• Small children notice fairly quickly that girls are not like boys, and women are not like men. They are different shapes, have different bits, later on they have different types of voices and hair in different places. During the late teens and early twenties, the superficial differences may become blurred – one person with a pony tail and earrings may be male, another with cropped hair and jeans may be female -but as long as they themselves know which is which, who are we to criticise?

    From the moment of conception, the foetus is programmed to develop the type of hormones that will give him or her male or female characteristics. A hormone is a substance produced by glands in one part of the body, which causes changes to occur in other parts of the body. The male child produces more of the male hormone, testosterone, and the female child more of the female hormones, the oestrogens (pronounced ‘eestrojens’). In fact, we all produce some quantities of both male and female hormones, but from puberty onwards ‘our own’ particular hormone starts to predominate and we develop the outward visible signs of one gender or the other.

    At puberty, a boy’s level of testosterone starts to rise. As a result, his voice gets deeper, he develops facial hair, and his bones and muscles become bigger and stronger. At puberty, a girl’s level of oestrogen (in a form called oestradiol) starts to rise and, among other things, her periods start, her breasts develop and her body takes on a rounder shape. During the years of menstruation we tend to regard the monthly bleed as the only sign of hormonal changes occurring, but the levels of our various hormones go up and down throughout the menstrual cycle, and what we know as the menstrual period is the body’s visible response to these many changes.

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  • - Adding progestogen to my oestrogen each month gives me a bad headache. What can I do about that?

    Headaches such as you describe are sometimes caused by fluid retention. It may be possible for you to reduce the dose of progestogen you are taking, and this possibility should be raised with your doctor.

    - I’ve had a hysterectomy and I’m taking Premarin pills. Are they likely to raise my blood pressure?

    No, Premarin should not have this effect. If your blood pressure is considered high, it should be treated with a medication for lowering blood pressure and you should continue with your oestrogen.

    - Does HRT have any effect on rheumatoid arthritis?

    A number of studies of oestrogens and rheumatoid arthritis have been published, with a mixed set of results. A 1986 study suggested a protective effect, while several more recent studies failed to confirm this. If there is an effect, we don’t yet know how long it lasts, whether some methods of delivering HRT to body tissues have a more beneficial effect on this condition than others, or what effect the addition of progestogen may have.

    - I’ve been having HRT to relieve severe hot flushes, and I’m wondering if the dosages are any different from those I need to protect me from osteoporosis or heart disease?

    This depends on the dosage you need to relieve your symptoms, and the individual way your body handles the hormones. If you are a young woman your symptoms are probably severe, and the dosage you are taking is likely to be ample for protecting your bones and heart. If you are older, your hormone dose may be low and your level of protection may be doubtful. To further complicate the situation, two women of the same age and with similar symptoms may handle the hormones somewhat differently, resulting in a greater level of protection for one or the other.

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  • Nearly a third of women aged forty-five to fifty-five who participated in the Melbourne Women’s Midlife Health Study complained of headaches. Given this prevalence, it is surprising how little research has been done on the relationship between headaches and hormones. For a small number of women, their first experience of headache seems to occur around the time of menopause, while for others they become less frequent. It is not known why this is so.

    If you begin to have severe headaches, including migraine and visual or sensory disturbance, at about the time you start on HRT, you should stop and have the problem investigated. If you already had a headache problem and are on HRT, the situation should be watched closely. Be sure to check that your doctor is prescribing a ‘natural’ rather than a ‘synthetic’ oestrogen and a form of progestogen that is least likely to make headaches worse. Changing the brand of oral oestrogen or changing from a pill to a patch or implant may also help.

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  • Women know that the menopause brings flushes and sweats, and generally cope if they are not too frequent. For some women, however, they happen so often and are so severe that they tend to dominate life. Amandine Dupin (better known as the French novelist George Sand) was forty-nine when she wrote in a private letter, dated 1853, ‘I am as well as I can be, given the crisis of my age. So far everything has taken place without grave consequence, but with sweats that I find overwhelming, and which are laughable because they are imaginary. I experience the phenomenon of believing that I am sweating fifteen or twenty times a day and night … I have both the heat and the fatigue. I wipe my face with a white handkerchief and it is laughable because I am not sweating at all. However, that makes me very tired.’

    As many women can testify, hot flushes and sweating episodes are far from imaginary, being intimately associated with fluxing levels in certain hormones and a rise in skin temperature by several degrees. Some women have accompanying nausea and palpitations. Flushes tend to be more prevalent in women who experience a rapid change in sex hormone levels, for example following a hysterectomy and bilateral salpingo-oophorectomy (that is, removal of both ovaries as well as the uterus and cervix), than in women who have a natural menopause. Flushes and sweats are also more likely in women who smoke, have a history of premenstrual syndrome (commonly abbreviated to PMS) or experience flushes and night sweats before menopause.

    The duration of these problems may also influence a woman’s decision to seek medical help. Flushes and sweats that disappear after a few months are easier to cope with than the same symptoms lasting for years. Studies show that flushes go on for about two years in most of the women affected. About 20 per cent have them for five or more years, and about 10 per cent are still having occasional flushes into their sixties. Descriptions of flushing and sweating episodes vary enormously. Some women tell us that their hot flushes are like a spray of hot oil that quickly passes. Others note that the sensation of heat is inevitably followed by shivering and cold sweats. Yet other descriptions of night sweats make them sound like clammy journeys through tropical rainforests without the beautiful surroundings, the aftermath of which is a need to change sheets and nightwear.

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  • According to Dr Derek Llewellyn-Jones, a Sydney obstetrician and gynaecologist and a prolific writer on health issues, at least a hundred symptoms have been attributed to the menopause, but only two can be related absolutely to the hormonal changes that are going on. They are hot flushes and vaginal dryness. Nonetheless women in the reproductive years can experience similar symptoms. In any given two-week period, for instance, one in ten women who are not menopausal experiences a hot flush.

    Irritability and moodiness are another good example of symptoms not confined to menopausal women, a point made by Dale Spender in the Sydney Morning Herald of 14 April 1993. ‘Now that we are all familiar with the psychological distress caused by unemployment,’ she said, ‘we can see that it is very similar to the so-called symptoms of menopausal women. [If they are] Denied a useful role and a sense of affirmation, the outcome is low self-esteem, depression and a sense of futility about the meaning of life. In the past we just confused menopause with “downsizing”.’ Not only do women of menopausal age sometimes experience feelings of scaled-down worth, they are also coping with the physical effects of fluxing hormones. Perhaps they might handle the situation better if they did not have to cope with these dual pressures simultaneously.

    SIGNS OF MENOPAUSE

    You may become aware that menopause is around the corner when some or all of the following signs show up:

    ? unpredictable menstrual bleeding that is sometimes very light and regular, at other times heavy and prolonged

    ? hot flushes and accompanying sweats

    ? bladder problems resulting in a need to urinate more frequently and troublesome urinary tract infections

    ? uncharacteristic irritability and mood swings

    ? short-term memory loss and difficulties with concentration

    ? sleeplessness and a generalised loss of zip

    ? a crawling sensation under the skin

    ? inexplicable weight gain and shifts in body fat distribution

    ? dryness of the vagina, making intercourse painful or less comfortable

    ? loss of libido

    ? less frequent appearance of the lubricative mucus from the cervix that indicates ovulation

    ? headaches, dizziness, heart palpitations

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