Hot flushes are likely to peak in the first months to years after the last menstrual bleed, although they also occur in many women who are menstruating regularly. In either case, they provide a good deal of embarrassment and discomfort.

The rate of hot flushes in the non-menopausal female population is about 10 to 20 per cent. For most women the rate of flushes declines rapidly after menopause, although about 10 per cent are still having flushes ten years later, rather longer than most women would like.

We do know that hot flushes parallel an increased output of luteinising hormone produced in a region of the brain that is close to the body’s heat centre. There also seems to be a link between flushes and changes to the normal working of blood vessels. One theory links low oestrogen levels with an increase in brain chemicals, leading in turn to a change in the temperature monitoring and regulating part of the brain. This is said to result in the experience of a hot flush, with its associated increase in pulse rate and blood flow to the skin.

Another thing that seems to affect the timing and severity of flushes is anxiety. It is sometimes possible to find connections between anxious situations and the onset of a flush. Stress, the vague state of tension that so much ill health is now put down to, can also increase the tendency to flush. Things that can trigger stress reactions include sleep deprivation, a hot and stuffy environment, thyroid disease and alcohol -common enough factors in anyone’s life.

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Lorraine’s experience of postmenopausal HRT included prolonged and heavy bleeding each month. Unusually, this persisted even after endometrial ablation. Her gynaecologist made a full assessment and gave Lorraine the option of stopping the HRT or, if she wanted to continue with it, to have a hysterectomy or a repeat ablation. She decided to withdraw from HRT and found her other major menopausal symptoms— flushes, vaginal dryness, insomnia and mood swings — were becoming less distressing.

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Whether it is taken every day or for ten to fourteen days per cycle, the total monthly dose of progestogen in HRT is similar to that given to a woman on the Pill. The dosage used by Tessa, who is taking progestogen daily, was arrived at by lowering the daily dose until she had breakthrough bleeding, then adjusting upwards.

Individual variability in the body’s capacity to deal with the hormones of HRT is another reason why a dose that relieves symptoms in one woman has little effect on another. In the case of hormone patches and implants, the position on or in the body affects the amount of hormone the body absorbs and therefore the dosage required.

When a doctor is deciding on the most suitable dosage or hormone format for you, your individual response will be crucial. The hormones used initially may not relieve your symptoms adequately, or they may have unwanted effects. It may then be necessary to change the kind of oestrogen or progestogen used, or to alter the dose.

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Recent studies show that approximately one-third of South Australian women and one-quarter of New South Wales women have had a hysterectomy by the age of sixty-five. Included in these figures are a number of women whose ovaries have been removed and who are therefore likely to develop more severe menopausal symptoms than the others.

The most common reason for hysterectomy is irregular, heavy and prolonged bleeding (lasting more than two weeks) that does not respond to treatment. This was the case for Roberta, who was forty-six when her uterus and cervix were removed. On the first occasion of prolonged bleeding she bled for fifteen days on end, after which her doctor recommended a hysteroscopy (a procedure that allows a doctor to view the inside of the uterus by inserting a small magnifying instrument via the vagina and cervix). This investigation did not reveal anything of significance and she was given progestogens (synthetic progesterone), which brought the bleeding to an end.

When a similar thing happened a few years later, a repeat hysteroscopy revealed several fibroids (fibrous growths that start in the muscle layer of the uterus, occur in up to 30 per cent of women, and are a common cause of profuse bleeding). Doctors gave Roberta a choice between putting up with the irregular and heavy bleeding, which they expected would subside after menopause (when fibroids usually shrink), and having a hysterectomy. ‘I coped with it for several more months but eventually I couldn’t take the bleeding, the lack of energy, and the feelings of uncertainty about when it would end’.

Given that irregular bleeding often occurs in the lead-up to menopause, it comes as no surprise to learn that most of the women in the New South Wales study who had had hysterectomies were aged between thirty-five and forty-nine years, with the highest rate in the forty-five to forty-nine age group.

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