If you are a woman, or you know a woman -- you probably know something about periods.
Periods -- and fertility, and pregnancy and the whole gamut of related subjects -- punctuate most women's lives at least monthly (unless you fall pregnant) for more than three decades.
But menstrual cycles don't last forever, which means that for women who experience them, those menstrual cycles will stop -- this is known as Menopause.
Whether you're a woman or a man, it's important to know about menopause. It's going to affect either you, your partner, sister, mother, female friends or other female relatives -- directly or indirectly -- for up to a decade. Yes, that's right, a whole damn decade.
And because menopause isn't limited to hot flushes and a woman's period's stopping just like that, here's what you need to know about the stages of menopause the treatments that are recommended by experts.
What Exactly Is Menopause?
To understand menopause, firstly we need to understand how the menstrual cycle works.
"Every girl is born with thousands of eggs in the ovary," President of the Australasian Menopause Society, Professor Bronwyn Stuckey said.
"In puberty, the eggs mature -- and one ovulates every month, generally, if things are going OK. Every ovulatory cycle, as the egg which is going to go on to ovulate develops, the cells around it produce oestrogen. The levels gradually rise until the egg pops out of the ovary and the rise in oestrogen causes the uterine lining to develop in readiness for conception. If the egg gets fertilised and implants and there is a pregnancy, of course oestrogen continues to rise. If not the oestrogen drops and there is a period," Stuckey said.
"Progesterone does not appear until after ovulation. The follicle which contained the egg becomes the 'corpus luteum' which secretes progesterone. The role of progesterone is to transform the lining of the uterus into a form which will be receptive to a fertilised egg. If there is no fertilised egg implanted (conception) then the progesterone too drops back to baseline. Menopause is when the ovaries run out of eggs, so the production of oestrogen drops quite dramatically."
Sydney-based GP Dr Ginni Mansberg explained that the menopause itself is to the official date -- 12 months after a woman's final menstrual peroid (FMP) -- when the ovaries are no longer producing any eggs.
"Menopause is actually the retirement of your ovaries all together," Mansberg said.
At What Age Does Menopause Happen?
"The average is 51, but a lot of people have early menopause and some people have later menopause," Stuckey said.
In fact, there are a number of other factors that can contribute to -- or cause -- early menopause.
The International Menopause Society notes that early menopause can occur for a number of other reasons -- surgical menopause (when a woman needs to have her ovaries removed), chemotherapy and radiotherapy can cause a woman to go through menopause early.
Women who smoke, women who have had a hysterectomy and women who live at high altitude may also experience early menopause.
"In Australia, premature menopause -- with the last menstrual period before the age of 40 -- is 1 percent of women," Stuckey said. This is known as Premature Ovarian Insufficiency.
"Early menopause, with the last menstrual period between ages of 40 and 45 is 5-8 percent of women. I think the variation in the last category is because some estimates include menopause post-chemotherapy and some do not."
However women can always judge accurately when they have gone through menopause -- because for everyone it is dated as 12 months after your last menstrual period.
"The reason people say menopause is 12 months after the last menstrual period is because you can't be sure in a shorter time than that, that there's not going to be another egg found," Stuckey said.
In fact, the period leading up to this date can be extremely difficult for many women.
"It's actually the seven or so years that lead up to menopause when you are almost in menopause but not quite in menopause, where you go through what I call hormone hell," Dr Mansberg said.
"And I think that peri-menopause period is the more difficult one to understand."
So, What Is Peri-Menopause?
Peri-menopause makes up just one part of what Stuckey explained as the menopausal transition.
"Pre-menopause, where everything's ticking along normally, through peri-menopause where things start to get chaotic, to menopause –- 12 months after the last menstrual period, where all the eggs are gone," Stuckey said.
The peri-menopause is period of time is when the ovaries are beginning to run out of eggs -- resulting in hormone imbalances that can lead to various other symptoms.
"As the ovaries running out of eggs, and the oestrogen is tending to drop and other hormones from the ovaries are tending to drop, the pituitary gland senses that, and it puts out more of FSH (follicle stimulating hormone) to try and stimulate the ovaries," Stuckey said.
"So the peri-menopause is a very up and down, rocky road of lowish oestrogen and then the pituitary gland manages to crank out a few eggs, and then very high oestrogen."
"Sometimes the ovary is unresponsive for a while. If there is no egg development there is no oestrogen, (so) women can get hot flushes while this is happening. Then the ovary can over-respond to the high levels of FSH and develop two eggs in quick succession or two eggs at a time with consequentially high oestrogen."
Mansberg explained that the period of peri-menopause can begin some years before official menopause.
"We're only really getting to know peri-menopause a lot better now. But our gut feeling is that it (begins) about seven years before menopause," Mansberg said.
Symptoms During Peri-Menopause
Although hot flushes do occur during peri-menopause, Stuckey explained that this is normally temporary, and alleviated by ovulation.
"In the peri-menopause you can get alternating symptoms, where you get hot flushes and you think that this is menopause, and then suddenly there's an egg found and there's an ovulation and those symptoms go away," Stuckey said.
