“Every woman deserves the best health care. Your needs change at different stages of your life – you may be preparing for pregnancy, awaiting the birth of your baby, going through the menopause or looking for answers to women health queries. Whatever stage you’re at, whatever your needs, our hub aims to empower you to understand your condition and take control of your own health”
Menopause including HRT.
In medical terms, the menopause is usually defined as the time reached one year after a woman’s last menstrual period. However, people often refer to the time leading up to as well as the time after a woman’s last period as being the menopause. The years leading up to the menopause are called the peri-menopause or the pre-menopause. The menopause is a normal stage of a woman’s life.
Strictly speaking, the menopause is your last menstrual period. However, most women think of the menopause as the time of life leading up to, and after, their last period. In reality, your periods don’t just stop. First they tend to become less frequent. It can take several years for a woman to go through the menopause completely. Women are said to have gone through the menopause (be postmenopausal) when they have not had a period at all for one year
A natural menopause occurs because as you age your ovaries stop producing eggs and make less oestrogen (the main female hormone). The average age of the menopause in the UK is 51.
Your menopause is said to be early if it occurs before the age of 45.
There are certain things that may cause an early menopause – for example:
- If you have surgery to remove your ovaries for some reason, you are likely to develop menopausal symptoms straightaway.
- If you have radiotherapy to your pelvic area as a treatment for cancer.
- Some chemotherapy medicines that treat cancer may lead to an early menopause.
- If you have had your womb (uterus) removed (hysterectomy)before your menopause. Your ovaries will still make oestrogen. However, it is likely that the level of oestrogen will fall at an earlier age than average. As you do not have periods after a hysterectomy, it may not be clear when you are in ‘the menopause’. However, you may develop some typical symptoms (see below) when your level of oestrogen falls.
- An early menopause can run in some families.
- In many women who have an early menopause, no cause can be found.
If your menopause occurs before you are 40, it is due to premature ovarian insufficiency. Read more about premature ovarian insufficiency.
The menopause is a natural event. Every woman will go through it at some point. You may have no problems. However, it is common to develop one or more symptoms which are due to the dropping level of oestrogen. About 8 out of 10 women will develop menopausal symptoms at some point. Around a quarter of women have very severe symptoms.
Symptoms of the menopause may only last a few months in some women. However, for others symptoms can continue for several years. Some women may have early menopause symptoms that start months or years before their periods stop (peri-menopausal or pre-menopausal symptoms). More than half of women have symptoms for more than seven years:
- Hot flushesoccur in about 3 in 4 women. A typical hot flush (or flash) lasts a few minutes and causes flushing of your face, neck and chest. You may also sweat (perspire) during a hot flush. Some women become giddy, weak, or feel sick during a hot flush. Some women also develop a ‘thumping heart’ sensation (palpitations) and feelings of anxiety during the episode. The number of hot flushes can vary from every now and then, to fifteen or more a day. Hot flushes tend to start just before the menopause and can persist for several years.
- Sweatscommonly occur when you are in bed at night. In some cases they are so severe that sleep is disturbed and you need to change your bedding and nightclothes.
- Other symptoms may develop, such as:
- Being irritable.
- Difficulty sleeping.
- Aches and pains in your joints.
- Loss of sex drive (libido).
- Feelings of not coping as well as you used to.
- Changes to your periods. The time between periods may shorten in some women around the menopause; in others, periods may become further apart, perhaps many months apart. It can also be common for your periods to become a little heavier around the time of the menopause; sometimes periods can become very heavy.
Problems following the menopause
Following the menopause women’s bodies may change in several ways:
- Skin and hair. You tend to lose some skin protein (collagen) after the menopause. This can make your skin drier, thinner and more likely to itch.
- Genital area. Lack of oestrogen tends to cause the tissues in and around your vagina to become thinner and drier. Learn more about vaginal dryness (atrophic vaginitis). These changes can take months or years to develop:
- Your vagina may shrink a little and expand less easily during sex. You may experience some pain when you have sex.
- Your vulva (the skin next to your vagina) may become thin, dry and itchy.
- You may notice that you need to pass urine more frequently and may even leak.
- Some women develop problems with recurrent urine infections.
