‘The only word I can use to describe how I felt during this period is wretched. I work in a doctor’s surgery and spend my working day in contact with the patients. I was moody, bad-tempered and thoroughly unpleasant to everyone – yet I couldn’t stop myself being tike that. My feelings about myself reached rock-bottom and my normal self-confidence disappeared completely until I could hardly bring myself to get out of bed in the morning. I think if I’d worked anywhere else I would have lost my job within a few weeks; but luckily the menopause specialist nurse in the practice recognised my changed personality for what it was, suggested I asked my GP about HRT, and I’m now back in the human race again.’

If you have had a similar experience, you are not alone. A great many women between the ages of 40 and 60 find they become moody, unable to concentrate, and very tired. Many of the psychological problems of the menopause are due to night sweats causing disturbed sleep, and will resolve themselves once broken nights come to an end. Others are due more directly to the loss of oestrogen. Part of the brain contains many oestrogen receptors, and if oestrogen levels fall, mood changes may occur; once the oestrogen is replaced by HRT, most women find their confidence and self-esteem restored and their problems with mood swings, forgetfulness and anxiety considerably alleviated. HRT is not as reliable in improving these complaints as it is for flushes and sweats, but if your general wellbeing and feelings about yourself have taken a plunge, then it’s worth asking about HRT. It won’t, however, do anything to alleviate depression, anxiety or unhappiness that existed before the menopause, and which is not due to lowered levels of oestrogen.

Oestrogen seems to have a ‘mental tonic5 effect, and lowered levels of the hormone during and after the menopause can lead to a whole range of psychological problems, such as:

• less energy and drive

• irritability

• mood changes

• headaches

• feelings of unworthiness

• loss of self-esteem

• loss of self-confidence

• feeling unable to cope

• difficulty in concentrating

• feelings of aggressiveness

• depression

• anxiety

• forgetfulness

• fear of loneliness

• unusually prone to tears

• loss of libido (sex drive)

There are still too many doctors who, faced in the surgery with a woman aged between 40 and 60 complaining about any of these problems, will say, ‘I’m afraid it’s just your age, my dear,’ or ‘You’ll just have to live with it -there’s nothing I can give you that a good night’s sleep/doing some voluntary work/joining an evening class won’t cure.”‘ And he writes out a prescription for some antidepressants and hopes she won’t bother him again. (In this book, the doctor is depicted as male, simply to avoid confusion with the patient who, in matters concerning the menopause, is inevitably female.)

Prescribing tranquillisers and anti-depressants for problems in the mind that are caused by a fall in oestrogen is difficult to justify. Yet for many women, even nowadays, that is all they get, and then everyone is surprised that it seldom has the desired effect. It is hardly believable that 30-40 per cent of women aged 45-55 with menopausal depression are still prescribed tranquillisers and anti-depressants despite the fact that replacing their oestrogen will usually reduce these symptoms and thereby, in the majority of cases, lift the depression.

The majority of psychiatrists still believe that anti-depressants, tranquillisers or psychotherapy are the best forms of treatment for women at these three critical times of depression, yet they appear to have a low success rate. By contrast, replacing the oestrogen that is probably causing the depression appears to be very effective in many women. If the psychological symptoms are due to a lack of oestrogen, they will respond to a course of HRT; if they are due to some other cause, then HRT will not bring any real benefit. As HRT is a much cheaper form of treatment than psychotherapy or in-patient psychiatric care, it is surely worth considering as a first-line form of treatment for depression that occurs around the time of the menopause.

*13\42\4*

- Can premenopausal women increase their bone strength? The reason I ask is that my bone density is low, possibly due to a time many years ago when I was anorexic and didn’t have periods for over a year.

You are right in thinking that your low bone density probably relates to the time when you were anorexic, which is likely to have had an adverse effect on your peak bone mass. With the current state of knowledge about osteoporosis, the most helpful things to do at this stage are to make sure your diet is nutritious and well balanced, with plenty of calcium-containing foods (see chapter 6), to avoid smoking, to exer-

cise regularly, and to get regular sun exposure, which will help your body make vitamin D (essential for calcium absorption).

*125\38\8*

Christine was incensed by some friendly advice to ‘use it or lose it’ when she related that sex with her husband was unsatisfactory. ‘How can I use it when it feels like scratching an

open wound?‘ she asked. Once she had faced the need for alternative sources of lubrication, and the vaginal lining became more elastic under the influence of oestrogen cream, a localised form of HRT prescribed by her doctor, Christine lost her fear that sex would hurt, and she started enjoying it again. ‘All I need for good health and a long life is vegetables, fish, laughter and sex, not necessarily in that order,’ she quipped.

Other physical aspects of menopause that can unsettle the desire for sexual intimacy involve changes in skin sensation. Barbara noticed a heightened sensitivity to touch soon after her menopause and literally could not bear the feeling of her nipples being stroked or her clitoris being stimulated, previously pleasurable sensations. ‘I explained this to my husband so he didn’t take it personally, and we agreed it would be a good idea if I discussed it with my doctor. She was very reassuring, explaining that the changing balance of hormones around menopause can have an effect on the sensitive nerve endings in the skin of some women, and that the altered sensation usually passes with time.’

*91\38\8*

To benefit bones, exercise has to be vigorous and prolonged, averaging three to five hours a week in total (adding together short bursts of activity) at 75 per cent of maximal aerobic capacity, that is, three-quarters of the peak workload that your heart and blood vessels can manage. And this workload has to be maintained. In one study, the benefit to bone density achieved during one year of an exercise program was lost entirely in the year after it finished.

Other inherited and lifestyle factors believed to contribute to osteoporosis include race (Asian and Caucasian women are at greater risk than Polynesian and Negroid women), a small body build, an excessive intake of alcohol or caffeine (from coffee, tea and soft drinks), insufficient dietary calcium, smoking, the intestinal malabsorption condition known as coeliac disease, a high salt intake, a diet rich in fat and protein, and the excessive use of antacids containing aluminium, or of cortisone-like drugs.

*56\38\8*

When doctors talk of synthetic hormones, they are referring to hormones that are structurally different from those produced by the body and are not broken down or converted into other substances in the usual ways. One synthetic oestrogen widely prescribed for the treatment of menopausal symptoms until the mid-1980s, and still on the market, is Estigyn. This contains ethinyl oestradiol, a common component of the contraceptive pill and a far more powerful oestrogen, in terms of its effect on body tissues, than the natural oestrogens.

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