Menopause: what your body tells you and what you can do

What exactly is menopause?

The terms transition and menopause are often used interchangeably, but medically speaking, they do not mean exactly the same thing.

The transition is the period in which menstruation changes and eventually stops. During this phase, ovarian activity decreases and the production of estrogen and progesterone changes.

The perimenopause is the period around the last menstruation. Menstruation often becomes more irregular, and symptoms such as hot flashes may occur. This phase can last for several years.

The menopause is the last menstruation. This moment can only be determined retrospectively: when someone has not had a period for twelve months, without any other explanation, it turns out that the last menstruation was the menopause.

The postmenopause is the period after menopause.

In the Netherlands, menopause occurs on average around the age of 51. However, the timing varies from person to person. Symptoms can begin several years before the last menstruation and persist for years afterward.

What role do hormones play?

During menopause, the remaining egg cells are depleted and the function of the ovaries changes. As a result, the menstrual cycle and the production of estrogen and progesterone become more irregular. Eventually, the production of estrogen, in particular, declines permanently.

These hormonal changes play a clear role in:

• changes in menstruation;
• hot flashes and night sweats;
• changes to the skin and mucous membranes of the vagina;
• bone loss after menopause.

Hot flashes likely occur because hormonal changes affect temperature regulation in the brain. Nighttime hot flashes can disrupt sleep and consequently cause fatigue, irritability, or gloominess during the day.

We cannot directly attribute all physical and psychological changes in this phase of life to a deficiency of estrogen or progesterone. Age, sleep deprivation, work pressure, illness, medication, and changes in personal circumstances can also play a role.

What symptoms can occur during menopause?

Symptoms characteristic of menopause are:

• a changing or irregular menstrual pattern;
• hot flashes;
• night sweats;
• vaginal dryness, itching, or irritation;
• pain during sex because the vagina becomes lubricated less quickly.

Other symptoms frequently mentioned during this life stage are:

• poor sleep;
• fatigue;
• mood swings or irritability;
• sadness or anxiety;
• concentration or memory problems;
• reduced sexual desire;
• muscle and joint complaints;
• hair loss.

With this last group of symptoms, it is not always clear whether they are caused directly by hormonal changes. They can also be related to poor sleep, aging, or other physical and psychological factors. According to Thuisarts, for example, it is not certain that anxiety, depression, forgetfulness, and joint complaints are caused by menopause itself. Therefore, psychological complaints deserve an independent assessment. Women who have previously experienced depression have a higher chance of developing depressive symptoms again during menopause.

When should you see your GP?

Make an appointment with your GP if:

• the symptoms clearly interfere with your daily functioning;
• you experience heavy or prolonged bleeding;
• you experience bleeding after twelve months without a period;
• you experience bleeding after sex;
• you may be entering menopause before the age of 40;
• you are persistently sad or anxious;
• you are unsure whether the symptoms are due to menopause or something else;
• you want to discuss hormonal treatment.

Pregnancy may still be possible during menopause. Therefore, use contraception for as long as is necessary according to your personal situation.

When is a blood test useful?

In women aged 40 and over with a changing menstrual pattern and characteristic symptoms, the GP can usually recognize menopause without hormone testing.

Measuring FSH, LH or estradiol is not recommended to determine whether someone is in normal menopause or to predict when the last menstruation will occur. These hormone levels can fluctuate significantly during perimenopause. A single result can therefore cause both a false sense of security and unnecessary anxiety.

Routine measurement of progesterone for sleep problems or irregular periods also has no proven added value.

Blood tests may be necessary on indication, for example:

• FSH and estradiol: in case of suspected early menopause before the age of 40;
• TSH: if the symptoms may be consistent with a thyroid disorder;
• hemoglobin: in case of prolonged or heavy menstrual bleeding;
• pregnancy test: when pregnancy is possible is;
• other investigation when symptoms or medical history warrant it.

A TSH test can aid in the investigation of a thyroid disorder, but does not always distinguish between thyroid symptoms and menopausal symptoms on its own.

