Alcohol and illegal drugs such as marijuana and cocaine can contribute to problems of initiating and maintaining sleep. Many other drugs used to treat a variety of medical conditions also possess the undesirable side effect of disturbed sleep. Barbiturates and other hypnotic drugs, for example, may produce sleep disruptions not only while they are being used but during the period of withdrawal as well. Some benzodiazepines have a short half-life (the period in which half the drug is metabolized), in some cases as little as four hours. This is desirable when control must be exercised over how long the drug acts in the body; the downside is that once the drug begins to wear off, sleeplessness may return. This phenomenon is called rebound insomnia. Interrupted sleep is also associated with the use of or withdrawal from those agents used in cancer chemotherapy and thyroid preparations, opiates, and anticonvulsive drugs.

Often a patient is reluctant to tell me about the use of controlled substances, especially the illegal ones or stimulants such as amphetamines. If I suspect that is the case, I will order blood or urine analysis tests. In extreme cases the use of EEG tracings can indicate the presence of drugs. My interest in ordering such tests is not to catch a patient in the act but to obtain as complete a medical profile as possible, so that I can understand the true nature of the problem and deal with it in the most appropriate fashion.

*119\226\8*

The average age of the menopause in the UK is fifty-one. But perfectly normal women may have a much earlier menopause, with their periods stopping before the age of forty-five, while others find they carry on menstruating till their mid fifties.

A premature menopause, one that happens before the age of forty, can be caused by a number of factors. It can happen spontaneously when the supply of egg cells in the ovaries becomes exhausted. It can also be induced artificially by radiation or removal of the ovaries. If you are advised to have a hysterectomy, find out whether your ovaries are also going to be removed. If they are, ask why. Some doctors may tell you it is done as prevention against ovarian cancer. The thinking is that if you don’t have your womb, you won’t need your ovaries. But beware. If your ovaries are removed, you will go into a surgical menopause and this can be traumatic for you and your body. As it is a sudden event, the female hormone supply from the ovaries will be cut off overnight, whereas going through a natural menopause (even without a womb) can take anywhere from fifteen to twenty years as the hormone levels gradually decline. Nature takes things gradually so that your body can adjust to the changes at its own pace and then the menopause can be just a smooth change in your life. If you are not of menopausal age and you have your ovaries removed, this is one of the situations when HRT may be necessary.

The timing of the average menopause is linked to a number of factors:

- The timing of your mother’s menopause is a good indication of your own. But even if you know she had a difficult menopause, there is no reason to fear that you will suffer in the same way. You will see later that there are plenty of things you can do to improve your own health.

- Smokers will tend to have an earlier menopause by about two years. It seems smoking has an effect on the secretion of oestrogens from the ovaries, causing a decrease in these hormone levels. This can also be seen in infertile women of childbearing age who are smokers. Their hormone patterns begin to mimic those of a menopausal woman.

- Women who suffer from PMS tend to have a later menopause by about a year.

- A hysterectomy, without the removal of the ovaries, can accelerate the onset of the menopause by about five years.

- Women who have fibroids may experience a later menopause because they have higher levels of oestrogen.

- Women who weigh more than 63.5kg (10 stone) can have a later menopause because of the oestrogen manufactured in the fat cells.

- Poor nutrition can bring on an earlier menopause.

- Women who have not had children tend to have an earlier menopause.

It would seem more beneficial to have a later menopause because of the protective effects of the female hormones for bone health. But a woman who is still menstruating around the age of fifty-five should have a check-up in case there is a medical reason for the continuing periods, such as fibroids.

*3/101/5*