Health and medical information

The notion that menopause and depression are linked was a ‘fact’ commonly stated in medical textbooks well into this century. ‘They [menopausal women] are peevish, irritable, morose and depressed’, Emil Novak wrote in the classic 1923 text Menstruation and its Disorders. ‘The various psychoses of the menopause constitute an important group . . . Many [women] have full blown insanity with melancholia, paranoia and maniacal conditions.’

We can laugh now, but such views had a devastating effect on women’s lives. Many were placed in psychiatric hospitals for problems that could easily have had more to do with society’s weaknesses than theirs. Numerous recent studies have failed to confirm that depressive syndromes increase in middle-aged women. One of the largest studies, conducted by the US National Institute of Mental Health in the 1980s, found that women aged forty-five to sixty-four actually had significantly less depression than men in the same age group.

While fully developed depression is unusual at menopause, ‘feeling blue’ — or thunderously black — is quite common. It’s really hard to separate family stresses and things like financial problems from biological and psychological factors. For some women there seems to be a link between hot flushes, night sweats, insomnia, lethargy, and feeling decidedly depressed. If you are one of these, your cycle of sleeplessness may be broken if you get rid of the flushes with HRT. Even if you are sleeping well, you may find that HRT helps you to dispel uncharacteristically gloomy spells.

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WOMEN WITH BENIGN BREAST LUMPS Most breast lumps are benign, and once they have been checked there is no special reason to avoid HRT. If examination of a lump shows any unusual cells or indicates that the growth of cells is abnormal, you are already at increased risk of breast cancer and the lump should be monitored carefully to pick up any change at an early stage. Regular monitoring of breast health by mammography, medical examination and self-examination of the breasts are vitally important.

WOMEN WITH ENDOMETRIOSIS This condition may be reactivated by oestrogen when treatment is started soon after menopause, especially if the menopause was surgical and the hormones are given in implant form. If a woman with endometriosis receives HRT, the patch or oral form of therapy is advisable. In theory the use of progestogen should help to keep the endometriosis under control in the first year after surgery, but this has yet to be confirmed.

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There is some evidence to suggest that when progestogen is given for ten to fourteen days per cycle to women prior to menopause, it should be taken in phase with the existing menstrual cycle if it is still apparent. This helps to reduce the occurrence of breakthrough bleeding. The experience of Josie, who developed severe hot flushes at the age of forty-five while stiD menstruating regularly, illustrates the point. Her cycle length had always fluctuated around twenty-one days, and when she took progestogen for the first twelve days of each month she experienced repeated breakthrough bleeding that required investigation.

At first her doctor tried manipulating the dose and type of oestrogen and progestogen, but this did not help. Finally, her doctor twigged to the possibility that the bleeding problems could be due to the fact that the hormones her ovaries were still producing intermittently were not synchronising with the hormones she was taking on HRT. Josie was advised to take the last progestogen tablet on the day before the start of the next menstrual bleed she was expecting. Thus, with a twenty-one-day menstrual cycle, she took the progestogen from day nine to day twenty. This simple alteration resulted in much less breakthrough bleeding.

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For most women menopause occurs between forty-eight and fifty-three, and it is usually preceded by a few years of changing ovarian function, including an end to the release of eggs (ova). Women may view it as ‘one of nature’s design faults’ or ‘a blessed relief from periods and pregnancies’. Each ovary of a newborn baby girl contains about a million immature eggs. Up to five hundred eggs develop to full maturity between puberty and menopause and are released from the ovary in the process of ovulation. No one is sure why the remainder degenerate, nor is it clear what triggers the sex hormone shifts and the stop-starts in ovarian function signalled in the years before menopause by altered bleeding patterns.

About the only certainty is that menopause occurs when the number of eggs in the ovary falls to a critical level.

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