Guide to living well with menopause

• Introduction
• Understanding menopause and its stages
• Guide to living well with menopause
• Understanding menopausal vasomotor symptoms
• Guide to living well with menopausal hot flushes
  • Treatments
• Understanding menopausal sexual changes
• Guide to living well with menopausal sexual changes
  • Treatments
• Understanding the psychological symptoms of menopause
• Guide to living well with the psychological symptoms of menopause
  • Treatment
• Understanding other menopausal symptoms
• Guide to living well with other menopausal symptoms
  • Treatments
    • Skin
    • Sleep
• Focusing on a healthy mind and body to live well with menopause

Introduction

Menopause is a time of significant and often unpleasant changes in a woman’s life. The majority of women (up to 85%) experience symptoms related to the dramatic hormonal changes of menopause. They usually begin in the period of menopausal transition, that is; the time leading up to the final menstrual period, and typically persist post-menopause (after the final menstrual period). They include hot flushes, sexual changes, psychological and mood changes, poor quality sleep and rapidly ageing skin.
Menopausal symptoms can significantly and negatively impact on a woman’s wellbeing and quality of life. However, there are many ways to manage menopausal symptoms including simple lifestyle and behavioural measures, as well as pharmaceutical and herbal remedies. It’s a time of significant change but it is possible to live well with menopause.

Understanding menopause and its stages

Different stages of menopause typically produce different symptoms and effects. Understanding the changes that occur at different stages can help a woman understand and cope with the changes. Menopause refers to the cessation of menstruation and the time of menopause is defined as the time of the last menstrual bleeding. However, menopausal symptoms typically affect women for a significant period of time, beginning in the menopausal transition and persisting post-menopause.
The menopausal transition or period when hormonal changes begin to cause irregular menses can be further categorised as early and late stage. The early stage is characterised by menstrual cycles which vary more than 7 days from normal length (21–35 days), while the late stage is characterised by extended periods (≥ 60days) between menstrual bleeding. The post-menopausal period is also divided into early (the first 5 years after final menstrual bleeding) and late (thereafter) stages.

For more information about the changes that occur in menopause and the symptoms that may be experienced, see Menopause.

Guide to living well with menopause

The prevalence of symptoms varies at different stages of menopause. For example, hot flushes are associated with the period of menopausal transition, while sexual difficulties increase with increasing time since menopause. Thus women often need to employ different strategies at different stages to minimise the impact of menopause, and its symptoms, on their wellbeing. However, there are some general measures which will assist women to live well with menopause, regardless of stage or symptoms. These include:

• Think positively about the life changes associated with menopause. The brain is a powerful organ and negative feelings are associated with a greater likelihood of  experiencing menopausal symptoms. Try to view menopause as the start of a new phase in life, rather than a negative interruption and focus on positive aspects like the cessation of menstrual bleeding;
• Remember that the sexual and other changes of menopause are normal and natural, even if everything feels different. It is important for women experiencing menopause to challenge beliefs which may reduce their self-esteem, such as unrealistic expectations about body shape and beauty. Aspects of ageing such as wrinkling and weight gain are normal and natural, and being aware of and accepting this is important. Focusing on life achievements and setting realistic goals for the future is also useful for women experiencing the changes of menopause;

• Love your new menopausal body, despite its different shape and appearance. Remember that the changes are normal and natural and try to be positive about your body and maintain its healthfor example by:
  • Maintaining a healthy diet including minimising alcohol and caffeine consumption;
  • Performing at least 30 minutes of moderate intensity physical activity every day; and
  • Quitting smoking;

• Set aside personal time which may be used for relaxation, pursuing new interests and roles in life. Joining a volunteer group or a hobby group may also be useful in this new phase of life;
• Get support from friends, family members, your intimate partner and, if necessary, health professionals;
• Identify and address stressors, including work and children which can create stress and make menopausal symptoms more severe. For some women it may be beneficial to identify and implement strategies to overcome issues in intimate relationships. For others, developing strategies to cope with child-related issues (e.g. leaving, or not leaving home) may be more important. If you find it challenging to address the stressors in your life, talk to a health professional to organise some additional support;
• Consider cultural factors which may influence menopause and you attitude to it. For example, if you live in a culture where older women are less valued due to their loss of reproductive capacity and changing appearance, this may influence you to have negative perceptions about menopause. Challenge the cultural perceptions which may influence you to think negatively about menopause.

