‘I heard that the earlier you start your periods the earlier they finish.’

‘Oh, I thought it was just the opposite, that the earlier you started the later you finish.’

When used by doctors, the term ‘menopause’ means, literally, ‘last menstrual period’, but women use it to mean that whole period of their lives between first starting to experience menopausal symptoms, such as hot flushes, and the end of their periods and the troublesome symptoms. Doctors use the word ‘climacteric’ to describe this period (from the Greek klimakier, meaning a critical period’), and they divide it loosely into three phases:

Pre-menopause. When periods are still regular, but the first symptoms may appear – usually hot flushes and mood changes.

Peri-menopause. When the ovaries’ function declines, periods become irregular, and symptoms either start or become troublesome. This leads up to the time of the last menstrual period.

Post-menopause From the time of a woman’s last period until the end of her days.

The problem with the concept of a ‘last menstrual period’ is that a woman doesn’t know she has had her last period until quite a long time afterwards. Was that last period the last one, or will you get another one in several months’ time? It’s not until about a year has passed without a period that it is safe to say you have finished. Consequently, the period of time we call the menopause (and doctors call the climacteric) has no clear beginning or end. For some women it will last only a year, for most about two to three years, but about one quarter of all women will still be experiencing ‘short-term’ menopausal symptoms five or more years after they began.

It isn’t known exactly what determines the age at which a woman reaches the menopause. Nutrition is important; poor nutrition brings it on earner. Women who have never borne children tend to have an earlier menopause than women who have had several children, and those whose last pregnancy occurred before their late twenties reputedly have an earlier menopause than those whose last pregnancy was in their thirties. Smokers reach the menopause up to five years earlier than non-smokers, probably because smoking lowers oestrogen levels, and ‘passive smokers’ (non-smokers who live or work amongst smokers) also tend to have an earlier menopause.

As a rough guide, most women (though by no means all) will experience the menopause at about the same time as their mothers or older female relatives did. But how do you know when that was? It’s highly likely that neither your mother nor your elderly aunts ever discussed with you their experiences of the menopause; hopefully, you will feel better able to talk to your daughter about it than your mother did to you.

It is safe to say, however, that at some time in your middle years, things will start to change. It is most likely to happen around the mid to late forties, occasionally in the early fifties, and in some women it can happen as early as their thirties. Although the age at which girls start their periods has got earlier over the last few hundred years, the average age for the menopause still remains at about 50. In the third century BC, Aristode noticed that women couldn’t have children after about the age of 50. In the Middle Ages, the age was put at 50-ish, and it is still that today. We can still expect to end our reproductive days at about the same age our pre-Christian forebears did, despite the fact that our expectation of life has more than doubled since then.

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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.

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- 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.

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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.

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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.

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