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The first thing a woman is most likely to notice is her periods becoming more irregular. The time between them may be less than usual or they may be further apart; they may last for a longer or shorter time; be heavier or lighter; or a combination of all these, varying from month to month. Very occasionally, a woman says she had a period at the expected time and then never had another, but this is unusual; irregular and unpredictable is how things are likely to be for quite a while.

(A small warning here: It’s quite normal to have irregular periods at regular intervals, or normal periods at irregular intervals, but continual ‘spotting’ between periods is something to see your doctor about.)

The next stage is to miss one or more, even several, periods completely. The menstrual loss may be less than normal, even scanty, but as long as periods continue, ovulation is still taking place and pregnancy is still possible. Gradually, the gap between periods increases and the duration of bleeding becomes less and less, until a woman might think, ‘Hurray, it’s all over.’ She may be right — or she may suddenly get another period months and months later (often at a most awkward time, such as during a holiday on a remote Greek island with the nearest chemist’s shop a three-hour boat trip away!). The moral is: If you are under 50 and have had no periods for two years, or over 50 and have had none for one year, then you can probably relax; otherwise, never go away without being prepared! (This rule of thumb also applies to the likelihood of becoming pregnant, but is probably unnecessarily cautious.)

The timescale over which all these changes occur varies greatly from one woman to another, so this is one instance where your friends’ experiences may not be very helpful. It is highly likely that during this time you will be experiencing a whole range of menopausal symptoms that you might feel unprepared for. The more you know about them – and what can be done about them — the more confident you will feel in yourself, and your self-confidence and self-esteem are less likely to suffer. Research has shown that many of those who find it hard to cope at this time just don’t realise what’s happening to them, or why, or what can be done to help them. The women who cope best are those who understand about the menopause and are able to develop a positive attitude to managing it.

Many women say, ‘I’ve had a hysterectomy. How will this affect my menopause?’ The answer is that it depends on the sort of hysterectomy you had. It is surprising how many women have no idea how much of their body was removed during their hysterectomy. Was it just the uterus (womb), or the uterus and cervix, or all that and the ovaries as well? To anyone reading this book who may have a hysterectomy at some time in the future (and to those who are still in touch with the hospital who carried out their hysterectomy in the past), it is advisable to know your body. In other words, don’t just let ‘them’ do things to you unless you know what it is, and why. Surgeons who would be very reluctant to remove a man’s testicles (where the male hormones are produced) will whip out a woman’s ovaries (where the female hormones are produced) in the twinkling of an eye, and she may never know. So ask, because it will greatly affect the next few months and years of your life.

There are two sorts of menopause: a natural menopause and a surgical menopause. With a natural menopause, hormone levels gradually fall over quite a long timespan and symptoms build up slowly. This usually happens between the mid-forties and mid-fifties, though it can start much earlier and end rather later. A surgical menopause is not gradual. You may have been on the waiting list for a hysterectomy for weeks (or even months), but as far as your body is concerned it is a sudden event. One minute you have all those female bits inside you, and an hour or so later they have gone.

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The patch is worth trying if you don’t tolerate oral oestrogen well (side effects like nausea, abdominal pain or headaches will tell you that). You’re much less likely to have these side effects with the patch because it cuts down the number of times the oestrogen passes through your liver. This means that the liver is not stimulated so much to produce proteins that may interfere with normal blood pressure and your fluid control systems.

The patch may also be more convenient than taking oestrogen tablets each day, because it is applied twice a week.

All the same, oral oestrogen is the way most doctors prefer to start patients who need oestrogen therapy. The main reason is that there is considerable research demonstrating the effectiveness of oestrogen pills in managing menopausal symptoms and protecting the bones, heart and blood vessels.

Regrettably, research on HRT patch formulations has not been going on for long. Recent studies indicate that the patch protects against osteoporosis if you use it for longer than six months, but so far there is very little long-term data regarding its impact on heart and blood vessel disease.

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It has traditionally been assumed that women at and after the menopause are likely to lose interest in sex — that sexual desire ebbs from the forties onwards and drifts relentlessly downwards. Older women who have an evident — perhaps even a lusty — interest in sex tend to be caricatured as clinging pathetically to lost youth, being somehow depraved, or as having ‘emotional’ problems. The American writer Dorothy Parker put the whole matter on a cheery footing in her poem ‘The Little Old Lady in Lavender Silk’. At ‘seventy-seven, come August’ she had faced up to the ‘passing from Summer to Fall’ and believed that, throughout her long life, there was ‘nothing more fun than a man’. These sentiments are echoed in recent careful reviews of medical and social research that paint a different, more complex picture of sexual activity after menopause.