In addition there are specific measures and treatments which may help women cope with individual symptoms of menopause.

Understanding menopausal vasomotor symptoms

Vasomotor symptoms of menopause, commonly referred to as hot flushes, are best described as sudden sensations of heat radiating from the chest and face, and resulting in profuse sweating which persists for 2–4 minutes. However, hot flushes can last for as little as a couple of seconds or as long as a couple of hours. Flushes may occur as often as every 5 minutes or as infrequently as once or twice a year. They are the most common menopausal symptom, affecting approximately 70% of women and typically begin in the late menopausal transition. In most women hot flushes persist for 0.5–5 years, but in a minority of women continue for up to 15 years.
While menopausal hot flushes are not life-threatening, they can be distressing and reduce a woman’s quality of life, sleep quality or social life. Experiencing hot flushes is associated with a greater risk of psychological complaints such as depressed mood and anxiety. However, there are many strategies which women can employ to ensure they continue living well when vasomotor symptoms arise.

Guide to living well with menopausal hot flushes

For the majority of women (60%) who experience mild vasomotor symptoms, general measures which improve overall health and wellbeing (discussed above) may be sufficient for living well with hot flushes. However, women may also benefit from lifestyle measures specifically aimed at reducing the occurrence of hot flushes including:

• Avoiding certain foods and beverages (e.g. spicy foods) which trigger hot flushes; and
• Measures to reduce body temperature (e.g. keeping the room cool).

If these measures fail and hot flushes occur, women may be able to cool off by:

• Having a cold drink or shower or using a fan;
• Breathing deeply and trying to relax;
• Running cold water on their wrists;
• Removing clothing: Dressing in many thin layers will make this easier;
• At night, getting out of bed.

Treatments

When lifestyle measures alone are insufficient to assist women to live well with menopausal hot flushes, a range of pharmaceuticals and herbal products may be of value. Hormone replacement therapy (HRT) is an effective treatment and relief of vasomotor symptoms is the primary reason women use the therapy. However, before using HRT it is important to obtain evidence-based information from a doctor about the risks and benefits of HRT, including the likelihood that vasomotor symptoms will return when the treatment is stopped
Due to the significant health risks associated with HRT (e.g. an increased risk of breast cancer), many women avoid it and opt for herbal remedies, for which rigorous evidence of effectiveness and safety is limited. It is important to obtain evidence-based information from a doctor regarding the effectiveness and safety of any herbal remedy before using it. Remember that natural does not necessarily mean safe.
Amongst the herbal products available, there is increasing interesting in isoflavone phytoestrogens; plant compounds with oestrogenic properties. Phytoestrogens derived from soy and red clover have been assessed for their effect on vasomotor symptoms. While some trials have reported positive results, others have reported that taking phytoestrogens did not affect the frequency or severity of hot flushes. Current evidence is considered insufficient to enable conclusions to be drawn regarding whether or not phytoestrogens effectively relieve hot flushes.

Understanding menopausal sexual changes

The hormonal changes of menopause have a profound effect on the function of genital organs and women’s sexual desire and response, all of which are regulated by the same hormones (predominately oestrogen and progesterone but also androgens and others). These hormones undergo dramatic changes during menopause. For example, levels of oestrogen which, amongst other functions, regulates the flow of blood to the vagina and vaginal lubrication during sexual stimulation decline rapidly and considerably. Unlike other menopausal symptoms which are usually temporary, sexual changes typically persist permanently following menopause. The majority of women experience changes in vaginal lubrication with menopause and these complaints increase in prevalence with increasing duration post-menopause. However, sexual symptoms may also occur in the menopausal transition or early post-menopausal period.
It is important to be cognisant that women’s sexual feelings and functions are also influence by psychological factors; some evidence suggests these are more influential than hormonal factors. Psychosocial and other symptoms associated with the menopause may also influence a woman’s sexual desire and response. For example, if hot flushes cause insomnia and irritability, this may in turn affect sexual functioning. Changes to a partner’s sexual function are also influential. For example, erectile dysfunction  increases with age and negatively affects both a man and his partner’s sexual functioning. It is the cause of negative sexual changes in post-menopausal women in about one-third of cases. Midlife changes and stressors such as children leaving home or difficulties in her intimate relationships may also impact on a woman’s sexual function around the time of menopause.