- ‘Thinning’ of the bones (osteoporosis). As you become older, you gradually lose bone tissue. Your bones become less dense and less strong. The amount of bone loss can vary. If you have a lot of bone loss then you may develop osteoporosis. If you have osteoporosis, you have bones that will break (fracture) more easily than normal, especially if you have an injury such as a fall. Women lose bone tissue more rapidly than men lose it, especially after the menopause when the level of oestrogen falls. Oestrogen helps to protect against bone loss.
- Cardiovascular disease. Your risk of disease of the heart and blood vessels (cardiovascular disease), including heart disease and stroke, increases after the menopause. Again, this is because the protective effect of oestrogen is lost. Oestrogen is thought to help protect your blood vessels against atheroma. In atheroma, small fatty lumps develop within the inside lining of blood vessels. Atheroma is involved in the development of heart disease and stroke.
Do I need any tests to see if I am going through the menopause?
Your doctor can usually diagnose the menopause by your typical symptoms. Hormone blood tests are not usually needed to confirm that you are going through the menopause. However, they may be helpful in some cases – for example, in women aged under 45 years.
Other blood tests or scans may be undertaken in some women, especially if they do not have symptoms which are typical of the menopause.
It is important that you keep up to date with the national cervical screening programme and breast cancer screening programme, if appropriate.
Without treatment, the symptoms discussed above last for several years in most women. HRT is a very effective treatment for the symptoms of the menopause. It replaces the oestrogen hormone that your ovaries stop making once you are menopausal. It has benefits and risks. Find out more about hormone replacement therapy (HRT).
If your main symptoms are in your vagina and genital area or if you are getting urinary symptoms, you are likely to benefit from using treatment that is inserted into your vagina or just applied to your genital area as a cream. Read about treatment for vaginal dryness and urinary symptoms.
HRT is available as:
- Skin patches.
- Gels to apply to the skin.
- Nasal spray.
- Tablets to insert into the vagina (pessaries).
- Cream to insert into the vagina or apply to the genital area.
- Vaginal ring.
There are several brands for each of these types of HRT. All deliver a set dose of oestrogen (with or without progestogen) into your bloodstream.
There are treatments other than HRT for menopausal symptoms. As a rule, they are not as effective as HRT but may help relieve some symptoms. Learn about alternatives to HRT.
Fertility and the menopause
Although women become less fertile as they get older, it is still possible to get pregnant around the time of the menopause. So, if you are sexually active and don’t want to become pregnant, you will need to consider contraception:
- Until a year after your last period if you are 50 or over.
- Until two years after your last period if you are under 50.
Gastrointestinal History and Examination
The gastrointestinal tract extends from the lips to the anus and includes the liver, biliary system and pancreas although, for the purpose of this article, consideration will start at the oesophagus, as problems with dentition or with salivary gland disorders and tumours are covered elsewhere.
Ask open questions and give the patient time to elaborate. However, it is very important to ascertain that you are ‘speaking the same language’. Avoid technical terms, jargon or abbreviations. Make sure that you understand what the patient means and get amplification of specific points. To patients, the word ‘stomach’ can mean anywhere from the diaphragm to the groin and includes the genitals. ‘Do you have a hard stool?’ may make the patient wonder if the chair in the kitchen is comfortable. Does ‘coughing up blood’ mean haemoptysis or haematemesis? Patients often describe pain as ‘chronic’, meaning severe rather than of long-standing duration.
Elucidation of specific points
The following are important aspects of the history, which require clarification:
- What does difficulty in swallowing mean? Dysphagia has many components.
- s there pain?
- Is there a feeling of obstruction?
- Is food regurgitated? If so, how long after swallowing?
- Is it a burning pain just after eating?
- If there is complaint of obstruction, ask the patient to point to the level. The obstruction is usually at that level or below.
- Globus hystericus is usually accompanied by a rather theatrical performance and, unlike neurological disorders, the patient denies being able to swallow anything but does not drown in their own saliva and often has not lost weight.
- See separate articles Dysphagia, Oesophageal Strictures, Webs and Rings, Gastro-oesophageal Reflux Diseaseand Oesophageal Cancer.
