How gynaecologist Dr Jennifer Gunter handles the menopause

Most of us hit the menopause with just a vague idea of what to expect. But knowing exactly what’s happening to our bodies can help us make life-changing decisions, says Dr Jennifer Gunter

The menopause is like being sent on a canoe trip with no guidebook and only a vague idea of where you are headed. There is no advice on how to manage any of the obstacles, such as rapids – that’s if any exist, who knows? From fear and uncertainty to unpleasant symptoms and medical ramifications, have fun figuring it out! Most women have no idea what to do when they are no longer having regular periods or any periods at all and are instead suffering with uncomfortable symptoms. When they try to seek help, instead of receiving important health screenings or therapies, they are often told, ‘This is just part of being a woman,’ or, ‘It’s not that bad.’

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Having started medical school when I was 20 years old and my obstetrics and gynaecology training when I was 24, I can’t remember a time when I didn’t have a detailed understanding of the hormonal changes of both the menstrual cycle and the menopause. And not just the biology, but how to apply it practically to my own body: I never once thought, ‘Wow, that is unexpected!’ My medical knowledge didn’t prevent me from having acne, hot flushes, or those ‘special’ heavy periods that are all typical of the lead up to menopause – but because I knew exactly what was happening and when to seek care, it made the whole process feel routine. This is why, to reduce suffering, I believe every woman’s understanding of the menopause should be up there with a well-informed gynaecologist’s. Knowing what’s happening to your body and that you’re not alone in your experiences isn’t just powerful medicine, it can help you make health decisions that work for you.

The menopause occurs when there are no more follicles in the ovaries capable of ovulating, meaning there are no more eggs. The average age of menopause for women in the UK is 51. Genetics are by far the biggest contributor to how old you are when menopause begins, with some studies suggesting they control its start by anywhere from 30 to 85 per cent.

Medically speaking, the time leading up to the final menstrual period is called menopause transition (often called the perimenopause) and the final menstrual period marks menopause. Everything afterwards is postmenopause. Menopause transition is a stage of variable length, characterised by erratic levels of hormones. During this time there may be a lot of false finishes, where a woman thinks she’s had her last period, and for others it’s a gradual meandering process. Or both. The only predictable thing about the menopause transition is its unpredictability.

Many women start their menopause transition with one body and end up on the other side of it with one that feels very different. This occurs because strength, size and shape are all affected by both menopause and ageing. Sometimes it can seem as if your body is a car with a new and completely different warning light that appears each day. An unwelcome exercise in, ‘Oh, what now?’

These are the main symptoms and what you can do about them…

Loss of strength and muscle mass

One of the physical changes of ageing is loss of muscle mass, which accelerates during the menopause transition, then levels back to age-related loss after menopause. This progressive loss of muscle mass is responsible for the slowing of the metabolism with age. Muscles give us strength and the ability to move, help with balance, and strengthen bones, hence the increased risk of falls and osteoporosis.

Handle it like a gynaecologist

The best way to slow the decline of muscle mass, and even reverse some of the loss, is through physical activity. Exercise is one of the main triggers to repair or replace muscle cells. It can’t prevent age-related loss of muscle mass – even elite athletes lose muscle over time – but exercise is protective.

The minimum for good health is 150 minutes of moderate or 75 minutes of vigorous aerobic activity a week. These are the lower limits of what is needed: working toward 300 minutes of moderate exercise or 150 minutes of vigorous exercise a week is a good goal. Combine this with muscle-strengthening exercises (eg, lifting weights, resistance bands), targeting all major muscles groups on two or more days a week, and balance training.

The good news is that it’s never too late to reap the rewards. I tell my own patients to start with a ridiculously little amount of exercise, just keep at it every other day. Exercise is like free money: even a little is good.

Weight gain

Many women are bothered by weight gain during their menopause transition and/or find that losing weight after menopause is harder than it was previously. The average age-related weight gain is approximately 0.3kg (0.8lb) per year and is primarily due to the loss of muscle mass that in turn reduces calories burned and raises insulin levels. It’s not uncommon for women to experience an age-related gain of 1.5kg to 3kg (3.3lb-6.6lb). Most of the gained weight is fat, so the percentage of body fat also increases with age.

Handle it like a gynaecologist

It’s important to acknowledge how hard it is to lose weight, but even more so to maintain that loss. Pay attention to your food consumption, cook at home (studies have linked meals out as a risk factor for obesity) and avoid ultra-processed foods.

The best eating plan is the one that works for you and is sustainable over the long-term. By this I mean, can you follow this plan? When you adhere to it, do you lose weight? Do you think you can eat this way for the rest of your life?

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Hot flushes

When many people think of menopause, they think heat. This is because hot flushes and night sweats – collectively known as vasomotor symptoms or VMS – affect 80 per cent of women at some point during their menopause. The hot flush experience lasts on average just over seven years.

Medically speaking, a hot flush is a wave of heat that envelops the head, neck, upper chest and arms. And it isn’t just a feeling of heat – the body is warm to the touch, accompanied by sweating, redness in the face, nausea, agitation and anxiety. A hot flush happens when a wonky inner thermostat informs your brain that you’re hot when you are not. It lasts an average of two to four minutes and for some women these episodes happen 20 or 30 times a day. They are associated with difficulties sleeping, depression, and can negatively affect quality of life.

