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It is normal and natural to lose oestrogen at the time of the menopause. If, like our forebears, we didn’t live much beyond the age of 50-ish, this wouldn’t cause many problems. Just as women in past ages were starting to get hot flushes and night sweats, along would come the Grim Reaper and their troubles in this world would be over. Few would live to experience the long-term effects of low oestrogen, such as osteoporosis, heart attacks and strokes.

We have looked at how and why oestrogen and progesterone levels fall. Now we will look at what effect this has, and why replacing these hormones — in the form of hormone replacement therapy (HRT) – can help.

Most women probably know about hot flushes, unpredictable moods and loss of sex drive, but what else might there be?

‘You won’t believe this, but I just didn’t realise my problems were due to the menopause. Of course I recognised the hot flushes, but not anything else. Over the course of 18 months I lost count of the number of times I went to my doctor – we got sick of the sight of each other. I went to him about pains in my joints (he gave me paracetamol), about insomnia and night sweats (he suggested a milky bedtime drink and sleeping tablets), depression (‘Why not do some charity work?’).

Other things I decided not to see him about, such as sexual difficulties and general mood changes. I couldn’t understand what was happening to me as I’d been such a normal, healthy person. Luckily one day I saw another doctor in the practice. She explained that all these things were probably due to the menopause, and she talked to me about HRT, gave me a check-up (which proved I was quite normal!), and I’ve been on HRT ever since.’

The consequences of low or falling oestrogen are grouped in three categories: (a) early symptoms that, for most women, last between about six months and two years, (b) rather later symptoms that tend to become more noticeable as the years go by, and (c) conditions that may not start for many years and then get steadily worse.

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- I am nearly sixty and am thinking of starting on HRT. Will I need smaller or larger hormone doses than I would have needed ten years ago when I went through menopause?

It’s likely that your hormone requirements and tolerance will both be somewhat lower than they were ten years ago. This is not the case for women who have been having HRT continuously since menopause: their needs and tolerance will not change much in ten years.

Having said that, your dose will depend on why you are thinking of starting HRT. If it’s for symptom control, you will need lower doses than if the main reason is to prevent or control osteoporosis or heart and blood vessel disease.

- Will HRT make me look younger, by removing facial wrinkles for example?

HRT will not remove wrinkles, but over a period of some months it may improve the texture and thickness of skin by increasing the collagen in it so that the skin looks fuller. An estimated 15 to 30 per cent of collagen is lost from the skin in the first five years after menopause. The best way to prevent wrinkles forming is to avoid excessive sun exposure, wear a hat, and use sunblocks and moisturisers.

- If I forgot to take my oestrogen tablets for a week, would I notice any difference?

Any symptoms you had before starting on HRT would probably return within a matter of days.

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When Libby Hathorn and Glenn Bates interviewed more than 130 Australian men and women aged up to fifty-five for their book Half-Time, they commented on the diversity of views that women participants held on sex. Regardless of whether they had reached menopause or not, some women found sex disappointing, and less enjoyable as they got older: it wasn’t fulfilling; it had become mechanical, lacked excitement and adventure; or their partner was insensitive to their needs and feelings. The opportunity to reduce or discontinue sexual activities under the socially acceptable excuse of ‘sexless middle age’ was for some a great relief. However, most felt that with age came greater self-confidence, less anxiety, a deep satisfaction in their sexual relations, and a greater enjoyment of cuddling and shared sexual intimacies than they had ever thought possible.

Women who had reached menopause also had varied views on sex. Some had lost interest in it and were not concerned at seeing it lose some of its significance in their lives, while others were taking more initiative in sexual relations. Though women said they needed to have more direct stimulation to get aroused during sex, and orgasms were less frequent for some, they still felt a strong sexual drive and found the total sexual experience very pleasurable.