Guide to living well with menopausal sexual changes

While the majority of women experience negative sexual changes during menopause, it is important to be aware that a minority report sexual improvements. The hormonal changes of menopause do not necessarily impair a woman’s sexual function. In addition many women report that although sexual changes (e.g. increased vaginal dryness) occur, they do not impact on the quality of their sex life, and they are not necessarily related to menopause. For example a new sexual partner or new sexual techniques may underpin changes in the way sex feels or a woman’s libido.
If you are having difficulty coping with the sexual changes of menopause, as well as the biological, psychological and social factors which influence them, you should talk to your doctor. Ideally your intimate partner should also be involved in the discussion, which will not only provide the basis for better understanding the changes which occur, but can also be used to identify treatments and other strategies which might make coping with sexual changes easier. While treatments are highly effective (80–100%), only a quarter of women seek treatment for sexual symptoms, so many remain unaware of the lifestyle, pharmaceutical and herbal remedies which may relieve sexual symptoms.
HRT is one option, but the therapy is not usually used to treat sexual symptoms alone and many women avoid it due to safety concerns. In cases where sexual dysfunction is underpinned by psychosocial factors like stress or relationship problems, HRT may be ineffective if the psychosocial influences on sexual function are not addressed. Usually the doctor will recommend a woman tries other measures before they prescribe HRT. In the first instance there is a range of simple measures which can be trialled, including:

• Use of vaginal lubricants;
• Addressing issues in the intimate relationship, including male sexual dysfunction;
• Practicing new sexual techniques, amongst which non-penetrative techniques like oral sex and intimacy may be of particular importance;
• Addressing socio-cultural factors which influence sexual function, for example social norms which portray sexual enjoyment as less acceptable for older women.

Other lifestyle and psychological measure which may increase sexual satisfaction amongst menopausal women include:

• Remembering that good sex takes two. If a couple’s sex life deteriorates in the menopausal period, it is important to remember that the woman is not to blame. Both partners need to try to talk openly about sex, how it feels, any fears they have, and what has changed. Where possible both partners should discuss the sexual problems and possible strategies for addressing them with a health professional;
• Having sex and thinking about it. Regular sex (either alone or with a partner) increases vaginal elasticity which typically declines with menopause and may contribute to sexual problems. The brain is the centre of sexual desire and plays a critical role in sexual activity, so thinking positively about sex can also play an important role in sexual satisfaction. Erotic films or literature or sex toys may be good stimulus for some couples. If sexual intercourse doesn’t happen, try something different. Non-penetrative sex acts like oral sex, cuddling and massage, as well as intimate time together are also important components of a healthy sexual relationship;
• Treating comorbid menopausal symptoms such as hot flushes which impact on sexual functioning;

• Treating conditions affecting their partners sexual function for example low testosterone  (hypogonadism) and erectile dysfunction;
• Focusing on their own sex life and not comparing. Every woman has different sexual feelings during menopause, for example libido may increase or decrease. Women should focus on what feels right for them and their partner, not what their sex life used to be like or what their friends are doing;
• Avoiding sexually transmitted infections if they are at risk.

Treatments

If these measures fail to bring about sexual satisfaction, the doctor may prescribed topical oestrogen (creams, rings or other preparations for vaginal use), or systemic oestrogen therapy (HRT). Doctors sometimes also include testosterone in HRT for women with sexual complaints, as it has been shown to have positive effects on sexual functioning. Various oestrogen containing products are more or less effective in treating specific sexual complaints. For example, an oestrogen releasing ring is more effective than a tablet for reducing vaginal itching or irritation, but the tablet is more effective in reducing vaginal dryness. Women should be specific about the sexual symptoms they are experiencing, as this will help their doctor determine which oestrogen and other hormonal products will be most suitable for addressing the specific complaints. Comorbid menopausal symptoms may also influence the most appropriate form of treatment. For example, systemic HRT is also typically effective in treating vasomotor symptoms, whereas topical creams are not.
Women may be interested in using herbal remedies to cope with the sexual changes of menopause. These remedies are commonly used; however, evidence for their effectiveness in relieving sexual symptoms and safety is lacking.

For more information about how you can have an active and fulfilling sex life after menopause, see Tips for a Great Sex Life after Menopause.

