Breaking down the mystery of menopause

Published on 21 March 2022

“I’d like you to think of a word, or words,” said Dr Susan Logan, by way of kicking off her Zoom webinar, “that describe menopause.”

Menopause, to put it simply, is the natural cessation of a woman’s menstrual cycle. So for many women, menopause isn’t necessarily a bad thing. 

“There’s lots of happiness, fertility isn't an issue anymore, contraception isn't needed, you don't need to buy pads anymore, and there's a freedom associated with it,” said Dr Logan, a reproductive endocrinologist whose background lies in obstetrics and gynaecology. “But not for all women.”

That’s because menopause also marks the end of a woman’s reproductive years, and is associated with a number of unpleasant physical symptoms, like hot flushes (or hot flashes) and mood changes.

As such, unsurprisingly, the responses that she got to her question were inclined towards the negative side of things. “Weight gain,” said one participant. “Old,” said another. “Crabby,” quipped a third. But a fourth, with a subdued kind of frankness, summed it up: “Fear”.

Menopause does get a bad rap in the eyes of many women – and it’s not entirely unwarranted, given the frequency of adverse symptoms associated with it. And therein lies the question: why does menopause happen at all?

To answer that question, it’s essential first to understand the biology of the human female. Women are born with all the eggs they will have in their life – numbering, on average, at about two million. This drops to about half a million by the time puberty kicks in (not because of ovulation, but rather because of a process called apoptosis, in which the eggs disintegrate on their own). By age 37, the number has dropped further to around 27,000; and by the time of menopause, most women only have about 1000 eggs left. 

Essentially, that lack of eggs is what leads to menopause, said Dr Logan, who is Senior Consultant at the National University Hospital’s (NUH) Department of Obstetrics and Gynaecology, and Senior Consultant at Alexandra Hospital (AH). “It’s not that the ovaries are completely empty…but there’s not enough to keep the hormone cycle going,” she said.

But it’s not just about the number of eggs – it’s also about the quality of them. At birth, most of the eggs are genetically normal, with a markedly smaller proportion of abnormal eggs. 

As time goes by, the normal ones get used up first. And by the age of around 37, the number of abnormal and normal eggs have become almost equal. 

“The way I explain it to patients, it’s like fruit and vegetables at Fairprice,” said Dr Logan. “The stuff that’s fresh and new goes first, and what’s left stays behind.”

Perimenopause and menopause

The average age during which menopause happens in Singapore? 49. 

Of course, this varies depending on a number of factors, said Dr Logan. Some reasons are genetic: for instance, some women start out with fewer eggs in the beginning, and in other women, their eggs naturally disintegrate faster than others. 

But there can be other reasons too. Surgery in the ovaries causes the egg reserves to go down, as well as other treatments like chemotherapy and radiotherapy. This can cause an earlier onset of menopause – “so in general, we don’t want to operate on the ovaries too much during the reproductive years,” she added.

There’s also premature menopause, a condition which occurs in about 1% of women under 40, one in 1000 in women under 30, and one in 20,000 in women under 20. 

This can be good from a cancer point of view, in that menopause reduces the risk of breast, womb, and ovarian cancers. However, “the risks associated with it far outweigh the benefits,” explained Dr Logan. 

“These include earlier risk of cardiovascular disease, osteoporosis, dementia, and earlier death. So this is not a good diagnosis to have.”

But for most women, menopause happens around age 49, and almost always by around the age of 55. The menopausal transition (also known as perimenopause) can also take a fair amount of time: between two and eight years. 

“In about one in four women, the symptoms can be pretty bad, so that they look towards getting help regarding this,” she added. 

So, what exactly happens during perimenopause? The first change is that the menstrual cycle shortens in length. As such, “many women report having two menses in a month,” shared Dr Logan.

Further into the perimenopause period, women may start to observe the skipping of periods. During this time, when periods do come, they may be “quite troublesome”, as Dr Logan puts it; in other words, heavy, painful, and prolonged. 

Finally, the menses begins to stop altogether. And after 12 months of no periods, a diagnosis for menopause can be made. 

