Ask the Expert: "I've been having hot flushes recently... should I be alarmed?"

Let’s begin with two stories, of Ms A and Mrs B.

Ms A was a high-achieving teacher in a tuition centre. This work was important to her self-identity: she deeply enjoyed her work with young people. In her late 40s, however, she began having hot flushes and night sweats—disturbing her sleep. She felt fatigue and poor concentration as a result, and had difficulties functioning at work. She started making mistakes. She received negative feedback from students and parents. Her performance appraisal was poor. Her supervisor’s feedback was negative. This upset her and at one point, she shared that she even felt suicidal. Her sense of self-worth and confidence took a plunge.

She decided to stop working.

Mrs B is a 47-year-old homemaker, married with two teenage children. She had perimenopausal symptoms as well, with hot flushes and night sweats that resulted in poor sleep and fatigue. Additionally, she had a low mood. She became easily irritable. She became easily angered, and verbally abusive to her husband and children. Her husband, becoming very upset, decided to move out.

These stories are sadly common amongst women with perimenopause.

Perimenopause can take a toll on relationships and work performance. Notably, both women weren’t aware of what was happening to them. Many women in Singapore lack knowledge and preparation for this transition in their lives.

In this edition of Ask the Expert, we ask Associate Professor Rukshini Puvanendran, who is the Co-Director of KK Menopause Centre at KK Women’s and Children’s Hospital, to break down for us what perimenopause and early menopause is, address common concerns, and educate us about the treatment options available.

I have been experiencing symptoms of menopause, including hot flushes, body aches and mood changes like low mood or irritability. A friend suggested that I might have menopause – but I still have my period. What am I suffering from?

Menopause occurs after a woman has her final menstrual period (defined as 12 months of no periods in a woman who is not pregnant or has other causes for loss of periods), and typically occurs in the late 40s or early 50s. Perimenopause is the transition period before a woman’s last period. The average age of menopause in Singapore women is 49, so most women should expect perimenopause symptoms a few years prior.

Getting evaluated is ideal, to determine if it is indeed perimenopause, and exclude other causes of hot flushes, eg thyroid or other hormonal imbalances. Some women experience premature ovarian insufficiency (POI) or early menopause too. Perimenopause symptoms, including hot flushes, night sweats, body aches, mood changes, and changes in the intensity and frequency of menstrual periods, are caused by hormonal fluctuations, and occur up to 10 years before menopause.

Symptoms can be confusing, as women are still having their periods and may lack awareness of hormonal changes. Perimenopause impacts a woman’s health, and can affect personal relationships and work performance.

How does perimenopause impact fertility, and what options are available for women who may want to conceive during this phase? 

We encourage women to start a family earlier than later as there are risks associated with advanced age pregnancies. 

Hormonal fluctuations which occur during perimenopause can affect fertility. Issues can include irregular menses which can lead to challenges in predicting the ovulation period; women who are conceiving at an advanced age may also have decreased egg quality or ovarian reserve and face pregnancy complications including miscarriage.

There are options available for women who still wish to conceive during this phase, and they should see a fertility specialist to discuss further. Some options include fertility medications, intrauterine insemination, in-vitro fertilisation, egg freezing, etc.

What might seeking treatment look like?

We encourage women to not “bear with it”. Take charge! Perimenopausal women with bothersome symptoms should talk to their primary care doctor. If symptoms affect quality of life, or if they undergo unusually early menopause (before 45 years old), they may be referred to a tertiary centre like KK Menopause Centre.

Generally, we look at menstrual history, reproductive history and family history, as well as any other medical illnesses to identify risks.

We evaluate patients’ physical symptoms and emotional health, ruling out situations that may mimic menopause symptoms, including thyroid imbalances or consuming certain medications. A full physical examination, as well as investigations like mammograms, scans and blood tests, may
be ordered.

Lifestyle interventions – nutrition, exercise, stress management, sleep optimisation, and avoiding substance use (cigarettes or alcohol etc) – form the foundation of treatment. Treatment may also include menopause hormone therapy (MHT) or non-hormonal medications to control symptoms.