Handle it like a gynaecologist

Cognitive behavioural therapy (CBT) for hot flushes involves education about what’s happening medically as well as developing skills that help replace any negative beliefs with those that are more positive – or at least more objectively accurate. For example, in response to a hot flush, I might think, ‘My brain feels like the antechamber of hell,’ and ‘This is never going to end.’ These negative thoughts may strengthen parts of the brain involved in messaging about hot flushes, actually increasing the risk or severity.

With CBT one goal is to learn to replace cognitive distortions with something more accurate. For example, ‘This is only going to last two to four minutes; that’s the
time it takes to brush my teeth.’ Whether CBT is physically stopping the heat or affecting the brain’s perception isn’t known; regardless, studies show that it can lead to changes in the brain that are visible on imaging and it can help many women suffering with hot flushes.

The gold standard treatment for VMS is hormone replacement therapy or HRT, and it’s the oestrogen that has the bulk of the effect (women with a uterus will also need progestogen). In general, the recommendations are to start with the lowest dose therapy that can relieve the symptoms. There are other non-hormonal prescriptions, such as gabapentin and venlafaxine, that can also be quite effective.

Bladder problems

It’s ‘typical’ for women to develop bladder conditions, such as urinary tract infections (UTIs) or incontinence, with both menopause and age, but it’s not ‘normal’, and there is an ocean of difference between those two words. ‘Typical’ means it’s no surprise that a medical condition happens, but it doesn’t mean that condition is safe or unproblematic. In contrast, ‘normal’ sounds as if the experience is something to be tolerated. Many women are told these symptoms are ‘normal’. This is unacceptable. Imagine if we told men with erectile dysfunction that it’s ‘not bad enough to need treatment’ or ‘it’s just part of being a man’?

Handle it like a gynaecologist

A UTI is the overgrowth of bacteria in the urine that leads to inflammation. UTIs are fairly common and recurrent; they also increase with age. The increased risk of UTIs after menopause is largely related to low oestrogen, so using intravaginal oestrogen is an effective preventative strategy.

Stress urinary incontinence is the leakage of urine with activities that put more stress on the bladder (lifting, coughing, sneezing). There are some basic strategies you can use to combat this: being mindful of water intake (having to drink eight glasses of water a day is a myth) and strengthening the pelvic floor muscles with Kegel exercises. Timed voiding – urinating on a schedule – can also be helpful and when pelvic floor exercises are combined with timed voiding, incontinence can improve significantly.

Genitourinary syndrome of menopause (GUSM)

This term refers to the significant changes that the vulva and vagina undergo during the menopause and with age – either directly from the lack of oestrogen or indirectly because of the reduction in blood flow to the tissues.

As many as 15 per cent of women report manifestations of GUSM during their menopause transition, and eventually up to 80 per cent of women will experience some symptoms, which include vaginal dryness, burning or a sandpaper-like feeling, pain with penetration, itching, irritation, decreased lubrication during sex, a change in odour and discharge. The vagina also shrinks a little in length and width, likely due to changes in blood flow and collagen, which, in addition to the loss of tissue elasticity and increased fragility, can also lead to pain with sex. (Although, interestingly, the penis also shrinks with age due to declining testosterone levels, decreased blood flow and collagen production. We just don’t hear about that as much…)

Handle it like a gynaecologist

The foundation of managing GUSM is vulva and perianal skincare. Avoid wipes at all costs and don’t use soap: it can damage the acid mantle (the protective layer of fat and other microscopic substances that coat the skin). Soap can also react with the vulva skin, raising the pH from a typical 4-5.2 to 10. After washing, moisturise: dryness is the enemy of irritation. Use incontinence pads if you experience any urine leakage: menstrual pads aren’t up to the job, and consequently stay wet leading to skin irritation. As for pubic hair, which increases humidity and hence traps moisture against the vulva, trim rather than wax or shave it, as removing hair by those methods damages the top layer of the skin.

Loss of libido

It’s normal for desire to decrease with age, but for some women, due to the menopause transition, that decrease can accelerate: in one study, 12 per cent of women aged 43 to 64 had desire disorders, and for women over the age of 65 that number was around seven per cent greater. Interestingly, this is unrelated to hormone levels, meaning there are many women with lower levels of oestrogen and testosterone with high levels of desire, and the reverse is true.

Handle it like a gynaecologist

When desire feels dead, the first step is to look at medications that may have loss of libido as a side effect, medical conditions, life in general, and communication with your partner.

As women age it isn’t uncommon to need more physical stimulation to achieve orgasm. A great way to boost arousal is with a vibrator. If you’re already using one, switch to one that can deliver more stimulation or one that can stimulate other areas. CBT, mindfulness and learning to cultivate desire – with communication, apps, books, erotica, foreplay and afterplay – are important strategies, as well as the right lubricant. Another consideration is, again, to work on strengthening your pelvic floor muscles with Kegel exercises as these physically contract during orgasm.

This is an edited extract from The Menopause Manifesto: Own Your Health with Facts and Feminism by Dr Jennifer Gunter, which will be published by Piatkus on 25 May, priced £14.99. To order a copy for £13.19 go to mailshop.co.uk/books or call 020 3308 9193.