- Flatulence, wind and bloating are often caused by aerophagy (swallowing air) or a diet too rich in fibre.
- If there is complaint of abdominal pain, ask the patient to point to the location of the pain.
- Does the patient use a single finger or spread the fingers and move the palm over much of the abdomen?
- What is the nature of the pain? Note body language. A burning pain is often described with an open hand moving upwards but a clenched fist is used to describe colic.
- Are there any aggravating or relieving factors? The former may include fatty food. The latter may include sitting forward or taking medication.
- How often is the pain felt and how long does it last?
- Is there radiation elsewhere?
- Do not accept such terms as ‘indigestion’ without clarification of exactly what the symptoms are. ‘Indigestion’, aggravated or induced by exercise and relieved by rest, is probably angina.
It is very easy for the doctor and patient to misunderstand each other on this subject.
Rather than asking if bowels are normal, as normal is such a variable parameter, enquire about any change in bowel habit and its duration.
- Do not accept words such as constipation or diarrhoea without further enquiry. What does the patient mean?
- How often?
- What is the consistency?
- Is there any urgency or faecal incontinence?
- Is defecation painful (dyschezia)? Is there tenesmus?
- Is there blood or mucus (call it slime to the patient) in the stool?
- If there is blood is it always there or just occasionally?
- Is it mixed in with the stool or separate and splashes the pan? This will help indicate if the bleeding is from low down or higher up.
- What is the colour of the motion?
Melaena is black, sticky and tarry and results from a significant high gastrointestinal bleed.
Steatorrhoea is pale, bulky, and very offensive in smell. It is often frothy, floats and takes several attempts to flush away. This indicates gastrointestinal malabsorption of fats.
This is especially important in this field.
- Is appetite good?
- Has it changed?
- Is there any change of weight up or down?
- If so, is this intentional? Distinguish dieting from abnormal weight loss.
- How much and over what period of time?
- Not everyone watches their weight. Are waistbands any tighter or looser than before? Loss of weight means malnutrition.
- Weight gain and expansion will accompany an enlarging abdominal mass or ascites.
- When seeing females aged between about 12 and 50 years record the date of the last menstrual period. Failure to do so with subsequent failure to diagnose a mass arising from the pelvis will cause immense embarrassment.
- Ask about smoking and alcohol consumption. If there is any reason to suspect excessive consumption of alcohol, refer to information under alcoholism for diagnosis and management in primary care, help and advice.
- Replies like ‘I just drink socially’ are meaningless, as they depend upon the company one keeps.
- Establish whether the patient drinks every day.
- Record exact amounts smoked and drunk and, if a range is given, record the upper figure, as it is more likely to be accurate.
- Ask about medication and make it clear that this means not just prescribed medication but drugs bought over the counter, ‘alternative remedies’ and illicit drugs.
- Herbal remedies can cause hepatitis.
- Opiate abuse will cause nausea, anorexia and constipation.
- Intravenous drug abuse carries a risk of hepatitis C, hepatitis B and HIV infection.
- Cocaine and amfetamine derivatives cause appetite suppression.
- Anabolic steroid abuse can cause hepatitis and even hepatocellular carcinoma.
- Establish in what form drugs are taken. Non-steroidal anti-inflammatory drugs as suppositories may still cause gastritis, as the drug is transported to the stomach in the blood. There is also a high risk of proctitis.
- The patient may admit to visiting health spas and receiving colonic lavage or high colonic irrigation.
- If there is proctitis, a delicate enquiry as to the person’s sexual predilection may be required in both males and females.
- Ask whether the patient eats a normal diet. Changes in eating habits may have resulted from the symptoms.
- Note family history.
- Ask about foreign travel and living abroad. Traveller’s diarrhoea is just one possibility. Many other exotic diseases can be acquired.
This is covered in a number of other articles too.
Children pose specific difficulties. See separate Paediatric Examination article.
As always, examination begins by looking at the patient.
A general inspection precedes inspection of the abdomen.
- Establish what the patient’s nutrition is like. Note whether the patient is thin and wasted, bloated and oedematous or obese.
- Note whether the skin looks pale or yellow. In black people, a slightly yellow colour of the palms is equivalent to pallor.
- Features of scleroderma may account for dysphagia.