What to expect with menopause

Despite the negative press it gets, Dr Logan maintains that menopause, ultimately, isn’t a disease. “As long as you live to be about 50, it’s an absolutely natural event that doesn’t require a diagnosis, and doesn’t necessarily require any treatment,” she said.

But many women do experience symptoms. A study of menopausal women by NUH revealed that muscle and joint pain was the most common symptom, reported by 75% of participants. This was followed by tiredness, reported by 70%, insomnia by 60%, and mood changes by 50%. 

The most common symptom, muscle and joint pain, is the main symptom experienced in Asians. Coupled alongside the physical inactivity that many women in this age group experience – especially those with desk-bound jobs – this results in muscle atrophy and the redistribution of fat, which in turn leads to a higher risk of diabetes and high cholesterol.

In addition, during menopause, bone mass also decreases significantly, by about 20%. The combined reduction in muscle and bone mass ends up leading to an increased risk of falls and fractures – and, in fact, said Dr Logan, women are at much higher risk of hip fractures as compared to their male counterparts. “It really is very much a gender based problem,” she added. 

In contrast, hot flushes, usually the poster symptom for menopause, was reported much less in the Singapore-based study, as compared to in Western countries – possibly because of genetic or dietary differences, said Dr Logan. Hot flushes refer to sudden and intense feelings of heat that start in the chest and move up towards the face. A hot flush lasts about one to five minutes on average, and may be associated with palpitations and alternating feelings of warmth and chills. But unlike a fever, they’re not associated with any real changes in body temperature. 

She also pointed out that while depression and anxiety are not specifically caused by menopause, some women – such as those who suffer from mood changes and insomnia – could be more vulnerable to these.

“And if you’ve had a history of postnatal depression, then that does increase your risk of similar symptoms during menopause,” she added.

Menopause may also take its toll on the urogenital system: in other words, the bladder, urethra, and vagina. During menopause, the walls of the vagina begin to atrophy due to the lack of oestrogen, which leads to vaginal dryness – and, in turn, sexual dysfunction. 

Citing a paper she’d worked on that was published earlier this year in leading menopause medical journal Maturitas, Dr Logan noted that out of the 1048 Singaporean women surveyed, aged 45 to 69 years, over half reported sexual activity over the past four weeks. Despite that, 70% reported some sort of sexual dysfunction. 

“So sex is still occurring, but desire, arousal, orgasm, comfort, and satisfaction are adversely affected,” summarised Dr Logan.

Apart from that, there’s also the increased risk of cardiovascular changes. Pre-menopause, women enjoy more protection from cardiovascular disease as compared to men, because of their higher levels of oestrogen. But in the menopausal years, as oestrogen levels drop, the risk of cardiovascular disease becomes much higher, shared Dr Logan.

“So the things that very much change are blood pressure, peripheral vascular disease, the risk of blood clots in our legs and lungs, and stroke,” she added. 

Ageing fabulously

One of Dr Logan’s passions, as she shares, is “fabulous ageing”. And indeed, although menopause isn’t an easy stage of life, it can be made easier.

“The reality is that at around 50, you’re usually juggling a lot of things,” said Dr Logan. “[Women] often are the linchpin for their families and wider families. So there may be a lot going on, and so menopause, and the symptoms associated with it, can destabilise that.”

But there are steps that individuals can take to manage symptoms associated with menopause, she said. For instance, women can engage in regular exercise and consume more calcium-rich and protein-rich food to boost their musculoskeletal health. Exercise also helps with symptoms such as mood problems, hot flushes, night sweats, and weight gain.

There are also medications and alternative therapies that individuals can take to relieve their symptoms. These include lubricants and moisturisers for better sexual function, hormone replacement therapy (HRT), neuromodulators for pain and insomnia, and other drugs for mood, bladder symptoms, hot flushes, and blood pressure. Women should also go for regular screenings to ensure that any disease is caught early.

Ultimately, self-management is of the essence, said Dr Logan. 

“About half your life is going to be spent [going through] perimenopause and menopause, and it’s really important how you grasp that, in terms of disease prevention and health promotion.

“Menopause is inevitable, it’s not a disease,” she concluded. “But there may be symptoms that need help…and there’s lots of help available. You just need to ask.”