Numerous studies show no clear evidence of a consistent and predictable decline in sexual desire or activity among older women. Rather there is wide variability, with the presence of a suitable male partner being more important than age. Edward Brecher’s 1984 study of sexuality and ageing, the largest since Alfred Kinsey’s study of 1938, found a clear decline in sexual activity among US women over the age of fifty compared with men. But when he took account of whether the women were married or widowed (that is, presumably deprived of easy access to a partner), he found almost identical levels of sexual activity for both sexes.

Other studies, such as that of Dr Gloria Bachmann, suggest that sexual activity may decline if problems such as lubrication are not dealt with; if night sweats and insomnia are severe and persistent; if either partner is ill; if the male partner has a medical problem or takes medication that affects his sexual capability; if partners are unhappy in their relationship; or if they are subject to other major life stresses. Perhaps such factors help to explain the finding of the Melbourne Women’s Midlife Health Study that nearly a third of women who had a natural menopause between the ages of forty-five and fifty-five reported a decline in sexual interest.

Cultural values and traditions may also have subtle influences on sexual activity. For example, if sex is valued mainly for the children that may result, sexual activity may be restricted to the fertile years. On the other hand, in societies that value sexuality in older women and do not consider that female attractiveness resides solely with the young, postmenopausal women are more likely to be sexually active.

So it is clear that there is little to suggest, among women with suitable opportunities, an inevitable or precipitous fall in sexual activity at or after menopause.

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Many women feel they are changing personality during menopause, like the female equivalent of Dr Jekyll and Mr Hyde. Germaine Greer likens it to ‘the person you know being stuffed inside a new one. The most unnerving, even terrifying, change is a sudden horrible propensity to blind rage . . . She finds herself calling down horrible vengeance and uttering mad threats, which seem to be throttled out of her, as if she was being squeezed in a giant hand. Sometimes the outburst is accompanied by a feeling of physical anxiety, amounting to pain, or a feeling of unbearable pressure in the head, or behind the eyes.’ The choking rage is usually followed by ‘exhaustion, helpless guilt and a futile wishing that whatever it was had not happened’.

The hormone replacement advocate Dr Robert A. Wilson (see chapter 2) linked the mood changes in his ‘gentle, almost angelic mother’ to his later efforts to find a ‘treatment’ for menopause. ‘At the time I could not understand it. What was a boy in his teens to make of a phrase like “change of life”? . . . Yet something terrible was obviously happening. I was appalled at the transformation of the vital, wonderful woman who had been the dynamic focal point of our family into a pain-wracked, petulant individual. I could feel the deep wounds her senseless rages inflicted on my father, myself and the younger children. It was this frightful experience that later directed my interest as a physician to the problem of the menopause.’

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Another intriguing discovery was the shift in attitudes to menopause as experience took over from expectation. At the beginning of the study about 70 per cent of those questioned said they would feel relieved or neutral when their menstrual periods stopped, and 3 per cent expected to feel regretful. Five years later, the overwhelming majority of women were positive or neutral about menopause. In other words, as women experienced menopause, their feelings about it became more positive.

One explanation for this positive shift could be that women have been ‘sold’ too pessimistic a view of menopause and feel relieved when they successfully negotiate it. The pessimistic sales pitch arises from folklore belonging to past eras and, paradoxically, to scientific studies of women’s health, many of which have concentrated solely on users of the health care system. These studies are biased because participants tend to be women experiencing the most difficulty, who do not represent all women.

Another possible explanation for the shift in views could lie in evolving approaches by women to their own health problems. Many women are becoming more aware, more questioning, and they are educating themselves better on health issues than did their mothers and grandmothers. ‘We have a growing population of consumers who do not accept drugs or the doctors’ say-so any more,’ says Nancy Peck, former coordinator of the Healthsharing Women’s Health Information Service funded by the Victorian Health Department and the National Women’s Health Program. Women like Ms Peck were in their thirties in the 1970s and were vocal about issues like rape, abortion and the Pill. As she enters her fifties, she and other women of her generation are speaking out about key issues such as menopause and HRT.

The current generation of forty-year-olds and fifty-year-olds has benefited also from weakened taboos associated with sex, reproduction, menstruation and menopause. While we are living longer and have more reason to worry about heart disease, fractures, strokes, lung cancer and breast cancer than previous generations of women, we are talking openly about these health problems” within the family, and usually with friends and trusted doctors as well, discussing how we might tackle them in our own lives and in the lives of our daughters and grand-daughters.

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