 

If you’re a man and would like to know what you can do to make you and your partner’s post-menopause sex life as satisfying as ever, see Husband’s Guide to Great Sex After Menopause.

 

Understanding the psychological symptoms of menopause

The causes of psychological symptoms of menopause such as increasing anxiety, depressed mood, low self-esteem, irritability and memory problems, are not well understood. These symptoms may impact not only on menopausal patients but also upon the individuals with whom they live, work and play.
Oestrogen exerts an effect on many brain functions and it is scientifically plausible that the hormonal changes of menopause may induce psychological symptoms. However, it is likely that psychological symptoms occur, at least in part, as a result of other menopausal symptoms and also as a result of stressors which are more common in mid-life (e.g. children leaving home). Factors such as menopausal vasomotor symptoms, relationship problems, a history of depression and unhealthy lifestyle, all increase the risk that menopause will bring with it negative psychological symptoms.
Many women experience negative psychological symptoms in menopause; however, it is important to remember that menopause is also associated with positive psychological changes. The majority of studies have reported that women exhibited improved psychological health following surgical menopause. Women approaching natural menopause often have positive expectations, for example that it will be the beginning of a new phase or offer new freedom from menses and the risk of pregnancy. Cultural factors influence the risk of psychological symptoms of menopause. For example, women who live in a culture which emphasises youthfulness and fertility as positive qualities may feel undervalued when they reach menopause, and are more likely to experience psychological symptoms.

Guide to living well with the psychological symptoms of menopause

General measures to improve overall health and wellbeing, such as having a positive outlook and healthy lifestyle, are important for those with psychological symptoms. Additional measures which may help these women live well with the psychological symptoms of menopause include:

• Ensuring regular cognitive stimulation if they are having memory or concentration problems;
• Socialising which can increase mental function;
• Practicing relaxation and stress relief techniques which can help them cope when symptoms arise;
• Talking to friends, family, or, in cases of severe symptoms a counsellor;
• Treating comorbid menopausal symptoms like hot flushes which can impair sleep and impact on mood; and
• Keeping a mood diary which may help identify triggers and develop coping strategies.

Treatment

HRT has been shown to reduce psychological symptoms in menopausal women; however it is not clear if this occurs through a direct effect or secondary to relief of comorbid hot flushes. Despite this uncertainty, HRT should be considered by women experiencing psychological symptoms (and particularly those who also experience hot flushes) in the menopausal transition. Progesterone reduces the mood enhancing effects of oestrogen. While progesterone must be added to all oestrogen-replacement regimens to reduce cancer risk, a HRT regimen with a higher oestrogen to progesterone ratio will usually be prescribed for women with psychological symptoms. Testosterone and other androgens may also be useful additions for these women.
There are also a number of herbal remedies, including gingko, ginseng, kava-kava and St John’s wort which have demonstrated some efficacy in reducing psychological symptoms such as anxiety and depressed mood. However, there are safety concerns regarding the use of ginseng and kava kava, and St John’s wort is less effective than other available treatments. Evidence also suggests that red clover isoflavone phytoestrogens can significantly reduce anxiety and depression in the short term.
Women with psychological illnesses such as major depression (which must be distinguished from mood disorders such as depressed mood) require treatment, even if they have never previously been diagnosed with a psychological illness. For some women menopause is a catalyst to discuss existing problems with a health professional, so it may be the time when an existing psychological illness is diagnosed for the first time.

Understanding other menopausal symptoms

Other symptoms associated with the menopausal period include sleeping difficulties and skin changes. Reduced oestrogen levels in menopausal women are thought to partly underpin the rapid ageing of skin many women experience in the menopausal period. Sleep difficulties including insomnia and breathing difficulties during sleep are amongst the most common complaints of menopausal women and are almost 3.5 times more likely to affect women in menopause compared to earlier in life. They may arise as a result of hormonal changes; however, menopausal vasomotor symptoms and stressful midlife changes are also thought to be implicated in sleep disturbance.
Like other menopausal symptoms, skin and sleep changes are benign but can significantly impact on women’s wellbeing and quality of life. Psychological symptoms may be exacerbated by negative feelings regarding the appearance of ageing skin. Poor quality sleep can also exacerbate menopausal mood disorders and impact on sexual functioning.

