One of the many problems in discussing the menopause and its treatment is the extreme variability of its presentation. Thus whilst some women experience severe multiple symptoms, others have none at all or only minimal problems that may pass virtually unnoticed. The duration of these symptoms is also extremely variable, as is their time of onset. In some women a few hot flushes only are noted for a few weeks in association with the cessation of menses, whilst in others, frequent debilitating attacks of sweating start 15 years after the menses have ceased and continue unremitting for several years. The typical collection of associated symptoms, which characterize the acute climacteric syndrome can be grouped into three types: a) vasomotor symptoms with the menopausal hot flush being the characteristic feature, b) target organ estrogen deficiency symptoms such as urogenital dysfunction and c) miscellaneous group with joint pain and psychosomatic symptoms.
Hot flushes are the most common symptom reported by 75% of women, and have the most impact on women's lives. Social and cultural factors as well as psychological characteristics of the individual women may influence their perception of vasomotor symptoms. In general, hot flushes and sweats are more commonly reported by European and North American women than in other populations. Overall menopausal symptoms are most pronounced in the first few years after the menopause. As a rule symptoms are initially more severe if the woman experiences an abrupt cessation of ovarian function as with surgically induced menopause.
The cause of the psychological symptoms noted around the time of the menopause (e.g. difficulty in making decisions, poor concentration, memory impairment, loss of confidence, feeling unworthy) is controversial. Some clinicians view psychological problems as the consequence of physical problems of the menopause, such as vasomotor symptoms, disturbed sleep and vaginal dryness, whilst others attribute the psychological symptoms to coincident life events.
Sleep disturbance, a common complaint in the menopause, probably has a multifactorial basis. The problem is more intermittent sleep or early waking, rather than true insomnia. A disrupted sleep pattern resulting from hot flushes and night sweats, could be responsible for emotional instability in some women.
Sexual difficulties are probably much commoner after the menopause than is generally appreciated. Thinning of vaginal lining as a result of a lack of estrogen contributes to sexual dysfunction and leads in addition to a variety of symptoms, such as itching and painful intercourse (dyspareunia). Urinary frequency, urgency incontinence and sometimes recurrent urinary infections also result from thinning of the lining of the urethra and bladder.
A different pattern of complaints has been reported in women who flush compared with that in women who do not. Women with hot flushes tend to have more complaints overall. This applies particularly to psychosomatic complaints, the severity of which is related to the severity of hot flushes. Significantly less psychosomatic complaints are found in women without flushes. The severity of headache/migraine also seems related to the severity of hot flushes.