"In peri-menopause there are often alternating symptoms of low oestrogen (hot flushes) and high oestrogen (breast soreness). The only symptom one can really ascribe to high oestrogen is breast tenderness (mastalgia)," said Stuckey. "The peri-menopause is the most difficult time for doctors to treat because there are menopausal symptoms, no regular cycle and yet still the possibility of conception. Insomnia, hot flushes, palpitations, arthralgia are oestrogen deficiency symptoms."
However, women's periods are likely to become less regular than they may have been in the pre-menopausal, fertile teens, twenties and thirties.
"There can be heavy periods, or periods very close to one another, and then a gap and then another period can appear after the pituitary gland manages to get the ovary going again," Stuckey said.
Mansberg explained that heavy periods are caused because a decrease in progesterone would normally stabilise the lining of the uterus. With not enough progesterone, but lots of oestrogen, very heavy periods can occur.
In fact, Mansberg told The Huffington Post Australia that around one in five women experience heavy periods during the peri-menopause.
Treatments for Peri-Menopausal Symptoms
Mansberg noted that the studies on treatments for peri-menopausal symptoms have been limited -- however there are a number of options that are worth investigating.
"There might not be a silver bullet that gets all of your peri-menopausal symptoms with a single medication or a single supplement," Mansberg said.
"The thing I'm going to say is that not all GPs do this well. If you're feeling like you're being blown off by your GP, or your GP is saying there's nothing they can do or is not listening to the symptoms that you have, go and see a gynecologist -- ask for a referral to a gynecologist."
What Happens Post-Menopause?
Peri-menopause officially ends 12 months after your final menstrual period (FMP). This marks menopause and the period when a woman officially enters post-menopause.
"Menopause means 'last period.'" Director of the Women's Health and Research Institute of Australia, Professor John Eden told The Huffington Post Australia.
"It is a time when the periods stop permanently because the ovaries have run out of eggs. By definition, 12 months of no periods needs to go by."
Unfortunately, this doesn't mean that there are no further symptoms. The Australiasian Menopausal Society states that 10 to 20 percent of women will have post-menopausal symptoms for more than 10 years after entering post-menopause -- and Eden agrees.
"Half of women have few or no symptoms. Others have severe sweats and flushes, which can last ten years or longer," Eden said.
"By the time you go into menopause itself, you have no oestrogen and no progesterone," Mansberg said.
It's this lack of oestrogen in particular that causes most of the symptoms women experience post-menopause.
"The symptoms that people experience with the drop in oestrogen are typically hot flushes -- which is a lack of proper temperature regulation. Joint aches and pains, dryness of the skin, dryness of the vagina and the vulva, and sleeplessness," Stuckey said.
"All of those symptoms are consequent upon the fall of oestrogen that happens with menopause."
Stuckey also explained that there are long term risks from oestrogen levels dropping -- mainly bone loss and cardiovascular disease.
"Once a woman goes through menopause the bones start to lose calcium and lose bone structure. Some rapidly and some not so rapidly -- that can lead to osteoporosis and osteoporotic fracture."
"(With) cardiovascular disease, there's an alteration in the composition of the lipids -- the good and bad cholesterol, which leads to accumulation of plaque in the arteries and also the arteries lose their ability, because of lack of oestrogen, to dilate properly with exercise," Stuckey said.
Treatments For Post Menopause Symptoms
Mansberg, Stuckey and Eden all said that women should consider Hormone Replacement Therapy to treat post-menopause symptoms, despite beliefs that HRT is linked to breast cancer, thanks to a 2002 study by the Women's Health Institute.
"The WHI study showed higher risk of breast cancer. So women all around the world threw out their HRT. Closer analysis of this study showed that it wasn't every woman. To get rid of hot flushes and to strengthen your bones and help your brain be sharper, you need oestrogen," Mansberg said.
Stuckey agreed that oestrogen treatment is important for post-menopausal women.
"Firstly, there is an incorrect perception for a woman at menopause, about what her risks and benefits are. Right at the top of women's minds is that their biggest is breast cancer, but that's not at all true. Their biggest risk is cardiovascular disease," Professor Stuckey said.
In fact, Professor Stuckey pointed to a recent study from Finland -- the result of which showed that women who stop HRT faced a higher cardiovascular mortality risk. Put simply, they run a higher risk of death from a cardiovascular disease.
"This is why there's been such a perception that taking oestrogen is risky -- and I think we need to educate people that it has benefits," Stuckey said.
"People will put up with horrendous symptoms. Not sleeping, not really being able to concentrate and function at work, having hot flushes because they perceive that if they take oestrogen they will get breast cancer. And we need to educate not only women, but also doctors, that that is not the way to think about it."
Professor Eden agreed that studies are now showing that Body Identical HRT regimen does not put women at high risk of breast cancer.
"A large world review published by Dr Asi last year, showed that this regimen has a significantly lower breast cancer risk than HRT regimens using a synthetic form of progesterone called, "progestin."
However, Eden said that Body Identical HRT is not the same as Bio Identical HRT.
"Body Identical HRT should not be confused with compounded, hand made 'Bio identical HRT' which has not been put through the rigorous testing demanded by the Federal regulator, the TGA," Eden said.