These are the most troublesome and common of the intermediate symptoms of the menopause. Vaginal dryness is itself the cause of pain during sexual intercourse and many of the recurrent bacterial infections. Without oestrogen, the lining of the walls of the bladder and urethra shrink and become thinner and drier. They are more likely to crack and split, and become vulnerable to infection. Within three years of the menopause, 10—20 per cent of women may visit their doctor with these problems; amongst women eight years or more since the menopause, the figure is up to 50 per cent. It may be embarrassing, but there’s a lot of it about. As with hot flushes, you are not alone, and if only women felt able to talk about these things more they might feel less isolated in their discomfort and embarrassment. Surprisingly, few women realise that these complaints are connected with the menopause at all. They just think it is all due to getting older and that nothing can be done about it; but, as with all the symptoms that are due to lowered levels of oestrogen at the time of the menopause, something can be done about it.

Vaginal dryness and soreness are very common problems for women in their fifties. The walls of the vagina respond to the presence of oestrogen, and as the level of the hormone falls, they become thinner and drier and less elastic. The vagina itself becomes shorter and narrower, and the cervix secretes less mucus. Noticeable symptoms that result from this can be dryness, pain during sexual intercourse, bleeding during intercourse, and a higher risk of bacterial infections. If HRT replaces the lost oestrogen, the vagina can be restored to a healthy state, and there is no reason why you should not continue a fulfilling sex life for as long as you and your partner want to.

Symptoms of pain, discomfort and embarrassment involving the bladder and urinary tract are felt by a great many women to be part of the misery of the menopause.

‘I hadn’t wet myself since I was a small child. Suddenly one day I coughed fairly violently, and with a horrifying sense of shame and embarrassment, I knew I had done at 55 what I hadn’t done since I was about four. Then it started to happen more often, whenever I coughed or laughed or sneezed. At first it was a little trickle, then it became so bad I had to wear sanitary towels most of the time – just in case. A friend of mine who works in a chemist’s shop said she knew of many women who bought sanitary towels for this purpose, and who could not bring themselves to buy incontinence pads.’

The urethra (the canal with carries urine from the bladder to outside your body) is yet another part of you that contains ‘oestrogen receptors’ and so it responds to the presence of oestrogen by remaining firm, strong and healthy. After the menopause, the walls of the urethra become thinner, more prone to infections like cystitis, and the muscles don’t work so well. These changes can cause pain on passing water, and a gradual lessening of bladder control. Complaints such as urgency (needing to pass water with very little warning); frequency (needing to pass water frequently); nocturia (needing to pass water during the night); and stress incontinence (passing urine when you sneeze, cough, laugh or take vigorous exercise), all usually improve significantly after a few weeks of HRT (provided there is no underlying infection or other problem). Up to 30 per cent of post-menopausal women suffer from these complaints, and may need to remain on HRT long-term if the symptoms are not to return.

If you have a continence problem of any sort and don’t like to talk to your doctor about it, you may find the surgery has a special Continence Nurse. Her job is to help people achieve continence wherever this is possible, or to manage incontinence if this is inevitable. You will find her helpful and sympathetic, and full of practical suggestions to improve your particular problem, whatever your age.

*15\42\4*

I have reduced my intake of dairy products because there’s heart disease in my family, and I’m concerned about the effect this may have on my bones. What alternative sources of calcium can you suggest?

Calcium-rich non-dairy foods include tinned fish with bones, oysters, nuts and seeds. You should eat them with your evening meal: other foods will help the process of calcium absorption. Vitamin D, obtained from an action of sunlight on the skin, also helps calcium absorption, while too much dietary fibre, spinach or broccoli interferes with it. Calcium is needed consistently on a daily basis, so make sure that whatever you do to keep up your supplies takes account of this.

Of course you could confine your eating of dairy foods to non-fat forms, and still get plenty of calcium from them without increasing the risk of heart disease.

*127\38\8*

TAKE YOUR TIME Four-minute sex is out. Spending time over love-making can enhance the experience for both you and your partner. Your natural lubrication needs a chance to develop, and men also tend to require more time to reach climax as they get older.