A blood test to determine if you are going through menopause is generally pointless.

What can you do yourself?

A healthy lifestyle can help support your general health, sleep, and resilience:

• exercise regularly, preferably daily;
• also engage in activities that load muscles and bones, such as walking and strength training;
• eat a healthy and varied diet;
• ensure you get enough calcium through your diet;
• ensure you get enough vitamin D according to current supplementation recommendations;
• try to maintain a regular sleep schedule;
• stop smoking;
• preferably do not drink alcohol, especially if alcohol triggers hot flashes;
• seek support if stress or psychological issues play a significant role.

Exercise is important for the heart, blood vessels, bones, muscles, and psychological well-being. However, it is not guaranteed that exercise will significantly reduce hot flashes.

Extra protein is not routinely necessary for every woman going through menopause. It is primarily important to obtain sufficient protein through a normal diet. Omega-3, creatine, or other supplements are also not a proven standard treatment for menopausal symptoms.

Creatine, in combination with strength training, may potentially contribute to muscle strength or mass, but the evidence for specific benefits regarding bone density and cognitive functions in menopausal women is still insufficient for a general recommendation. It should therefore not be presented as a full-fledged menopausal treatment.

What treatments are possible?

Which treatment is appropriate depends on the type of complaint, its severity, and personal preferences and medical history.

Hot flashes and night sweats

For bothersome hot flashes, cognitive behavioral therapy, mindfulness, and hormone therapy, among others, may be discussed.

Hormone therapy with estradiol is the most effective drug treatment for hot flashes. If the uterus is still present, a progestogen must usually be added to systemic estradiol to protect the uterine lining.

Hormone therapy can have side effects and risks. The risks depend on, among other things:

• age;
• medical history;
• the type of hormones;
• administration as a tablet, patch, gel, or spray;
• duration of treatment;
• personal risk factors.

Hormone therapy is not suitable for certain hormone-sensitive forms of cancer, a history of thrombosis or pulmonary embolism, a heart attack, stroke, liver disease, or unexplained vaginal bleeding. Systemic hormone therapy is also discouraged for smokers. The pros and cons must therefore be discussed individually with a doctor.

Hormone therapy can indirectly help you sleep better by reducing nocturnal hot flashes. However, it is not a general treatment for insomnia, depression, reduced libido, or cognitive complaints.

Vaginal complaints

For vaginal dryness, a moisturizing gel or lubricant can help. If this is insufficient, local vaginal estrogen may be considered. Absorption into the bloodstream is much lower with this than with systemic hormone therapy.

Psychological complaints

Persistent anxiety, gloominess, or other psychological complaints must be assessed and treated with the same care as outside of menopause. Hormone therapy is not a standard treatment for depression.

Health after menopause

After menopause, bone density declines more rapidly. Regular exercise, not smoking, a healthy diet, and sufficient calcium and vitamin D help to keep bones healthy. A bone density measurement is not routinely required for every woman; it is primarily considered if risk factors for osteoporosis or bone fractures exist.

The risk of cardiovascular disease also increases with age. Menopause is therefore a suitable time to pay attention to blood pressure, weight, exercise, smoking, and other cardiovascular risk factors. Hormone therapy is not started with the primary goal of preventing cardiovascular disease.

Conclusion

The menopause is a natural phase of life, but symptoms can have a major impact on daily life. Characteristic symptoms include changes in menstruation, hot flashes, night sweats, and vaginal complaints. Fatigue, mood swings, and concentration problems may also occur, but do not automatically have a hormonal cause.

For most women aged 40 and over, blood tests for FSH, estradiol, or progesterone are not necessary and do not provide a reliable answer to the question of which stage of menopause they are in. Targeted blood tests can be useful if early menopause or another condition is suspected.

If you are experiencing significant symptoms or are unsure about the cause, discuss this with your GP. Together, you can assess whether further testing or treatment, such as hormone therapy, is appropriate.