Menopause

Topic Highlights

●    Menopause is a normal part of aging in women wherein a woman's menstrual cycles stop completely, ushering in physiological, psychological and social changes in her life.

●    The condition results primarily from hormonal changes that reduce the number of ovum in the ovary.

●    This presentation helps understand the symptoms and signs of menopause, and its management through home care and professional guidance.

Transcript

Menopause is when a woman's menstrual cycles (periods) stop completely and the ovaries significantly reduce their estrogen production. Women experience their last menstrual period during menopause. This is a normal part of the aging process. It's not an illness or a disease. The average age in which menopause occurs is between 48-55 years. If it occurs before the age of 40, it is considered premature.

Many women experience symptoms due to hormonal changes that occur at menopause such as hot flashes and sweats, particularly at night. Other effects of the fall in hormones at menopause include loss of bone density, weight gain and altered cholesterol profile. Fluctuations in the levels of the ovarian hormone estrogen may begin well before menopause. This may result in a woman's cycles becoming irregular and periods being missed or periods happening more frequently and a lighter or heavier flow. This phase is called the perimenopause. Surgical menopause is when the ovaries are surgically removed. Women who have a hysterectomy without removal of the ovaries do not automatically have menopause as their ovaries may still be functioning. For such women menopause is indicated by symptoms rather than changed bleeding patterns.

Menopause occurs when the ovaries run out of eggs, or ova. At birth, a female infant has around 1-3 million ova in her ovaries; by the time of puberty and her first menstrual period she has about 400,000 ova; approaching menopause she may have less than 10,000 ova. During the reproductive years, follicle stimulating hormone (FSH), which is produced by the pituitary, stimulates the ovaries and one ovum develops and becomes ready for release, in a process called ovulation. As menopause approaches, the ova become resistant to FSH. There is also a reduced production of estrogen and progesterone by the ovaries. The decrease in estrogen production causes many symptoms and signs, as this hormone is important for the functioning of many other organ systems.

Some women just stop menstruating suddenly without any symptoms or signs while others will experience many symptoms in association with the cessation of periods. These are due to the sudden drop in estrogen. Common symptoms include hot flashes, night sweats, trouble in sleeping and tiredness. There may also be some weight gain around this time although it is not ascertained whether this is due to hormonal changes or due to aging.

Hot flashes are the most common symptoms of menopause and may start even before women experience any other changes. A woman will feel increased body heat in a wave-like pattern; skin may blush and feel very warm; sweating may be profuse; there may be dizziness, headache and rapid beating of the heart. Even women who do not have their sleep disturbed by flashes or sweats may report difficulties sleeping. This commonly results in daytime fatigue. Some women experience emotional symptoms during menopause, some of which include sadness, anxiety and depression. These symptoms may be severe in some women and may require professional help.

The tissues of the vagina and vulva (area around the vagina) may thin. The vagina also loses its ability to produce wetness (lubrication) during sexual arousal, which causes pain during sex. The lubrication is then improved by the use of an estrogen cream or water-based lubricant (such as K-Y jelly). Some women experience bladder irritability with a frequent urge to urinate and urinary incontinence (inability to hold urine). There may also be a burning sensation during urination. There is an increased risk of urinary tract infections. Women may notice that their breast become less full. Some women report increased breast size if they gain weight, whereas others experience loss of breast tissue.

There is also a loss of calcium in the bones, which starts during perimenopause. There is no associated pain but it can lead to osteoporosis, a condition where there is high risk of spontaneous fractures. Cholesterol profiles tend to change after menopause, with a rise in total cholesterol and low-density lipoprotein (LDL) cholesterol, which increases the risk of cardiovascular diseases.

Other common symptoms include:

●    Crawling sensations on skin

●    Lessened memory

●    Lessened concentration

●    Muscle/joint pains

●    Overall diminished well being

Many of the signs and symptoms that occur during menopause can be managed by lifestyle and diet changes. It is important to educate women about menopause, the symptoms and signs and what changes can be undertaken to help alleviate these without medications.

The occurrence of hot flashes may be alleviated by the following:

●    The use of black cohosh as an herbal supplement can be effective for women with mild symptoms

●    Regular physical activity

●    Avoiding spicy foods

●    Caffeine and alcohol

●    Dressing in layers

The increased risk of cardiovascular disease can be reduced by intake of a low-fat, low-cholesterol diet and with regular exercise, which will also help reduce weight gain. The occurrence of bone loss and osteoporosis can be reduced by adequate intake of calcium through diet and with calcium supplements. A woman's diet should include milk, yogurt, cheese, sardines, etc. to get a good supply of calcium. Medical professionals should determine the need for and type and dosage of calcium supplements.

Blood tests should only be done to confirm menopause in younger women and women who have had a hysterectomy. Elevated FSH levels indicate menopause. Premature menopause can be confirmed in women younger than 40 after three observed incidences of elevated FSH levels. Vitamin D is very important for maintaining healthy bone. Most of our Vitamin D comes from sunlight and many women have low blood vitamin D levels. Bone density is measured by a test called dual energy X-ray absorptiometry (DEXA) scan. This test involves taking X-rays of the hips and lower spine. If bone density loss is observed, the physician may prescribe medications and retest the patient after two years to test the response to treatment.

Screening tests, in the form of ultrasound scan of the heel, can also be undertaken to check for bone density. If low bone density is detected, it should be followed up by a DEXA. Cholesterol profile, which includes measurement of blood total cholesterol, HDL and LDL cholesterol, and triglycerides, is checked to determine whether the woman is at risk of cardiovascular disease.

After conducting the tests, based on the results and the degree to which a woman is bothered by her symptoms, the physician may prescribe some medications. Some of the medications that the physician may prescribe include:

Hormone replacement therapy (HRT) involves taking medications that contain a combination of estrogen (to alleviate symptoms) and progestin (to protect the uterus), or estrogen alone for women who have had a hysterectomy. HRT is commonly taken as tablets, through skin absorption (by gels and skin patches), as hormonal implants and via a vaginal ring. HRT is prescribed to alleviate symptoms such as hot flashes, sleep disturbances and mood changes. It also helps build up bone mass, and improve the cholesterol profile. But the adverse effects may include an increased risk of breast cancer, and for women taking estrogen in tablet form, a higher risk of gallstones and deep vein thrombosis. For women younger than 60, estrogen appears to have a protective effect against heart disease. It is vital that the physician discusses the pros and cons of HRT for each individual before prescribing.

Tibolone is a synthetic form of HRT which provides a good alternative to conventional estrogen-progestin therapy. Women who simply have vaginal dryness and urinary tract problems can use estrogen as a vaginal pessary or cream. For hot flashes, a drug called clonidine, which is also a medication that helps reduce blood pressure, may sometimes be useful. A number of drugs are now available for the treatment of osteoporosis. These should not be used in individuals with mild bone loss (osteopenia).

Biphosphonates reduce bone loss and fracture risk in women with osteoporosis. But they are poorly absorbed and should be taken on an empty stomach followed by fasting for another 30 minutes. It is also important to note that the person should not lie down immediately after taking the medication as it can irritate the esophagus.

Raloxifene, which is a selective estrogen receptor modulator (SERM), helps reduce bone loss and risk of fracture in women with osteoporosis.

Strontium ranelate is a new therapy for the treatment of osteoporosis.