Menopause

Menopause is one moment: your final period. The Pakistan Menopause Society's recommendations call it the final menstrual period, and note that it can only be confirmed once 12 months have passed with no bleeding (section 1.2.2). So nobody knows she has reached menopause on the day. She finds out a year later.

The years of change before it are perimenopause. Everything after it is postmenopause. In everyday speech "menopause" covers all three, which is half the reason the word confuses people.

The words in Urdu

Most official Urdu leaflets borrow the English word, مینوپاز. The plainer Urdu is ماہواری کا بند ہونا, mahwari ka band hona, the periods stopping. Two leaflets use a classical word that means "the age of despair". Roshara does not use it. A word that frames this stage as despair tells women to keep quiet about it, and keeping quiet is the problem.

The day itself feels like nothing. You will not notice your last period was your last. What you notice is what surrounds it.

The WHO lists the symptoms linked to menopause: hot flushes and night sweats, changes in how regular and heavy your periods are until they stop, vaginal dryness and pain during sex, leaking urine, trouble sleeping, and changes in mood, depression and anxiety. It says some women have few if any symptoms, while for others they are severe and can last several years.

It also notes that many women do not know their symptoms are related to menopause, and feel embarrassed to raise them. The Asia-Pacific Menopause Federation adds that Asian women are less likely to see a doctor about menopause symptoms. If that is you, the symptoms still count.

The WHO says menopause comes from the ovaries' follicles stopping work, so they no longer release eggs, and from a fall in estrogen in the blood. Women's Health Concern adds that this happens gradually: as you get older your store of eggs runs down and estrogen drops over several years.

It is not always gradual. The WHO says menopause can also be brought on by surgery that removes both ovaries, or by treatments such as chemotherapy or radiotherapy that stop the ovaries working. Those are covered on surgical menopause and chemo-induced menopause.

When it happens

The NHS website says menopause usually comes between 45 and 55. For Pakistani women the Pakistan Menopause Society puts the average between 45 and 49. The NHS website adds that early menopause or premature ovarian insufficiency can happen before 45. Age at menopause goes into what shifts the timing.

How it is confirmed

The NHS website says there is no routine test: a doctor may diagnose it from your age and symptoms. If you have had a hysterectomy, your periods stopped already, but the WHO notes you may still go through the other changes of the transition. Hysterectomy and menopause explains how it is recognised then.

Contraception

The WHO recommends contraception until 12 consecutive months have passed without a period. Women's Health Concern is more specific: under 50, it says to continue until you have had no period for two years; over 50, one year. If hormonal contraception is masking your periods, it suggests talking to your prescriber about when to stop.

What changes after

The WHO says women's advantage over men in heart disease gradually disappears as estrogen falls after menopause, and that loss of bone density is a significant contributor to osteoporosis and fractures. The postmenopause page covers what to keep an eye on.

The WHO says symptoms that affect your health and wellbeing should be discussed with a health-care provider, with your history and preferences taken into account. You do not need a crisis to book that appointment.

Bleeding after your periods have stopped is different: it always needs checking. The Pakistan Menopause Society lists postmenopausal bleeding among its red flags (section 2.3). See bleeding after menopause.

The WHO notes that menopause is often not discussed in families, communities, workplaces or clinics. In many homes the only sign of it is a mother who goes quiet for a few years.

When periods stop, so do some of the rules a woman has organised her prayer and fasting around since she was a girl. Women ask what changes. Those questions belong with a qualified scholar.