- Look for liver palms and a hepatic flap as described in the separate Abdominal Examination
- Look for abnormalities of the nails such as clubbing or koilonychia.
- Check the sclerae for jaundice.
- Note the angles of the mouth. Angular cheilitis may suggest iron deficiency. In pernicious anaemia around 50% of patients have a smooth tongue with loss of papillae but this can also be due to friction in those with a plastic palate with upper dentures.
- Note whether the mouth looks healthy.
- Note whether dentition is good.
- Note whether there is halitosis.
- Oral candida may be associated with oesophageal candidiasis, especially if immunity is suppressed.
Only now is it time to turn to the abdomen and, as always, first look.
- Abdominal distension may be apparent.
- Abdominal masses may be apparent on inspection.
- High pressure in the abdomen may cause protrusion of the umbilicus. Cirrhosis or portal hypertension may produce prominent blood vessels on the abdomen.
Now it is time for palpation and, again, reference is made to examination of the abdomen, which also includes palpating for splenomegaly and detection of ascites. Hepatomegaly can be difficult to detect and it is often useful to percuss the liver edge. The liver is dull to percussion while bowel is resonant.
Check for herniae. Femoral hernia is uncommon but very liable to strangulate.
In secondary care the dictum is that no abdominal examination is complete without rectal examination. In primary care this is less vigorously applied, especially if the findings are unlikely to affect management.
- Few GPs have the skills or resources for sigmoidoscopy but proctoscopy and digital rectal examination should be within the capacity of everyone.
- Such examination may reveal rectal prolapse or an obvious cause of rectal bleeding, although haemorrhoids are so common that they do not exclude other causes of bleeding.
- Carcinoma of the rectum may well be palpable.
- If an elderly person has diarrhoea, it is a distinct possibility that it is really spurious diarrhoea caused by faecal impaction with overflow. Therefore, before starting medication that may aggravate constipation, it is imperative to perform a rectal examination. The old adage is ‘Put your finger in it before you put your foot in it.’
This includes two important aspects:
Be aware of the warning signs that may indicate malignancy:
- Malignancy should be considered with significant, unintentional weight loss, progressive dysphagia, chronic blood loss, persistent vomiting and change of bowel habit in excess of six weeks’ duration, especially over the age of 40.
- Dyspepsiapresenting for the first time at age over 55 or irritable bowel syndromepresenting for the first time at age over 40 is also a warning feature.
Be aware of the many diseases not of the gastrointestinal tract and which need to be considered:
- In females think of gynaecological conditions, although they rarely cause pain outside the pelvis.
- Note the full differential diagnosis of pain in the chest. Both chest painand epigastric pain can be cardiac in origin and many a patient with ‘indigestion’ has died of heart disease.
- Abdominal pain can be from the urinary tract or a dissecting abdominal aortic aneurysm.
- Thyrotoxicosiscan cause weight loss.
- Congestive heart failurecan cause engorgement of the liver.
- Metabolic disease such as porphyriacan cause abdominal pain.
- Depressionor psychotic illnesscan cause hypochondriacal or bizarre symptoms. Recognition of depression is not always easy but remember that depression can result from somatic illness and is not necessarily the cause. Screening for depression in primary care may be employed if there is suspicion.
- Children, especially when small, represent an entirely different problem from adults.
- An important feature for children and babies is failure to thrive. Centile chartsplotting weight and height with time are extremely useful.
- Children vomit very easily and are often remarkably unperturbed by it. Parents will recall how a child has vomited during a meal and, before they have finished clearing it up, the child is eagerly finishing the meal.
- Vomiting with a high temperature, unrelated to the gastrointestinal tract, is common.
- The frequency of defecation in milk-fed babies is extremely variable as there is little residue, especially if they are breast-fed.
- If children are asked where it hurts, they usually point to the umbilicus, even if the primary lesion is tonsillitisor otitis media.
- Acute surgical problems in childrencan be very difficult to diagnose.
- Examination of children also presents special difficulties. These are covered in the separate Paediatric Examination
- If rectal examination is required for a baby, use the little finger, as it is smallest. Think carefully before performing a rectal examination on an older child, as it may be as traumatic as sexual abuse.