There are still many uncertainties about the long-term impact of HRT on body tissues. Research is under way, but definite answers will not be available until around the year 2000.

- Breast cancer risk may be increased by 30 to 80 per cent in women using HRT for ten years or more. If such a risk does occur (and this is controversial), their risk would rise to about one in ten, compared with about one in fourteen for similar women who do not use HRT. Women whose risk is at the higher end of the range arc those who have a strong family history of breast cancer, a previous breast cancer, or abnormal cells in a breast biopsy.

- The risk of endometrial cancer is five to ten times higher for women with a uterus taking oestrogen alone for more than five years, compared with similar women not on HRT. This increased risk docs not apply where vaginal oestrogen is used according to medical instructions, or when adequate oestrogen and progestogen are used by women with a uterus.

- There is a slight increase in gall bladder disease.

- Uterine fibroids and, rarely, endometriosis may bleed heavily with HRT, especially in women on implants.

- Breakthrough bleeding is a common problem with some regimens of HRT.

- Nausea, breast tenderness, weight gain and skin reactions may also occur, necessitating a change in dosage or in the way the hormone is given.

*84\38\8*

In surveys of women seeking medical help at and around menopause, about one woman in four reports psychological symptoms including poor concentration, faulty memory, loss of confidence, uncharacteristic sadness and difficulty making decisions. There has been speculation that lowered oestrogen levels are the cause of such symptoms by a direct effect on the output of chemicals involved in message transmission in the brain (called neurotransmitters). It is difficult to separate the effects of hormones from other factors that may influence psychological symptoms, such as stress at home or work, lifestyle modifications to do with diet and exercise, and major life changes.

Supporting the impression that this disquiet among women is not simply a matter of hormone levels, the Melbourne {Women’s Midlife Health Study found no apparent association between mental wellbeing and whether women were still having regular periods or had reached menopause. The differences in the findings of various studies may relate to the groups being studied: women who attend medical practitioners for help may well be more psychologically stressed than random samples of middle-aged women. In the Melbourne study, involving 2000 randomly selected women aged forty-five to fifty-five, those who felt mentally well were more likely to have low levels of stress in their lives, a positive attitude to ageing and to menopause, to exercise vigorously, to live with a partner, to be in good general health and to be a non-smoker. Women should first consider whatever non-medical steps they can take to reduce day-to-day stress. A daily walk, a regular game of tennis or an aerobics class might do the trick.

*49\38\8*

Positive attitudes to menopause and ageing have been linked with fewer menopausal symptoms, as have education and income level, occupational status, cultural background, and dietary and genetic characteristics. Japanese women are often cited as a shining example of a group with positive attitudes to menopause – women who are much less likely to report symptoms such as hot flushes than their middle-aged sisters in the West. To attribute their low incidence of symptoms to their positive views of menopause is an oversimplification, however, since there would appear to be many other contributory factors. For instance, Japanese women tend to have lower oestrogen levels than Western women both before and after menopause (apparently due to dietary and genetic influences), and their hormone level changes may be less acute and therefore less troublesome.

Early results of the Melbourne Women’s Midlife Health Study suggest that most women aged forty-five to fifty-five and born in Australia are quite positive about menopause and ageing in general. Most of the 2000 randomly selected women who were questioned were not worried about being too old to have children. Two-thirds were not concerned about their children leaving home, nor were the majority anxious that their attractiveness was waning. About half thought that some women became depressed or irritable in midlife, but most believed that the transition was hardly noticed by women with many interests. Only 9 per cent of these women rated their health as worse than that of other women of the same age. Over 90 per cent experienced some symptoms of ill health, particularly generalised aches and stiff joints, lack of energy, nervous tension, headaches and migraines. But most women regarded these as relatively minor concerns.

A comparable US study, which followed for five years the wellbeing of more than 2000 middle-aged Massachusetts women selected at random from the general population, came up with interesting findings on the pattern of such symptoms over time. On the one hand, lack of energy, feeling blue or depressed, headaches and menstrual problems were reported much less often at the end of the five years than at the beginning. The reverse was true for hot flushes and cold sweats, which were reported nearly twice as often.

*15\38\8*