Guide to living well with other menopausal symptoms

As with all menopausal symptoms, lifestyle changes and other simple measures can help women live well with menopausal skin and sleep symptoms. Healthy sleep and healthy skin are both associated with psychological complaints so emphasising the importance of a positive attitude and dealing with stressors that can impair sleep may be particularly important. Those with skin symptoms should also:

• Wear broad spectrum sunscreen;
• Avoid harsh soaps and other products which may exacerbate dryness; and
• Use moisturising skin creams.

Those experiencing sleeping difficulties may benefit from:

• Treating comorbid menopausal symptoms;
• Behavioural therapies targeted at improving sleep including sleep hygiene  measures, ritualising sleep patterns, and, in severe cases, sleep deprivation;
• Practising relaxation or stress management techniques including biofeedback;
• Avoiding stimulation and heavy meals immediately before sleep.

Treatments

Skin

HRT is an effective treatment to reduce skin ageing as it reduces the loss of collagen, which gives skin its firmness and elasticity. It has also been shown to improve wound healing. However, due to associated health risks, HRT is not prescribed when skin changes are the only menopausal symptom. For women who are not able or do not want to use HRT, another treatment option is soy isoflavone phytoestrogen tablets or creams. One study reported that skin appearance improved with the use of phytoestrogen-containing cream. Other treatments which may be considered include creams containing vitamin A, dietary supplements, and selective oestrogen receptor modulators (medicines which affect the way the body uses oestrogen).
A range of cosmetic treatments which can change the appearance of aged skin (e.g. reduce wrinkles or sagging) are also available. Women considering cosmetic treatments should be cognisant that these procedures are not medically indicated and no physical health benefits are associated with cosmetic treatments. Cosmetic changes which result from the treatments do not necessarily result in improved body image or self-esteem, or greater satisfaction with the treated body part. It is also important to bear in mind that the skin changes of menopause are normal and natural, even though they may cause dissatisfaction.
Women who are considering cosmetic procedures have a range of options, from minimally invasive treatments with botulinum toxin A injection or soft tissue fillers, to more complex and risky procedures such as cosmetic surgery.

For more information about educating patients about the risks and benefits of cosmetic surgery, see Cosmetic Surgery: Making a decision.

Sleep

If behavioural measures fail to improve sleep in menopausal women, other treatment options exist. Medicines used to treat insomnia may be of value in severe cases. Treatment of comorbid conditions (e.g. fibromyalgia) may also improve sleep. There is some evidence to support the use of phytoestrogen therapy with either soy or red clover isoflavones, however, evidence for the use of other herbal remedies for improving sleep quality is lacking. Women with severe, chronic insomnia may be referred to a sleep clinic for treatment.

Focusing on a healthy mind and body to live well with menopause

Menopause is a time of significant changes which often have a negative impact on quality of life. However, it is possible to live well with menopause. A healthy body and mind are the basis of a happy, healthy menopause. Lifestyle and behavioural changes such as healthy eating, exercise and avoiding harmful substances should form the basis of any strategy to live well with menopause. Psychosocial measures such as socialising, participating in leisure activities, thinking positively about life and one’s menopausal body and seeking support when needed, also play an important role in making menopause a positive new phase of life rather than a negative event.
However, cultural and other factors mean some women are impacted more greatly by menopausal symptoms than others. For those that find behavioural therapies alone are insufficient to make living well with menopause a reality, the addition of established and emerging treatments should be considered and discussed with a doctor. Attention should be given to matching treatments to the specific symptoms experienced. Taking the time to fully understand the risks, benefits and evidence base for various therapies is a vital component of living well with menopause.

