During pre-/perimenopause, there is a gradual decline in ovarian function and oestrogen production as the body begins to change in preparation for menopause. The decline and sudden absence of oestrogen has a huge impact on your body and emotions.
In the beginning hot flushes, night sweats (nocturnal hot flushes); sleep disturbances, mood swings and joint pains are the most common symptoms. While symptoms vary greatly among individual women, other menopausal symptoms could include irregular periods, forgetfulness, vaginal thinning, diminished libido and bladder problems. Some women live through the whole menopausal period without suffering any of the classic symptoms.
Experiencing hot flushes (also called flashes) is the most common symptom of menopause, as 75- 80% of women suffer these feelings of intense heat over the trunk and face with an accompanying flushing of the skin. Hot flushes are caused by dysfunction in the temperature-control centre in the brain.
A hot flush generally lasts less than five minutes, and may range from one or two per day, to one every 15-30 minutes.
The sweating that accompanies hot flushes usually starts a minute after the feeling of palpitations. If you experience hot flushes at night, they are called night sweats.
Hot flushes tend to be more pronounced late in the day, in hot weather, after ingestion of hot foods or drinks, or during periods of stress and tension.
They may begin during perimenopause before menstruation stops. Most women have hot flushes for more than a year, while 25- 50% will suffer them for up to five years if they’re not treated. New studies indicate that hot flushes often last 10 – 12 years.
Insomnia (sleeplessness) can be caused by hot flushes at night. These may be accompanied by night sweats as a result of fluctuating hormone levels. Insomnia may already be experienced some years before menopause, and it may cause daytime tiredness.
Very few women simply suddenly stop menstruating. Before ovulation stops altogether, the menstrual cycle generally becomes more irregular in length. You may experience changes in your menstrual flow, e.g. blood flow may be heavier or lighter. Erratic or irregular periods can start anything from two to eight years before menopause.
Finally, the intervals between menstruations become longer, with missed periods or episodes of spotting only.
The irregularity may last two or three years before menstruation finally ceases. When no bleeding has occurred for one year, a woman’s menopausal transition is said to have occurred.
If you experience bleeding after this time, it’s important to discuss this with your doctor as it could a sign of a serious underlying problem.
Mood swings, forgetfulness and other psychological symptoms
Psychological symptoms such as moodiness, irritability, anxiety, depression, tearfulness, forgetfulness and difficulty in concentrating are often the focus of jokes about the menopause, but there is no objective evidence that cessation of ovarian function is associated with severe emotional disturbance or personality changes.
Mood swings can be a problem particularly for women with a history of premenstrual syndrome or post-natal depression. During the perimenopausal time span, some women notice worsening PMS or experience it for the first time. Menopause ends PMS.
The symptoms of menopause can precipitate an underlying psychological problem, but it cannot cause it.
Many women suffer joint pain as one of their earliest symptoms. Often starting during perimenopause, it may suddenly become painful to get out of bed, walk upright to the bathroom or get dressed. Quite often the joints of the back, fingers, knees and ankles are affected. The severity of the joint pain may decrease after a few months.
Vaginal dryness and sexual discomfort
Sexual discomfort due to vaginal dryness is a common symptom. Decreased oestrogen can lead to thinning of the epithelial lining and the underlying tissues of the vaginal wall may become thinner and less elastic, a condition known as atrophy.
This causes decreased lubrication, which in turn, may lead to substantial pain during and after intercourse. As painful intercourse is seldom a turn-on, it might lead to a decline in sexual desire.
Vaginal dryness and thinning may continue after menopause. Some doctors estimate that at least half of all women over 60 have some degree of vaginal dryness. Vaginal changes may also increase the risk of infections due to reduced local protection against micro-organisms, which may enter the vagina due to self-contamination or sexual intercourse.
Middle-age spread and weight gain
Oestrogen is responsible for the female pear-type fat distribution and a lack of oestrogen will cause the fat distribution to change to the male apple-type fat (the so-called middle-age spread) distribution. This type of fat distribution, especially around the midriff, is associated with an increase in the risk for cardiovascular disease.
Appetite may decrease, but the stress associated with this period often leads to an increase in appetite.
Other gastro-intestinal symptoms associated with menopause include nausea, flatulence, constipation or diarrhoea.
Beginning in perimenopause, some women may experience a gradual decline in sexual desire (libido). However, 60% of women experience no change in libido, 20% experience a decrease and in 20% of cases libido improves.
Although no correlation has been found between oestrogen levels and libido, it appears that testosterone may also affect libido.
Other factors which could lead to changes in sexual function include:
• Painful intercourse due to vaginal dryness (atrophy)
• A woman’s perception of her changing body
• Incontinence which could lead to sexual avoidance
• Sleep disturbances due to night sweats
• Depression, stress and anxiety
• Many medications, including some anti-depressants
• Reduced libido and impotence in the male sexual partner
Urinary incontinence (leaking bladder)
Decreasing oestrogen levels can weaken the pelvic floor muscles controlling the bladder and urethra (tube through which urine is passed from the bladder).
The tissue of your urinary tract also becomes less elastic. These changes can lead to painful urination (called dysuria), urination at night (called nocturia) and the need to urinate urgently (called urge incontinence).
Another symptom which may be associated with these changes is stress incontinence, which is involuntary urine leakage. This occurs with coughing, laughing, sneezing, exercising or sudden exertion. However, stress incontinence can have organic causes and is not alleviated by MHT.
Hormone therapy will only have a positive effect on symptoms stemming from bladder irritability. Other problems that may arise are frequent bladder and vaginal infections.
Causes of Menopause
Reviewed and updated by Dr Dr Carol Thomas MBChB (UCT) FCOG (SA) MMed (O&G) (UCT), Specialist Gynaecologist in private practice, Cape Town, Secretary South African Menopause Society and Director of the WomanSpace. March 2015.
(Previously reviewed by Dr Mike Davey, President of the South African Menopause Society, and Prof B. Schaetzing MD, FCOG (SA), FRCOG, PhD. Part-time Consultant, Dept of Obstetrics & Gynaecology, Faculty of Health Sciences, University of Stellenbosch)