Feedback from women about their experiences of sex at and after menopause confirms this range of views. Some, such as Betty, who fell in love with a younger man while in her fifties, view sex as a crucial part of the relationship. ‘I feel good about myself and about my partner, and wonderful sex seems to flow from that. Since I’m no beauty, I’ve always tried to make sure I’m interesting company: this means spending time regularly on activities that extend my interests and challenge me. My partner and I are very conscious of looking our best for each other, and so eating healthy foods and taking regular exercise have become part of our life together.’

Others we spoke to had found new opportunities for romance, triggered by a change of partner, a variation or development in the relationship with their existing partner, a greater acceptance of themselves, or simply a freedom from anxieties about contraception and pregnancy. Other couples had compensated for joyless sex by developing satisfying non-sexual activities, or else sex had been relegated to the background because one or other partner felt overwhelmed by problems associated with dependent children, dependent parents or inlaws, or financial burdens.

June’s life is full of pressures from which sex provides no release. She has effectively vetoed sex with her husband, declaring her unwillingness to put any more energy into it. In doing so, she admits that she is also making a statement about her dissatisfaction with her husband for letting himself ‘go to seed’.

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Little is understood about why these mood swings occur, seemingly without conscious intent or reflection. One theory proposes a direct role for the fluxing ovarian hormones, the brain being one of the organs influenced by oestrogen. Others link menopausal mood swings with the relationship stresses that often occur during this life stage; the expectations, attitudes and personality of the woman; and influences like culture, social class and employment. Then again, maybe there is a biological explanation for mood swings.

Germaine Greer suggests that menopause may put ‘women back in touch with their anger after thirty-five years of censorship by oestrogen’. She adds that the middle-aged female employer (one could add executive, wife or mother), dealing with people who ignore what she says on the basis that she is menopausal, is quite likely to have to think of a number of strategies to get their attention. ‘A good deal of the anxiety of the middle-aged woman is caused by her awareness that she is turning into some kind of a harridan, a scold, a fishwife, but if you can’t get attention any other way, what are you to do?’

Other unproven hypotheses for mood changes have shifted the focus to environmental factors. These include allergies to foods and petrochemical products, and the accumulation in bones during adolescence and early adulthood of lead, which is then released into tissues and blood with the onset of menopausal bone loss.

Studies of the effects of hormone therapy on personality suggest that use of oestrogen may moderate mood swings and cause women to become more agreeable. A recent Oxford University study found that oestrogen in the form of implants reduced shifts in mood, possibly because of changes in neurotransmitter function in the brain.

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Modern medicine tends to equate the menopause with a formidable array of symptoms, and longer-term deterioration of body tissues that it blames on oestrogen deficiency. The implication is that menopausal women need hormone therapy to minimise or avoid symptoms and to maintain good health into old age. This view of menopause is increasingly under attack as oversimplified. Critics say that the absence of serious menopausal problems in many women who undoubtedly experience an overall drop in oestrogen (and other sex hormone) levels has not been adequately explained.

Some critics of the medical view also argue that the increased incidence of many diseases attributed to menopause may largely reflect ageing processes that would occur even if there were no such life stage as menopause. Others say that the focus on hormonal factors leads to the neglect of other possible biological contributors to symptom development and later health problems. These include lack of exercise, smoking, and poor nutrition involving inadequate vitamin and mineral intake. There is also criticism of the tendency to neglect psychological and social influences on mood states like irritability, depression and anxiety, which may be glossed over as ‘menopause-related’ without further investigation. The emergence of these symptoms at menopause may have less to do with hormones than with the reappraisal of personal relationships, or changes in self-confidence or self-esteem.

Although the medical view is widely criticised, women themselves are often the first to vouch for the effectiveness of oestrogen in relieving distressing symptoms like flushes and sweats. There is also good evidence that oestrogen has a beneficial effect on bone structure and blood vessel function, in some women at least. The challenge facing thoughtful doctors and those who run menopause clinics is to try to work out, in conjunction with their patients, the pluses and minuses of hormone use. And it is imperative that women learn all they can, so that they are equipped to make informed decisions in favour of HRT or against it.

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