References

1. Goodman NF, Cobin RH, Ginzburg SB, et al. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the diagnosis and treatment of menopause. Endocr Pract. 2006;12(3):315-37. [Abstract | Full Text]
2. Nelson HD, Haney E, Humphrey L, et al. Management of menopause-related symptoms. Summary, Evidence Report/Technology Assessment No. 120. AHRQ Publication No. 05-E016-1 [online]. Rockville, MD: Agency for Healthcare Research and Quality; March 2005. [cited 16 January 2012]. Available from: [URL link]
3. Utian WH. Skin: Impact of menopause, ageing and hormones. Menopause Management. 2009: May/June: 11-13. Available from: URL Link
4. Soules MR, Sherman S, Parrott E, et al. Executive summary: Stages of Reproductive Aging Workshop (STRAW). Fertil Steril. 2001;76(5):874-8. [Abstract]
5. Position statement: Scientific definitions for menopause related terminology [online]. Buderim, QLD: Australasian Menopause Society; 27 August 2002 [cited 18 January 2012]. Available from: [URL link]
6. National Institutes of Health State-of-the-Science Conference statement: management of menopause-related symptoms. Ann Intern Med. 2005;142(12 Pt 1):1003-13. [Abstract | Full text]
7. Grady D. Clinical practice. Management of menopausal symptoms. N Engl J Med. 2006; 355(22):2338-47. [Full Text]
8. Deeks AA. Is this menopause? Women in midlife: Psychological issues. Aust Fam Phys. 2004;33(11):889-93. [Abstract]
9. Berterö C. What do women think about menopause? A qualitative study of women’s expectations, apprehensions and knowledge about the climacteric period. Int Nurs Rev. 2003;50(2):109-18. [Abstract]
10. Bartlik B, Goldstein MZ. Maintaining sexual health after menopause. Psychiatr Serv. 2000;51(6):751-3. [Full text]
11. Managing menopause: Self-esteem [online]. Clayton, VIC: The Jean Hailes Foundation for Women’s Health; 6 November 2009 [cited 18 January 2012]. Available from: [URL link]
12. Managing menopause: Body image [online]. Clayton, VIC: The Jean Hailes Foundation for Women’s Health; 23 October 2009 [cited 18 January 2012]. Available from: [URL link]
13. The Jean Hailes Foundation for women’s health. Menopause Management. 19 June 2008 [cited 18 January 2012]. Available from: [URL Link]
14. Managing menopause: Culture [online]. Clayton, VIC: The Jean Hailes Foundation for Women’s Health; 23 October 2009 [cited 18 January 2012]. Available from: [URL link]
15. Royal College of Nursing. Complementary approaches to menopausal symptoms- Guidance for RCN nurses, midwives and health visitors. 2006. [cited 18 January 2012]. Available from: [URL link]
16. Managing menopause: Depression and anxiety [online]. Clayton, VIC: The Jean Hailes Foundation for Women’s Health; 6 November 2009 [cited 18 January 2012]. Available from: [URL link]
17. BMJ Group. Menopause- what is it? BMJ Patient Leaflet [online]. 2009. [cited 18 January 2012] Available from: [URL Link]
18. Emotional health at midlife and menopause [online]. Clayton, VIC: The Jean Hailes Foundation for Women’s Health; November 2009 [cited 18 January 2012]. Available from: [URL link]
19. Bachmann GA. Vasomotor flushes in menopausal women. Am J Obstet Gynecol. 1999;180(3 Pt 2):S312-6. [Abstract]
20. Shanafelt TD, Barton DL, Adjei AA, Loprinzi CL. Pathophysiology and treatment of hot flashes. Mayo Clin Proc. 2002;77(11):1207-18. [Abstract | Full text]
21. Managing menopause: Symptoms: Hot flushes/night sweats [online]. Clayton South, VIC: Jean Hailes Foundation for Women’s Health; 19 May 2008 [cited 18 January 2012]. Available from: [URL link]
22. Mucci M, Carraco C, Mancino P, et al. Soy isoflavones, lactobacilli, magnolia bar extract, vitamin D3 and calcium- controlled clinical study in menopause. Minerva Ginecol. 2006; 58(4): 323-34. [Abstract]
23. Fact sheet: Menopause [online]. Clayton, VIC: The Jean Hailes Foundation for Women’s Health; October 2009 [cited 18 January 2012]. Available from: [URL link]
24. North American Menopause Society. Estrogen and progestogen use in postmenopausal women: 2010 position statement of The North American Menopause Society. Menopause. 2010;17(2):242-55. [Abstract]
25. Hachul H, Brandao LC, D’Almeida V, et al. Isoflavones decrease insomnia in post menopause. Menopause. 2011; 18(2): 178-84. [Abstract]
