Eventually, the time comes when the ovaries produce almost no oestrogen or progesterone, although they continue to produce hormones called androgens. Androgens (of which testosterone is an example) are hormones that produce male characteristics, but these androgens definitely belong in the female body, and influence general health, sexuality and muscular strength. Some androgens are converted to oestrogen in the body’s fat cells, so women with more fat produce more oestrogen after the menopause and may have fewer problems with hot flushes, vaginal dryness and osteoporosis than thinner women. So there is some advantage in having that extra body fat! The disadvantage is that overweight women may produce too much oestrogen, and run an increased risk of developing cancer of the womb or breast. Although all women will be producing some oestrogen from the adrenal glands, there is not enough after the menopause to keep bones strong, prevent menopausal symptoms and protect against arterial disease.

Until the menopause, a woman’s natural level of oestrogens is very much higher than her natural level of androgens. Once the menopause has passed, oestrogens fall to a very low level but androgens continue to be produced; this may explain why older women sometimes develop increased facial hair and their voices deepen slightly.

The coming of the menopause doesn’t mean you are now ‘unfemale’, or unfeminine, or old, unless you let it affect you that way. If you tell people you feel less female, they will start to view you that way; if you start to look, behave and dress like an old woman, people will treat you as old. There are so many advantages to reaching the time of the menopause, it would be a pity to let society’s view of older women spoil it all. You have now left behind you the difficulties of looking after young children, you are almost certainly more confident and self-assured than you were 20 years ago; your periods have ended, and with them premenstrual tension, pelvic aching, cramps, tampons, and the need for using birth control. You are probably better off financially than when you had children and a building society to support, and as family responsibilities lessen there is more time for new interests and activities. The end of fertility does not mean the end of your attractiveness as a person; it can mean a whole new era of your life dawning, full of possibilities for fulfilment that were unattainable when you were younger. In the days when most women didn’t live that long, the menopause meant old age; now women have at least another 30 years left to live, years full of new opportunities.

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The medical definition of a total hysterectomy is the removal of the uterus and cervix, so your neighbour should still have her ovaries intact. This is the usual type of hysterectomy performed in Australia. If the ovaries are removed along with the uterus and cervix, the procedure is called a hysterectomy plus a bilateral salpingo-oophorectomy.

- Why am I still having heavy monthly bleeds after ten years on HRT?

A large uterus, and therefore a large surface area of endometrium, is sometimes responsible for heavy bleeds. Another possibility is that fibroids protruding through the endometrium are being stimulated by the hormone therapy to grow and bleed. If you discuss this problem with your doctor, it is likely that he or she will suggest a hysteroscopy to check the endometrium. If there is no apparent problem, you may find that your bleeds become lighter with continuous combined HRT (that is, a small dose of oestrogen and progestogen daily).

– I had a couple of clots in my leg fifteen years ago. Should I avoid HRT?

This depends on whether the clots occurred spontaneously or followed surgery, childbirth or some type of traumatic accident. In either case a thorough assessment of your blood clotting system is called for at the outset.

If the clots appeared ‘out of the blue’, there is reason for caution with HRT because of the possibility that it may aggravate your clotting disorder and lead to a blocked blood vessel and, at worst, a stroke or heart attack. You may be willing to accept this risk if your menopausal symptoms are particularly severe. If so, the safest HRT option for you is a patch.

If, on the other hand, your clots followed surgery, birth or trauma, it is reasonable to try HRT in patch form after an assessment of your clotting system.

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If you do not want to have to cope with any bleeding, a change to the combined oestrogen and progestogen regimen may reduce breakthrough bleeding, or else you may consider having your endometrium removed. Paradoxically, although fewer women experience withdrawal bleeds with the combined format, about 10 per cent are still experiencing breakthrough bleeding a year later. The problem of breakthrough bleeding appears to be worse in women who are close to menopause or who have a recent history of disturbed bleeding, and it is for this reason that they are more likely to be given progestogen for part of the cycle rather than throughout it. Older women who are commencing HRT after several years without a bleed seem to have fewer problems with breakthrough bleeding.

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In the early menopause group, the incidence of hot flushes may reach 70 per cent or more. Insomnia, which affected about 40 per cent of menopausal women in the Melbourne study, is sometimes due to a woman waking repeatedly in the night, drenched from heavy sweating. The distressing combination of night sweats and insomnia may interfere with sexual interest and activity as well as making it more difficult to cope with the following day and its pressures.

Pauline was prescribed tranquillisers by the first doctor she consulted about her problems of night sweats and insomnia. ‘I told the doctor how I’d wake in the early hours of the morning in a lather, I’d toss and turn and still not get back to sleep. In the process I’d disturb my husband, who’d get cranky because he had a lot on his plate at the time. He’d growl at me and snarl during breakfast.’ Pauline finally consulted another doctor, who reassured her that the night sweats would probably become less intense and disappear over a few years. She explained the situation to her husband and discussed ways of minimising the night-time disturbance -including fewer bedclothes, more fresh air in the bedroom, and a spare nightgown in the bathroom, just in case.

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In some women the signs of menopause last a few months, in others for two or three years. About a third of women are still experiencing distressing problems five years after their last period, and about a fifth have disturbances including hot flushes for a total often years. In general, you will be relieved to know, the severity of symptoms decreases with time.

The place of hormone measurements

Even before your menstrual periods become noticeably irregular, there are subtle changes going on in your ovaries. Studies involving the monitoring of women’s sex hormones over many years show that there are small shifts in hormone levels for about ten years before the last menstrual bleed. This contrasts with the view held by many women that menopause is a relatively sudden life change.

Denise, for example, regarded menopause as a swift transition, since she was keenly aware of changes for only a little more than a year. ‘I was shocked when my always-predictable menstrual cycle went haywire. Instead of five days, I was bleeding for eight days and my cycle got longer. Then things went back to near-normal for a while, before I had bleeding and spotting for nearly two weeks and another long cycle. This sort of irregularity continued for about fifteen months, including a month when I had nineteen days of bleeding and spotting with just two days relief in the middle. I have a theory that this irregular bleeding helps women adjust to menopause in a positive way. I mean, when I looked back and could see that menopause had occurred, I was truly relieved that my body had become predictable once again.’

By the time symptoms are obvious, sex hormone levels can be fluxing significantly from day to day. Interpretations of hormone measurements at this time are notoriously misleading, which is why most doctors prefer to rely on symptoms as the most useful guide to the stage of menopause. In a world where we rely on tests in so many areas, this may seem unsatisfactory. But the fact is that despite sophisticated hormone measuring systems, there is still no test to show that menopause is occurring or to predict just when the last menstrual bleed will take place.

There are some situations in which hormone tests can be very helpful indicators of what is happening to the reproductive system. These include the following:

after a woman’s own hormone production has stabilised and her menopause is confirmed;

in women who have had a hysterectomy or an artificial

menopause and are experiencing distressing symptoms; and in women who have been given sex hormones in the form of implants.

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