TALK ABOUT IT Don’t assume that your partner understands what is going on inside your body or mind. Try to describe what you are experiencing – otherwise a partner may misinterpret your reluctance to have sex. It may also be desirable to arrange a consultation for both of you with a doctor or counsellor, to discuss your sexual concerns and possible approaches to overcoming them. If this is impossible, talk about your feelings with a friend, a sympathetic doctor or a counsellor.

LIBIDO There are many documented cases of libido disappearing entirely in older people, men as well as women.

It seemed to George Bernard Shaw that, when he lost interest in women, he lost interest in living. ‘I am ageing very quickly. I have lost all interest in women, and the interest they have in me is greater than ever and it bores me. The time has probably come for me to die.’ If your lack of interest in sex concerns you, see your local doctor or an experienced counsellor. Alternatively, you could telephone your nearest Marriage

Guidance Council office, the state office of the Australian Medical Association or the Australian Psychological Society and ask for the names of people who specialise in this field. If loss of interest in sex is not worrying you or disturbing your relationships with others, there is no need to take any action.

*93\38\8*

If you are concerned that osteoporosis is quietly eating away at your bones, you may gain reassurance or an incentive to make lifestyle changes by doing the following.

- Check whether you have any inherited or lifestyle factors that may contribute to your risk of osteoporosis.

- Recall whether you have ever fractured a bone, say in the forearm or wrist, when the pressure or force applied to that part of the body was minimal.

- Ask someone to measure your height to see if it has decreased and to tell you if your back is becoming rounded.

- Think through your experience of general aches and pains in,the bones.

Having gone through a check-list like this, Joan’s concerns about the state of her bones intensified. Although only fifty-three, she believed she had a full hand for osteoporosis: many years of eating disorders and dieting, a sedentary lifestyle, and a mother recovering from her second hip fracture. After discussing the situation with her doctor and having a bone density measurement that suggested a problem in the making, she revamped her lifestyle step by step. ‘My doctor was reluctant to prescribe hormones because of a previous breast cancer, but started me on a gentle but regular exercise program. A year later I am doing things I wouldn’t have dreamed of. Simple things, like walking to the local shops and post-box instead of driving. I feel hungrier and eat more, yet because I am exercising regularly I am not putting on weight. My enjoyment of life has definitely picked up.’

*58\38\8*

There are three main types of oestrogen produced by the body; oestrone, oestradiol and oestriol (see pages 171—2). They influence the functioning of various parts of a woman’s body:

the growth and development of the uterus and its lining (the endometrium)

the thickness and tone of the vaginal lining and the vagina’s production of secretions

the fullness, tone and secretions of the vulva, cervix and urethra

bone growth

temperament and sexual interest, by an action on the brain

many other body tissues such as the skin, heart, blood vessels, breasts, liver and joints

OESTROGENS USED IN HRT The main reasons for giving oestrogen at and after menopause are to relieve distressing or debilitating symptoms and to reduce future risk of fractures and heart disease. In general, ‘natural’ oestrogens are the preferred form of oestrogen in HRT, and a number of alternatives are available.

Severe symptoms are especially likely in women who have had a surgical menopause, and this partly accounts for their relatively high use of HRT. They are also more likely to seek treatment than women who have had a natural menopause. Women taking oestrogen alone tend to stay on their hormone therapy for longer than women taking oestrogen plus progestogen (with or without testosterone), perhaps because they do not experience the unwanted side effects sometimes associated with the progestogens. In recent years Estigyn has fallen from favour among specialist menopause clinicians because of increased stimulation of liver-derived proteins that may result in high blood pressure, fluid build-up, and an increase in clotting factors. In other words Estigyn, being synthetic, is capable of ‘revving up’ the liver far more than the natural oestrogens. A major reason why synthetic hormones are more likely to cause side effects than natural hormones is that the body takes longer to break them down, providing more time for them to act on various tissues. This effect may be enhanced with age, which is why doctors prefer not to use them in the older woman.

The natural oestrogens used in HRT formulations tend to have fewer effects on liver function (and consequently on blood pressure and blood clotting) than the synthetic oestrogens. They may be considered suitable if you are one of those women for whom the synthetic hormones of the Pill were not considered safe.

*24\38\8*