Gidon Lieberman is our Chief Medical Officer. He’s a leading consultant gynaecologist and fertility specialist with over 25 years of experience. He’s accredited for laparoscopic and hysteroscopic surgery, gynaecological ultrasound and management of the menopause. He’s especially interested in helping patients combat infertility – and is very well known for his excellent analogies.
Menopause is a very normal physiological and psychological transition to go through, but the words and definitions around menopause are often a bit confusing and can be used inconsistently. In this article we'll explain the terminology that's most often used when talking about menopause and the most important things for you to know.
Menopause terminology explained
We say that someone's last natural period is called their menopause. We have to wait one full year to be confident that this was their last natural period. So, if your last period was on the 17th of July 2020 when you were 50, we would confirm you are menopausal on the 17th of July 2021. The medical term is actually postmenopausal.
The reproductive years from when periods first start until the menopause is called pre-menopause. Using the same example as above, while you are 14- 49 years old, you will be premenopausal. Premenopausal people will have periods bar some exceptions e.g. pregnancy, gynaecological problems, medical intervention, a Mirena coil, or certain medication.
Quite a lot of confusion comes with the term perimenopause. This term is used to describe the time when a person begins to have menopausal symptoms but is still having periods. In the UK, this phase typically starts around the age of 42 – 43. Since a perimenopausal person is still having periods, they will also be considered premenopausal.
The menopause happens when a person's egg store is depleted to practically zero. Eggs instruct the ovaries to release two ‘female’ hormones – which are actually present in all people, males and females alike – estrogen and progesterone. If there are no eggs, the hormone levels will fall. A third hormone called testosterone does not require there to be eggs, but testosterone levels will also fall after the menopause - more on this later.
Eggs are stored in the ovaries which sit in little bubbles of fluid called follicles. These follicles constantly release estrogen which rises and the falls during the menstrual cycle. Progesterone is released after egg release or ovulation.
Menopause doesn’t just happen all of a sudden. Egg number and egg quality will gradually decrease as you age – particularly after the age of 37. The first sign of declining egg quality and number is a decrease in fertility and increase in miscarriage rates. Many symptoms will begin whilst periods are still present in your 40s - this is perimenopause. Biologically, there is a reduction in the number of good quality eggs with the subsequent decrease in hormone levels.
The most common menopause symptoms
The familiar menopausal symptoms are mainly due to a lack of estrogen, and so providing estrogen medication is the first and main building block of HRT. The female body has estrogen receptors in all sorts of places in the body. The brain and central nervous system, blood vessels, skin, hair follicles, bones, bladder, vagina and vulva. It’s not that surprising that a fall in estrogen causes wide ranging problems including mental, psychological, sexual and physical symptoms.
Longer term depletion of estrogen can lead to osteoporosis and heart disease. Replacement of hormones can help prevent these changes and also possibly help prevent dementia.
Most symptoms will stop being significant within two to three years, but symptoms can last much longer. Many people will be able to deal with perimenopausal symptoms with changes in lifestyle, diet and exercise but some people will want HRT. This is by no means the magic answer and unhelpfully there have been a lot of myths about HRT in recent years. More than 50% of people who are offered HRT will not use it.
I think that a fall in fertility is the very first symptom of decreasing egg number and quality. The age-related fall in fertility rates was how I began my interest in menopause. I noticed that some people reported feeling really well when we were using hormone replacement before replacing frozen embryos. As the patients were experiencing declining ovarian function, the addition of hormones during fertility treatment provided symptomatic relief.
Ovarian function does not decrease at a predictable nor even rate, and there will be intermittent episodes of normal and abnormal function in the perimenopause. That’s why periods can stop for some time and then restart, leading to why symptoms can come and go.
The egg life cycle
We know that egg number falls with age, but it’s not widely known that the most number of eggs a person will ever have is when they are about 24 weeks old in their mother’s uterus. At this point they have about 6 million eggs. This number falls rapidly and by birth they have 2 million eggs. When this person starts their periods (called the menarche), they only have about half a million eggs. Leading up to menarche people don’t have periods, so what happens to the eggs? The answer is that each and every egg has a pre-determined date to die or breakdown. So most eggs die without ever being ovulated – in fact only 0.5% of the initial number of eggs will ever be ovulated.
The automatic egg death will happen no matter what. Even if a person was to never ovulate in their entire life (for instance they were on the pill all their life), they would still go through the menopause at the same age. Pregnancy and breast feeding are not protective in this regard.
Testing for the menopause
It’s common that people ask for blood tests to confirm whether they are menopausal. The NICE guidelines suggest offering blood tests to people who are not yet 45 years old, but they do not suggest doing blood tests if the individual has perimenopausal symptoms and is over the age of 45. The reason for this is that the ovarian function and hormone levels will be altered in almost all people who are 45 or older. If hormone levels are normal in perimenopausal individuals, it does not mean that they have previously been normal or will be normal in the future.
We know it’s slightly contentious but having blood tests during HRT treatment is not necessary for the majority of those on HRT. Blood tests are sometimes useful when there are unexpected responses (over or under). Standard dosages of HRT do not need to be followed up with blood tests. The exception is testosterone, where a level should be checked every 3 or 4 months after starting treatment.
When will I have the menopause?
The average age of menopause (last period) in the UK is between 47 and 52 years old with an average age of 51, but symptoms may well start many years before. Some people will have the menopause before the age of 45, which we call an early menopause – but is still considered to be natural. An early menopause is managed in the same way as menopause is in older people.
About 1:100 people will have the menopause before the age of 40, which is called Premature Ovarian Insufficiency (POI). This often comes out of the blue and can have a massive impact on a person's life. We generally are very keen on treating people with POI with hormonal support to prevent long term consequences of low estrogen – namely bone thinning and cardio-vascular problems. Without treatment, people with POI will sadly have a decreased life expectancy, so it’s really important to seek help and advice as early as possible.
There isn’t a way to precisely know when someone will have their last period. Although blood tests and scans can give you information about your current hormone and follicle status, it’s really not possible to use investigations to predict this. In fact, the best predictor is knowing when your mum had her menopause.
So in summary, menopause is natural but its effects can be challenging. Many people will have symptoms when they still have periods, others will be relatively symptom free. Everyone is different, and there are lots of different options to help should you need it.
At Fertifa, we're proud to be opening up conversations around menopause and normalising important discussions. If you're looking to provide your people with menopause support, get in touch here. We'd love to work together 💜