26. Lipovac M, Chedraui P, Gruenhut C, et al. Improvement of postmenopausal depressive and anxiety symptoms after treatment with isoflavones derived from red clover extracts. Maturitas. 2010;65(3):258-61. [Abstract]
27. Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Management of the Menopause. 2008. [cited 18 January 2012]. Available from: [URL link]
28. Lipovac M, Chedraui P, Greunhut C, et al. The effect of red clover isoflavone supplementation over vasomotor and menopausal symptoms in postmenopausal women. Gynaecological Endocrinol. 2011; online edition. [Abstract]
29. Burbos N, Morris E. Menopausal symptoms. BMJ Clin Evid. 2010; 2: 804. Publisher
30. American College of Obstetricians and Gynaecologists. Herbal products for menopause. 2003. [cited 18 January 2012]. Available from: [URL link]
31. Bélisle S, Blake J, Basson R, et al. Canadian consensus conference on menopause, 2006 update. J Obstet Gynaecol Can. 2006;28(2 Suppl 1):S7-S94. [Abstract | Full text]
32. Leventhal JL. Management of libido problems in menopause. Presented at: Cojoint Annual Meeting of the American Society for Reproductive Medicine and the Canadian Fertility and Andrology Society 32nd Annual Postgraduate Program. Toronto, Canada; 25-26 September 1999. [Full Text]
33. Hinchliff S, Gott M, Ingleton C. Sex, menopause and social context: A qualitative study with heterosexual women. J Health Psychol. 2010;15(5):724-33. [Abstract]
34. Decks AA, McCabe MP. Sexual function and the menopausal woman: The importance of age and partner’s sexual function. J Sex Res. 2001;38(3):219-25. [Abstract]
35. Managing menopause: Libido [online]. Clayton, VIC: The Jean Hailes Foundation for Women’s Health; 30 November 2009 [cited 18 January 2012]. Available from: [URL link]
36. Managing menopause: Relationships [online]. Clayton, VIC: The Jean Hailes Foundation for Women’s Health; 6 November 2009 [cited 18 January 2012]. Available from: [URL link]
37. Fixes for a stalled sex life [online]. Mayfield Heights, OH: North American Menopause Society; 4 March 2010. [cited 18 January 2012]. Available from: [URL link]
38. Drew O, Sharrad J, Sexually transmitted infections in the older woman. Menopause Int. 2008; 14(3): 134-5. [Abstract]
39. Brizendine L. Managing menopause-related depression and low libido. J Fam Pract. 2004; 16(8). [Full text]
40. Shifren JL, Avis NE. Surgical menopause: Effects on psychological well-being and sexuality. Menopause. 2007;14(3 Pt 2):586-91. [Abstract]
41. Eichling PS, Sahni J, Menopause-related sleep disorders. J Clin Sleep Med. 2005; 1(3): 291-300. [Full Text]
42. Accorsi-Neto A, Haidar M, Simoes R, et al. Effects of isoflavones on the skin of postmenopausal women: a pilot study. Clinics. 2009; 64(6): 505-10. [Abstract | Full Text]
43. Shaver JL, Zenk SN. Review: Sleep disturbance in menopause. J Women’s Health Gender-based Med. 2000; 9 (2): 109-118. [Abstract]
44. Parish JM. Sleep related problems in common medical conditions. Chest. 2009; 135(2): 563-74. [Abstract | Full Text]
45. Ashcroft GS, Dodsworth J, Van Boxtel E, et al. Estrogen accelerates cutaneous wound healing associated with an increase in TGF-β1 levels. Nature Med. 1997; 3: 1209-15. [Abstract]
46. Lipovac M, Chedraui P, Gruenhut C et al. Effect of Red Clover Isoflavones over skin, appendages and mucosal status in postmenopausal women. Obstet Gynacol Int. 2011. [Full Text]
47. Sator PG, Skin treatments and dermatological procedures to promote youthful skin. Clin Interv Aging. 2006; 1(1): 51-6. [Full Text]
48. Skovgaard GRL, Jensen AS, Sigler ML. Effect of a novel dietary supplement on skin aging in post-menopausal women. Eu J Clin Nutrition. 2006: 60; 1201-6. [Full Text]
49. Verdier-Sevrain S. Effect of estrogens on skin aging and the potential role of selective estrogen receptor modulators. Climacteric. 2007; 10(4): 289-97. [Abstract]
50. Zuckerman D, Abraham A. Teenagers and cosmetic surgery: Focus on breast augmentation and liposuction. J Adolesc Health. 2008;43(4):318-24. [Abstract | Full text]
51. Psychological aspects: Your self-image and plastic surgery [online]. Arlington Heights, IL: American Society of Plastic Surgeons; 2008 [cited 18 January 2012]. Available from: [URL link]