Postmenopause

The Pakistan Menopause Society defines postmenopause as everything from the final period onwards. Because a final period is only confirmed after 12 months without bleeding, you step into postmenopause looking back: by the time you know, you have been there a year.

The STRAW+10 staging system, which the PMS recommendations follow, splits it in two. Early postmenopause covers the first years, when hormones are still settling and bone is lost faster. Late postmenopause is the long stretch after, when the society says the body's general ageing becomes the main story.

Urdu has no separate word for it. Roshara says مینوپاز کے بعد, menopause ke baad: after menopause.

For some women the hot flushes and broken nights fade. For others they carry on: the Pakistan Menopause Society says symptoms may persist for several years.

Some symptoms tend to start here rather than end. The PMS recommendations list vaginal dryness, burning and irritation, pain during sex, needing to pass urine often or urgently, and repeated urine infections among the changes of the first few years after menopause. Together these are called genitourinary syndrome of menopause, and the society says they are commonly long-term and progressive, and may come back when treatment stops. See vaginal dryness and bladder and urinary symptoms.

Then there are the changes you cannot feel. The NHS website says osteoporosis is often only diagnosed when a fall or knock breaks a bone. Cholesterol, blood sugar and blood pressure give no warning either.

Lower estrogen after menopause affects more than periods. The NHS website says women lose bone quickly in the first few years after menopause. The WHO says women's advantage over men in heart disease gradually disappears as estrogen falls.

The Pakistan Menopause Society adds a fair caution: not every midlife health problem is down to estrogen. Age, lifestyle and other conditions play their part too (Table 1).

Why this matters more here

The British Menopause Society notes a higher rate of heart risk factors in South Asian women around menopause, including insulin resistance, diabetes, weight around the middle and high blood pressure. The Pakistan Menopause Society names, among the challenges for Pakistan, an early age of menopause, endemic vitamin D deficiency, a high burden of osteoporosis and limited exercise (section 4.1). See vitamin D and calcium and diabetes risk.

The Pakistan Menopause Society asks doctors to use the menopause visit for prevention: checking blood pressure, BMI, fracture risk, blood sugar, cholesterol and tobacco use, and talking about lifestyle, muscle strength and activity (Table 1).

Its Table 4 adds a bone density (DXA) scan, where available, for women at higher risk: after a fragility fracture, with premature ovarian insufficiency or early menopause, after long-term steroids, with repeated falls or with marked loss of height. It also lists breast and cervical screening appropriate to age and risk. Health screening and osteoporosis go into both.

The same recommendations set out six areas of lifestyle care: healthy eating, physical activity, restorative sleep, mental wellbeing, avoiding risky substances such as smoking, naswar and shisha, and supportive relationships (section 4.2).

For a fuller read on health after menopause, NHS inform has a page, with versions in several languages, Punjabi among them.

The Pakistan Menopause Society lists relief of symptoms, treatment of vaginal and urinary changes, and maintaining bone health as the main reasons for HRT (section 5.1). It says the balance of benefit and risk is most favourable when HRT is started before 60 or within 10 years of menopause (section 5.12). Starting later is not ruled out: the HRT page covers what NICE and The Menopause Society say about starting after 60.

For vaginal and urinary symptoms on their own, the society notes that women using low-dose vaginal estrogen do not need an added progestogen (section 5.4). It also lists non-hormonal medicines for osteoporosis (section 6.4). Which, if any, suits you is your doctor's decision.

Any bleeding after your periods have stopped needs checking. The Pakistan Menopause Society lists it as a red flag (section 2.3), and the NHS website says it should be checked even if it is only a small amount or has only happened once. See bleeding after menopause.

The same recommendations list other red flags: a breast lump, nipple discharge or skin change; chest pain, swelling in one leg, sudden breathlessness or a severe new headache. Chest pain and sudden breathlessness need help straight away.

And if you break a bone in a minor fall, ask whether your bones should be checked. The NHS website says that is often how osteoporosis is first found.