The menopause: preparing women for what to expect.

After the age of about 35, the natural cycle becomes less predictable. Oestrogen levels fluctuate, leading to some anovulatory cycles. Sometimes periods stop suddenly but more often become erratic and less frequent for a year or two before the final period (menopause). About 75% of women experience symptoms at the time of the menopause, which typically lasts 1-3 years and occurs at around the age of 50. Long-term effects of the menopause are a rapid decline in bone density and greater risk of heart disease. Useful life-style adjustments for menopausal women are to eat calcium-rich foods, stop smoking, restrict alcohol intake and exercise regularly, especially weight-bearing exercise such as walking, dancing or sports. Hormone replacement therapy (HRT) is effective in reducing menopausal symptoms and appears to reduce the long-term risks of osteoporosis and heart disease. Women may start taking HRT before periods cease if they have troublesome symptoms during the pre- and peri-menopausal stage. Women who have had a hysterectomy may use oestrogen on its own. Women who have a uterus need a combination of oestrogen and progestogen. Current evidence suggests that to take HRT for up to 5-8 years incurs no additional risk of breast cancer, although to take it for longer than 10 years seems to increase the risk slightly.