By 2050, over 1 billion women will be aged over 60 worldwide. With women living older, there is a need for a clear understanding of the menopause amongst healthcare professionals, policy makers and the general public. So, what are the effects of the menopause and what can be done?
In her presentation at EMAS 2019, Dr. Margeret Rees explained that there are a wide number of symptoms related with different stages of the menopause, from perimenopause to postmenopause. In the perimenopause and early menopause, vasomotor symptoms (VMS) are likely. In the late postmenopause, there are increasing symptoms of urogenital atrophy.
VMS affect up to 85% of menopausal women, with the peak occurring in the late menopausal transition. Unfortunately, the exact cause has not yet been determined. However, hot flushes have been associated with abnormal vasoconstrictor approach.
The duration of VMS has been shown to be significant, with the Penn Ovarian Aging Study demonstrating that over 1/3 of women experience moderate or severe hot flushes for more than 10 years. 
At EMAS 2019, Dr. Mark Brincat discussed that HRT is the most effective treatment for VMS. However, other treatments do exist. Phyto-oestrogens, coumestans and isoflavones may have a beneficial effect, however not to the same extent as HRT.
Vulva and vaginal atrophy
Vulva and vaginal atrophy (VVA) is a term used to describe symptoms associated with decreased estrogenization of the vulvovaginal tissue. It affects up to 50% women after menopause.  Dr. Rees explained that many cases of VVA may go under-reported due to a feeling of embarrassment or concern that symptoms are not important enough. Many others go undiagnosed or undertreated.
It is clear that more information is required for women at risk of VVA. Many do not understand that VVA is a chronic condition that can lead to long term sexual dysfunction and painful sex. This is especially important as there are effective treatments available that may significantly improve women’s quality of life.
Dr. Mark Brincat explained that Hormone Replacement Therapy (HRT) is the most effective treatment for VVA. Vaginal Erbium Lasers were also highlighted as having positive results, especially in combination with other treatments.
It is important to remember that delaying treatment only increases the burden of symptoms, increases psychosocial factors and reduces quality of life for the woman.
Recurrent urinary tract infection
While women have a 20% lifetime risk of developing a urinary tract infection (UTI), this risk increases by 1% with every decade of life. After menopause the increased incidence of UTI is linked with:
- urinary incontinence
- post-void residual urine.
There are effective options for both treatment and prevention of recurrent UTI. Topical and vaginal estrogens can reduce incidence of infections while antibiotics can act as an effective treatment.
Cardiovascular disease and stroke
Cardiovascular Disease (CVD) is the number 1 cause of death for women worldwide. Dr. Rees explained that CVD presents differently between men and women. Heart disease in women presents on average 7-10 years later in women than in men.
HRT can be effective as a treatment for primary CVD, however for secondary CVD and secondary stroke it is not recommended. Dr. Amos Pines explained that in early stages of atherogenesis, HRT can promote vasodilation, decrease inflammation and decrease lesion progression. However, with established atherosclerosis, HRT instead can decrease vasodilation and increase inflammatory activation. 
Dr. Fiona Watt explained that joint pain is more common after the menopause. One study suggested that post-menopausal women are twice as likely to have joint pain and stiffness. 
Age often confounds assessment of the effects of menopause on the joints, with degeneration often starting before menopausal transition. However, Dr. Watt explained that menopause is related to reduced cartilage volume, fall in bone density and loss in muscle mass. All of these have a negative effect on joint function.
What causes this?
Dr. Watt explained that there is evidence for hormonal and genetic impact on musculoskeletal pain. Sex hormones are important for normal joint processes. Therefore, sex hormone deficiency is a potential target for treatment for women with postmenopausal musculoskeletal pain and osteoarthritis.
Dementia and cognitive decline
Cumulative estrogen exposure over women’s lifetime influences cognitive ability later in life. Age at menses and menopause may have an impact, with Dr. Blazej Meczekalski explaining that women experiencing menopause at younger ages were associated with reduced cognitive performance in older adulthood.
Dr. Antonio Cano explained that cognition is not straightforward and covers a range of functions including:
Visual recognition memory
Dr. Meczekalski and Dr. Cano both discussed that estrogens can protect brain structures, including the hippocampus which is related to memory. Many mechanisms are involved in this process including dendritic sprouting and the anti-amyloidogenic effects and antioxidant effects of estrogen. Therefore loss of estrogens during menopause may explain some of the cognitive decline seen in postmenopausal women.
Treatment of cognitive decline is not clear. Some evidence suggests that HRT may reduce Alzheimer’s Disease if started during the critical window around the onset of menopause and continued for over 10 years.  Similarly, there is limited evidence that estrogen therapy could be of short-term benefit when initiated at the time of surgical menopause. However, currently most evidence suggests that HRT does not impact cognitive function in a positive or negative way.
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