Health news blog

Oestrogen is produced in the ovaries, and causes changes to occur in the breasts, uterus (womb), cervix, vagina, skin and hair, blood, bones, and even the mind. It affects so many parts of a woman’s body that it is not surprising that we really notice the changes that occur when the level starts to fall at the time of the menopause.

All of the essentially ‘female’ organs contain oestrogen receptors, which respond to the presence of oestrogen in the body. This means that, while oestrogen levels are normal, the breasts are firm and full; the walls of the vagina are thick and elastic, and able to secret mucus (especially during sexual intercourse); skin texture is firm; and bones are strong. Oestrogen also keeps blood vessels healthy, produces a feeling of wellbeing, and contributes to sex-drive. During those periods of a woman’s life when her oestrogen levels are high (especially during the middle months of pregnancy), she will look and feel absolutely terrific. ‘Glowing’ and ‘radiant’ are words typically used, reflecting the feet that a woman’s hair is lustrous, her skin blooms, and she radiates a feeling of wellbeing and contentment. After the baby is born, some women’s oestrogen levels fall so low that their hair and skin suffer badly, and the feeling of wellbeing may be replaced by postnatal depression.

The other important hormone of the female reproductive cycle is progesterone; it is produced each month by the ovaries after ovulation (the production of an egg) has taken place. The main functions of progesterone are to prepare the womb for a fertilised egg (ovum) and to maintain pregnancy. Progesterone works with the oestrogens to cause the lining of the womb to thicken in preparation for a fertilised egg. If fertilisation does not occur, the lining of the womb comes away in the form of the monthly period.

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The technique you describe, endometrial ablation, has been introduced recently into many Australian hospitals. It involves the use of a laser or diathermy (heat) to remove as much of the womb lining – the endometrium – as possible, and is usually considered for women with heavy menstrual bleeding.

Unfortunately there is a misconception that this surgical technique is much the same as a hysterectomy. It isn’t. Studies of the uterus after these operations show that some endometrial tissue always remains. This may explain why some patients continue to bleed on and off after an endometrial ablation. It also reinforces the need for future care to protect women from an increased risk of endometrial cancer if they are on HRT after they have had an ablation. A progestogen is required either continuously, in combination with oestrogen, or for ten to fourteen days each month.

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If you have a uterus you will not necessarily experience withdrawal bleeds when you begin HRT. However, such bleeds (for a few days at a predictable time of the month) are more likely if progestogen is taken for ten to fourteen days a month along with daily oestrogen. In the case of a woman taking progestogen for the first twelve days each month, the withdrawal bleed typically starts between day twelve and day seventeen and occurs monthly. About half the women taking progestogen in this cyclical manner have withdrawal bleeds for ten years or more. In most cases the bleeds become progressively lighter. When HRT is discontinued, the bleeds stop.

Women taking progestogen each day in combination with oestrogen are less likely to have withdrawal bleeds as time goes by. Shirley was one of the 10 to 20 per cent of women using this format who have irregular spotting or bleeding six months to a year after starting. She found the irregular bleeding a nuisance but persisted with HRT because of a remarkable improvement in her vaginal symptoms and joint pain. Shirley’s doctor suggested that continuation of the bleeding beyond twelve months should be investigated by endometrial biopsy or hysteroscopy and biopsy. By the time a year was up, all bleeding had stopped.

Whether you take progestogen for a part or all of a cycle, the first few withdrawal bleeds are likely to be the heaviest, particularly if you start on HRT around the time of menopause. At this stage there may be some endometrium left, and the initial courses of progestogen produce the first bleeds after several months of build-up.

Heavy withdrawal bleeding generally responds to an increase in the dosage or potency of the progestogen used to balance the oestrogen. If bleeding continues despite alterations in dosage, it suggests the presence of uterine fibroids or endometrial polyps. These should be investigated by hysteroscopy and biopsy, and may be removed subsequently along with most of the endometrium by techniques including endometrial ablation. Even after this therapy, women need to keep taking progestogen as it is impossible to remove all of the endometrium.

Women who do not start HRT until several years after the menopause usually have less endometrium than those at, or with a recently completed, menopause. If you are older than that, the amount of endometrium may be insufficient to produce any visible withdrawal bleed. The absence of a withdrawal bleed indicates that there is little endometrium to be shed.

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A combination of oestrogen and progestogen may be recommended for dealing with hot flushes and night sweats if you still have your uterus. When the uterus has been removed, the use of oestrogen alone is considered a safe way to reduce the impact of flushes. High doses of progestogen alone are occasionally helpful in controlling them, but this approach is usually suggested only if oestrogen therapy is not recommended or tolerated.

Any doctor who prescribes HRT to help women with flushes will know that this symptom responds very well to oestrogen, often within a week. If you are a woman with debilitating or embarrassing flushes, the possibility of getting relief in such a short time may be persuasive. Some questions remain, however, about Jiow much of the benefit is due to HRT and how much to the psychological support the doctor provides.

Research shows that a significant number of women experience improvements in flush frequency and severity when they take a medication lacking any active ingredient. This is known as a placebo response – that is, the patient’s symptoms are relieved when a harmless substance, like a sugar pill, is substituted for a biologically active agent. Too few studies of menopausal therapies, of both the prescribed and ‘alternative’ kind, have been sufficiently well designed to separate the effectiveness of the therapy from a woman’s response to the empathy, support and interest shown by her practitioner. Of three major studies of oestrogen therapy for hot flushes that have taken the placebo response into account, all have demonstrated an improvement.

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As well as the signs of menopause we have listed, which usually last for several months or years, some longer-term body changes get a hurry-on at around the time of menopause. These may be caused by both the altered output of sex hormones and other physiological and biochemical changes that affect men as well as women. They typically occur over many years and include some or all of the following.

? There is a reduction in bone strength and density that is most pronounced in the first five to six years after menopause. Whether this translates into an increased risk of fractures depends on many things, including the strength of the bones in the first place (that is, the peak bone mass) and the rate at which bones lose density. (Men experience a similar decline in bone density in later life, but not the rapid loss that women have in the first few years after menopause.)

? The strength of the support tissues of the body, such as muscles and cartilage, may also decline. This can lead to backache, joint and muscle pain, and trouble with your ‘waterworks’ from time to time. A prolapse may also occur if the uterus, bladder or bowel moves down into the vagina because of weakened pelvic muscles and ligaments. Surgery or the insertion of a polythene ring or pessary into the vagina may be necessary to lift the pelvic organs away from the pelvic floor. Occasionally a hysterectomy may be performed to overcome a serious prolapse problem.

For some women there is a declining desire for sex (‘I’d just as soon curl up with a good book’), while for others, one of the redeeming features of menopause is the discovery or rediscovery of their sexuality.

? The blood flow to the sex organs may be reduced, and the nipples and clitoris may become oversensitive.

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