I’ve never heard of MHT – what is this treatment, and is it available in Singapore?

The underlying cause of menopause symptoms is a decrease or lack of female hormones – replacing
these hormones improves the symptoms. MHT is the most effective treatment for typical symptoms like hot flushes and night sweats. Widely used since the 1980s, MHT is available in Singapore in the form of oral tablets, gels and patches.

However, a local qualitative study co-authored with KK Women’s and Children’s Hospital showed that only 5 per cent of menopausal and perimenopausal women sought MHT, despite its efficacy.

Data from another 17-year-period study showed that five-year use of MHT in women in their 50s had several benefits: reducing heart disease, fractures and all-cause mortality, including cancer mortality. While starting MHT if you are over 60 is not recommended, MHT has been shown to be safe and effective for most women under the age of 60 who are not at risk of breast cancer or blood clots.

In your experience, what are some misconceptions or common questions that women have about perimenopause?

Misconception: There is no point in seeing a doctor since perimenopause is a natural ‘old person’s condition’. You just have to bear with it and the symptoms will get better eventually.

Fact: Perimenopause can begin in the late-30s, and the age at which it starts will differ in individuals. It does not occur in women only in their late 40s or 50s.

The hormonal changes that a woman undergoes in the perimenopause transition can result in physical and emotional changes, as well as symptoms. These symptoms can be confusing and challenging for a woman but the good news is that they are treatable with understanding of what is happening as well as lifestyle optimisation. Some women may benefit from medication.

We hope to create awareness that it is very normal for health changes to occur during the perimenopause transition and help is available to manage these symptoms better. There is growing evidence that an optimal management of menopause will greatly contribute to healthier ageing and a better quality of life.

Currently, 70 percent of women did not seek treatment for perimenopausal symptoms, as per the above-mentioned KKH-co-authored study.

Women should not ‘bear with it and hope for the best’. Instead, take charge! If they have perimenopausal or menopausal symptoms that affect their lives, step forward to seek medical help.

Misconception: Perimenopause or menopause only affect the reproductive system.

Fact: Perimenopause and menopause are natural biological processes that every woman goes through, and every woman’s experience is unique. Few women seek support for perimenopause and menopause, convinced that these are phases they have to bear with. For the few who do, they traditionally turn to a gynaecologist. This alone may not be sufficient.

Growing evidence shows that hormonal changes during perimenopause or menopause can affect a woman from head to toe, from her skin, brain, teeth, heart, bones, to her muscles and emotions—not just her reproductive system.

The transition may leave them feeling vulnerable and uncertain. Hence in October 2023, KKH enhanced and expanded our Menopause Service (started in the 1990s) and launched the KK Menopause Centre. The Centre adopts a multi-specialty approach – combining specialties in gynaecology, family medicine, dermatology and mental health, alongside group support, coupled with early assessment, detection, and intervention of age-related disorders, to enable all women to age gracefully and healthily.

The Centre also aligns with the national goal of a HealthierSG, by getting more women to be aware of their symptoms and to seek help earlier. Optimal management of a woman’s health in midlife will enable her to have better health as she ages.

The stories of Ms A and Mrs B are telling: even for women who face severe symptoms, receiving proper treatment can heighten their quality of life.

Ms A received mental health counselling and the counsellor advised a medical assessment. She was evaluated and she understood that she was undergoing perimenopause. She started making lifestyle changes and was also treated with a course of MHT. Her symptoms improved and she was able to function better. She is currently giving private tuition.

Mrs B’s sister brought her for a medical consultation and she was able to have an understanding of what was happening to her. Her symptoms improved with MHT and she is undergoing family counselling to improve her relationships.

The first step to addressing these symptoms is to be aware of what might be happening to you, and seek medical help, as these women have done.

Associate Professor Rukshini Puvanendran is the co-director of KK Menopause Centre, and head and senior consultant for Family Medicine Service at KK Women’s and Children’s Hospital. Her clinical interests are in Midlife Women’s Health, including Menopause and Osteoporosis. For more information on KK Menopause Centre, please visit their website.