This is partly explained by differences in their efficiency at absorbing and metabolising the hormones used in HRT. The slower these processes are, the longer the hormones have to cause adverse effects. Individual differences in responses to oral HRT may also be due to medical conditions — gastric problems, chronic diarrhoea, vomiting or pernicious anaemia, for example – or to interactions with other medications like antibiotics and anti-epileptic drugs.

Your body build also affects the dosage required. Menopausal women who are overweight or have considerable muscular development may need less oestrogen than slim women, because they are producing considerable amounts of oestrogen in fat and muscle tissue, in addition to receiving a small but steady supply of oestrogen from their ovaries.

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Occasionally menopausal women who use oestrogen develop a skin disorder called chloasma when exposed to the sun. The development of patches of darker skin on the face, legs and hands is similar to the skin reaction that sometimes occurs during pregnancy. The cause of the problem is uncertain, but deposits of melanin in the skin are involved. The discoloration usually becomes less noticeable when oestrogen therapy ceases, but it may become more noticeable on exposure to the sun, even after stopping HRT. Wearing a hat and applying a maximum-protection sunscreen should become part of your outdoor routine. Your doctor may have some suggestions about the most appropriate sunscreen in your particular case, and forms of treatment that may remove the discoloration.

Skin irritation or rash can occur when hormone patches are used and, less commonly, women report a more generalised allergic response. As we saw in the case of Margaret in chapter I, this can be severe enough to cause the abandonment of patch therapy. The problem appears to be worse in hot climates, and the reported incidence varies from 5 to 40 per cent in user groups worldwide. Occasionally there is also a severe local allergic response to the patch adhesive.

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The relationship between psychological symptoms and the menopause is evidently far from straightforward. A complex interplay of factors affects psychological functioning – among them personality, hormone changes, alterations in social and family stresses, the presence or absence of physical illnesses, and perhaps also feelings of loss and grief at entering the final third of life and realising the inevitability of death. To make the situation even less clear, there will always be a small group of women with severe psychiatric illnesses, who just happen to be menopausal at the time their illness comes to prominence.

Additionally, psychological symptoms blamed on menopause are inclined to show placebo responses: as we explained earlier, the symptoms may be relieved almost as well by a dud pill as by a prescribed product, arguably because part of the ‘healing therapy’ is the extra support and interest the patient is receiving.

The medical literature is probably best summarised by stating that whereas there is little evidence for an association between menopause and fully developed psychiatric disease, such as clinical depression, less severe psychological upsets seem to affect some women as they approach menopause or soon afterwards. HRT seems to relieve this state of affairs and to heighten a woman’s sense of wellbeing. Thus many women on HRT experience improvements in their psychological functioning, (concentration improves, confidence is restored, decision-making seems easier) and regain a spring in their step.

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The menopause is a time of transition, a nudge that sets us thinking about what is behind us and what we want from the years ahead. Both the internal changes of our bodies and their interaction with other factors in our lives seem to influence the symptoms of menopause that we experience.

HORMONE LEVELS There is no doubt that problems such as hot flushes and vaginal dryness are associated with the sex hormone changes of the menopause. Hot flushes have been linked with rising levels in a brain hormone called luteinising hormone and falling levels in the most powerful form of oestrogen, oestradiol. The changed balance of hormones also helps to explain symptoms of vaginal dryness and urinary frequency. Hormones are not the only controller of symptoms, however.

ANXIETY Sudden bouts of anxiety seem to be linked with hot flushes in some women. The more anxious you feel the more likely you are to have hot flushes.

SEXUAL ACTIVITY Even though vaginal dryness and painful intercourse are often blamed for reduced sexual activity and arousal in women after menopause, it is not clear which is the cause and which the effect. Research suggests that women who don’t often have sex tend to have more problems with vaginal dryness than those who have it frequently. In addition, the more often a menopausal woman is sexually aroused and active, the more easily natural vaginal lubrication is achieved, and the more comfortable and enjoyable sex tends to be.

The use of vaginal lubricants and ‘male dew’, or hormone therapy, may break the cycle of discomfort that is sometimes associated with sexual activity, and result in the release of natural lubricants. This is not to suggest that arousal is merely a physical matter; psychological influences to do with mood, touch, words and images are also important. Libido is not merely a matter of hormones. What is in your head and heart will also affect your interest in sex, and such things are not dependent on HRT. Interestingly, sex may have an influence beyond stimulation in preventing genital dryness as, according to research conducted by family planning authority Professor Egon Diczfalusy from the Karolinska Institute in Sweden, semen itself- absorbed through the vaginal walls — is a rich source of oestrogen.

STRESS Extreme demands on physical and mental energy, loosely termed stress, increase the tendency to flush. Hot and stuffy rooms, excessive amounts of alcohol and caffeine, a poor diet, sleep deprivation and thyroid disorders are common stress-related triggers of hot flushes.

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