Recently I attended both the Australasian Menopause Society Congress and the Australian Sexual Health Conference and discovered there was more overlap than might be imagined between these two areas of health.
The average age of menopause in Australia is 51 years within a range from about 45 to 55. Whilst some women move through the menopausal transition relatively smoothly, others experience significant and debilitating symptoms including hot flushes, drenching night sweats and sleep disturbance. A small group experience menopause before the age of 40. These are often women who have undergone chemotherapy, radiation therapy, or surgical removal of the ovaries. Premature menopause can be a devastating diagnosis, and is often accompanied by especially severe menopausal symptoms.
The thought of approaching menopause can cause anxiety. Women in their late forties and early fifties frequently request a hormone test to check if they are menopausal but the reality is that hormone tests are not helpful in this instance. This is because the hormone levels can change from week to week or even day to day, so a blood test is not a reliable indicator of menopause and best avoided.
So, is it important to know whether you have reached menopause? Certainly you need to know whether contraception is required and we advise that women over 50 should consider contraception until one year after the last menstrual period, while those younger than 50 should continue for two years. The chance of a pregnancy is, of course, very low at this age and some women may decide that it is a risk worth taking. Fewer than one per cent of women fall pregnant at this age but there is always the chance that you are that one in a 100!
All women approaching menopause also need information about looking after their bone health and preventing heart disease. Healthy lifestyle advice is the cornerstone of all menopausal discussions and regular exercise, a healthy diet and limiting alcoholic drinks may also have some benefit when it comes to mild menopausal symptoms. However these measures are simply not enough for some women when it comes to managing their hot flushes and night sweats.
Whilst there are many over-the-counter remedies for menopause symptoms available without a prescription they are generally ineffective and may simply be a rather expensive "placebo". Women also need to be aware that the so-called "bio-identical hormones", which usually come in the form of lozenges or troches that are placed in the inside of the cheek, are unregulated and can be associated with a very real risk of serious side-effects including uterine cancer. The Australasian Menopause Society as well as family planning organisations advise women not to use them.
The most effective treatment for hot flushes and night sweats is Hormone Replacement Therapy (known as HRT) which needs to be prescribed by a doctor. It consists of oestrogen plus a second hormone called a progestogen which, in women who have not had a hysterectomy, prevents thickening of the lining of the uterus. Whilst HRT cannot be used by all women, for example those with a history of breast cancer or blood clots, it is a safe option for many women, especially when used for up to five years after the onset of the menopause. There is no overall benefit from starting HRT many years after the menopause. We aim to use the lowest possible dose of hormones to control symptoms and the latest information from the Menopause Congress suggests that delivering HRT in the form of patches may be safer than oral tablets.
In the past, HRT has had a bad press in Australia and elsewhere as a result of a single USA-based trial called the Women's Health Initiative in 2002. Media reports of the trial were alarming and resulted in thousands of women abruptly stopping their HRT. It has taken many years for confidence in this useful therapy to be restored. Most American women in the trial were older and less healthy than Australian women who are prescribed HRT today. It is important for all women to be familiar with the latest evidence-based information so they can decide, in consultation with their doctor, whether HRT is a suitable option for them.
So where do menopause and sexual health overlap? Some menopausal women may have a long-term sexual partner, others may be meeting new sexual partners, whilst again others may not have a partner. Menopausal women, like women of all ages, may feel satisfied or unsatisfied with this aspect of their life. For sexually active women life can seem a bit unfair since, just when they are saying goodbye to contraception, along comes menopausal vaginal irritation and dryness!
Vaginal dryness results from a thinning of the lining of the vagina as oestrogen levels fall. It can cause general discomfort as well as painful intercourse. Avoiding scented soaps, strong detergents and tight synthetic clothing can be helpful and a variety of specialised vaginal moisturisers can be bought at the chemist. In addition, women can be prescribed vaginal oestrogen in the form of small tablets or creams inserted into the vagina a couple of times a week. This is an extremely low dose form of HRT, which is only directed to where it is needed in the vagina, making it very safe for most women.
Women who are embarking on new relationships also need to be aware of protective measures to prevent sexually transmissible infections (STIs). Chlamydia is the most common bacterial STI and it is increasing in older as well as younger women. Most women who have a chlamydia infection have no symptoms although it can sometimes result in increased vaginal discharge, irregular vaginal bleeding or pelvic pain. If chlamydia is left undiagnosed and untreated it can result in infertility in younger women as well as ongoing pain in women of all ages. Testing for chlamydia is very straightforward - as is treatment - but prevention is always better than a cure and condoms provide the best protection we have against STIs.
Condoms come in many different varieties including those made of polyurethane, which are useful for people with a latex allergy. Many people are unaware that we have a so-called "female condom" available in Australia, which is also made of polyurethane. We have been selling female condoms at family planning clinics for several years but I have to admit they are hardly a best-seller. I often wish they were just a bit more acceptable to both women and men but unfortunately there are some "design issues" including a slight rustling noise.... New designs are being trialled so, hopefully, their appeal may increase in the future! Negotiating condom use in a new relationship can be challenging for women and men, especially those who are "dating" again after the end of a long-term relationship. At Family Planning NSW we are putting together an awareness campaign for older women about staying safe and preventing STIs in new relationships. Expect to see our campaign early next year.
For more information on menopause and sexuality visit the Australasian Menopause Society website.
Dr Deborah Bateson is the Medical Director of Family Planning NSW