Fertility After 40 & Menopause
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The number of couples in their late 30s and 40s attempting pregnancy is increasing. Currently 13% of patients at Monash IVF are aged 40 or over. It is common to delay starting a family for a number of reasons: second relationships, career and educational demands, desire for financial stability, waiting for a stable relationship. However it is important to understand that fertility in women declines with age, particularly in the late 30s and 40s. This is a normal part of the aging process.
As women become older, the chance of becoming pregnant is lower, the chance of having a miscarriage is higher and there is an increased risk of chromosomal abnormalities in the baby. In the general population, the chance of becoming pregnant after the age of 40 is estimated to be only 5% per cycle compared to about 20% per cycle in the under 40 age groups. One-third of couples where the woman is over 35 may have fertility problems. Treatments such as IVF cannot reverse the effects of age on fertility.
A woman has gone through menopause when she has not menstruated for 12 months. Menopause usually occurs between the ages of 48-55 years with the average age being 52 years. It occurs earlier in women who smoke. There has been no change in the onset age of menopause over the years. A minority of women will go through menopause before the age of 40 years. Fifty to 60% of women seek help in dealing with the problems of menopause. However, there are some women who experience no symptoms at all.
Menopause occurs because the woman’s ovary runs out of eggs and she therefore no longer produces oestrogen (E) – the female hormone. It is an irreversible process. One of the earliest signs of impending menopause is a shortening of the menstrual cycle from 28 days to 24-25 days. Later, the cycles may occur increasingly infrequently when the woman does not ovulate (release the egg) and therefore does not produce progesterone (P). Testosterone (T) will continue to be produced by the ovary but in smaller amounts.
The most common symptom of menopause is hot flushes which occur in over 85% of menopausal women. They are more likely to occur at night (night sweats) and may precede the menopause by a number of years and may last up to 5 years after menopause. Other symptoms are skin and hair dryness, vaginal dryness and possible pain during interctheirse, urinary frequency, incontinence, loss of libido, a variety of psychological symptoms including loss of memory, anxiety, mood swings and irritability, and a lack of energy. Other common complaints include headaches, dizziness, palpitations, insomnia and muscle aches and pains.
Two major problems associated with menopause are osteoporosis (thinning of the bones) and heart disease. Both these problems may occur many years after the onset of the menopause.
Bone is lost at a faster rate after the menopause due to a lack of E. It is estimated that 11% of bone loss in a 70 year old woman is menopause related. The characteristic features of osteoporosis are back pain, loss of height (2.5 inches on average), the dowagers hump, and bone fractures. The common fractures are those of the bone of the spine, upper arm, hip, wrist and ribs. A diet which is low in calcium and a lack of exercise can exacerbate the bone loss that occurs at the menopause.
During reproductive life the risk of heart disease in a women is much lower than in a man. However, at menopause this risk rises. In Australia, in women over 55 years, the leading cause of death is heart disease. It is thought that E protects against heart disease because of its effect on the blood fats.
E causes an increase in HDL (the good fat) and a decrease in LDL (the bad fat). A lack of E causes the reverse.
Hormone replacement therapy (HRT) may be used to reverse the symptoms of menopause as well as to try and prevent the development of osteoporosis and heart disease. Most women take HRT to relieve their symptoms and HRT works very well for these problems.
HRT also reduces the risk of osteoporosis and both hip and spinal fractures by 50-90%. An adequate dose of E must be taken for prevention. A calcium-enriched diet and exercise is also mandatory in menopausal women. The optimum calcium intake for a post-menopausal woman is 1500mg/day. Three hours of weight-bearing exercise a week such as walking is ideal. A bone density measurement may be used if a woman is unsure about commencing HRT. In this situation a low bone density may necessitate therapy. If the bone density is normal, then re-assessment should occur in two years.
HRT and in particular Oestrogen Replacement Therapy has been shown to decrease the risk of heart attack and stroke. This decrease in risk is also for women with a previous history of a heart attack. Women on HRT may also experience a lowering of their blood pressure even if they suffer from high blood pressure. Screening for risk of heart disease can be carried out by measuring the total cholesterol and HDL and LDL levels.
The major concern that most women express regarding HRT is if their risk of breast cancer will increase. Most studies show no increase in this risk and it has been shown that if a woman develops a breast cancer while on HRT she tends to have a better prognosis because the tumour is often less advanced. A woman should be encouraged to examine her own breasts monthly and a mammogram should be performed every 1-2 years.
The types of E therapies available are: oral tablets, vaginal creams and tablets, implants, and patches. In general, except for vaginal creams, all types of medications are effective in relieving the general symptoms of menopause and protecting against osteoporosis and heart disease. The side-effects of E are breast tenderness and an increase in vaginal discharge. It is a fallacy that women gain weight on HRT.
P therapy is given orally in tablet form and may also be given as a patch in combination with E. The side-effects of E are breast tenderness and pre-menstrual type symptoms.
T therapy is administered as injections or implants and is used mainly to increase the libido. The addition of T is particularly important in a woman who has had her ovaries removed. The side effects of T are possibly an increase in male pattern hair growth, oily skin and hair and voice deepening which is irreversible.
The therapy regimen chosen depends on the presence of a uterus or womb. If this is not present then only E therapy given daily, in whatever chosen form, is required. However, if a uterus is present then P therapy needs to be administered for at least 12 days of each month. The potential disadvantage of this treatment is that regular monthly bleeding will occur. To prevent this both E and P can be given daily. After 6-12 months of this treatment most women will stop bleeding completely. If P is not tolerated because of side-effects then it may be given every 3 months for 14 days.
How long should treatment be continued? For as long as the woman desires it to continue. The symptoms of the menopause such as hot flushes may only last a short period of time. If HRT were used for this purpose then treatment can be stopped to see if this symptom returns. However, the protective effects of HRT on both bone and the heart are life long and therefore HRT therapy should be continued for life if used for this purpose.
The information in this article was provided by Monash IVF. For more information, please go to the Monash IVF Website at http://www.monashivf.edu.au
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