Menopause

15th October 2021


Descriptive Terms | Diagnosis | symptoms | Long Term Effects | Effects of Menopause by the Time of Onset | Management | Non-Physiological Menopause

Overview

Menopause is the permanent cessation of menstruation at the end of the fertility period that results from the loss of regular ovarian function. It usually occurs around the age of 50. 95% of women attain menopause between the age of 45-55 years.

After forty years, ovulation becomes irregular and infrequent, and anovulatory cycles are common. The ovarian response to gonadotropins is reduced and finally ceases. FSH and LH level increases due to the lack of inhibitory effect of estrogen. Most women notice irregular scanty periods though in some sudden amenorrhea or menorrhagia occurs. Eventually, the menopausal pattern of low estrogen levels with grossly elevated LH and FSH (usually > 50 and >25 U/L respectively) are established.

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Descriptive Terms for Menopause

  • Menopause: Menopause is confirmed if there are no menses for one year.
  • Postmenopause: postmenopausal period starts after menopause.
  • Perimenopause : (Menopausal transition) Time period from the onset of ovarian dysfunction until 1 year after the last period till diagnosis of menopause is made. This time period is also known as climacteric. Usually, occurs 2-8 years (Average 4 years) before menopause. (Can be up to 14 years). It is the most symptomatic phase as hormones are fluctuating. Before the last period variability of the cycle usually is increased. The persistent differences in consecutive cycles of  7 or more days define the early menopausal transition. Skipping 2 or more cycles defines late menopausal transition.

Diagnosis

Diagnosis is clinical according to symptoms and menstrual irregularities and amenorrhea. Menopause is confirmed if there are no menses for one year and the age is appropriate. The hormonal test is of little value due to their variations, which frequently occur in association with episodic and irregular ovulatory cycles during perimenopausal years. FSH level may be measured but this test is rarely necessary except perhaps in women who have had a hysterectomy or women who are younger than the usual age of menopause. Consistently elevated levels confirm the diagnosis. The possibility of pregnancy should also be considered.

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Menopausal Symptoms

Menopause is a normal healthy phase in a women’s s Life, but each woman has a unique experience. In the majority of women, menopause occur without any symptoms. Few may seek medical advice. Everyone does not develop all the symptoms. Menopausal symptoms are also called climacteric symptoms. Symptoms can last from 6 months to more than 10 years and range from none to severe. 60 % of women may have mild to moderate symptoms, 20 % of women have no symptoms and 20% may have so severe symptoms that they significantly interfere with daily life.

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Symptoms may include:

  • Hot flashes or night sweats
  • Menstrual irregularities
  • Mood disturbances
  • Gastrointestinal symptoms
  • General symptoms
  • Physical changes

Hot Flashes and Night Sweats

Hot flashes or hot flushes are one of the earliest symptoms that occurs during the perimenopausal period. Hot flashes occur due to vasomotor instability in 75-80 % of women during menopause. They tend to resolve spontaneously within 5 years of menopause. At night they are termed night sweats. Periodic attacks of hot flashes occur on the face and neck and sometimes all over the body. They have been described as burning, overheating sensation with reddening of the skin and different degrees of sweating. Core temperature increases. The episodic flash may last from 30 seconds to 5 minutes. Some have a fast heartbeat up to 200 beats per minute during a flash. There may be a feeling of dizziness, nausea, and feeling of being unwell. An episode of hot flashes usually occur 3-5 time per day but they can occur frequently up to 20 times per day.

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Menstrual Irregularities

Menstrual disturbance occurs in 90% of women, and in 10 % menses cease abruptly. Menstrual cycles gradually become increasingly anovulatory and variable in length often shortening from about 4 years before menopause.

Mood Disturbances

Mood disturbances occur in 25-50 % of women such as anxiety and depression, mood swings, irritability, tiredness, lack of energy, forgetfulness, and loss of concentration. Some of these symptoms may be attributed to hormonal changes but there can be external influences such as relationships, financial issues, previous history of depression, etc.

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Physical Changes

All the physical changes are due to the withdrawal of estrogens. However, few may be part of the aging process. Estrogen deficiency causes atrophy of genital organs and secondary sexual characteristics. Skin becomes coarse and thick. Hairs appear on the chin and upper lip. Atrophy of muscles and decreased bone density is attributed due to a lack of estrogens.

General Symptoms

There can be a lack of sleep, weakness, headache and migraine, vertigo, joint aches and pains, breast tenderness, or skin pigmentations.

Gastrointestinal Symptoms

The causes may be due to associated disease or changes due to age. There may be an increase or decrease in appetite, tooth loss, weight gain, bloating, indigestion or constipation.

Long-Term Effects of Menopause

Cardiovascular Disease

High blood pressure of hypertensive women often becomes manifest at the menopausal age. This is just a coincidence, Direct correlation has not been confirmed. Occasionally patients may feel palpitations ( racing heartbeat). The level of low-density lipoprotein cholesterol (LDL) increases. Estrogen has significant plasma cholesterol-lowering action. Estrogen has a supportive effect on the vessel wall that favors vasodilation and prevents atherogenesis. The change in LDL level may partly explain why atherosclerosis and coronary artery disease become more common among women after menopause. Cardiovascular disease is the most common cause of death in women over 60.

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Bone Density

Bone density normally increases, reaching a peak between 20 and 30 years of age. After this, there is a steady decline until menopause, then an accelerated phase of bone loss until 60 years followed by a further steady decline. Estrogen inhibits bone resorption. Up to 20 % of bone density loss occurs in the first five years after menopause. After the age of 60 in women the likelihood of osteoporotic fractures of the hip and spine increases.

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Urogenital Atrophy

Estrogen and progesterone receptors are present in the urogenital tract and pelvic floor musculature. Estrogen deficiency causes atrophic changes within the urogenital tract and pelvic musculature resulting in urinary problems and urogenital prolapse in some cases. Urinary symptoms occur in 50 % of women, such as frequency, urgency, nocturia, incontinence, and recurrent infections.

Cognitive Function

At present, there is no clear evidence that menopause is associated with an acceleration of the onset or incidence of dementia. Most women, complain of some changes in memory and cognitive function. These changes can partly be explained by the impact of vasomotor symptoms and other symptoms on the pattern of sleep.

Effects of Menopause by the Time of Onset

Immediate (0-5 years)

Hot flashes, mood changes, joint aches and pain, dry and itchy skin, and hair changes.

Intermediate (3-10 years)

Vaginal dryness, soreness, Dyspareunia, the urgency of urine, recurrent urinary tract infections, and urogenital prolapse.

Long-term ( > 10 years)

Osteoporosis, cardiovascular diseases. Dementia.

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Management

Long-term problems can be prevented by diet and lifestyle changes. Treatment is symptomatic. It includes:

  • Lifestyle modification
  • Complementary and alternative medicine
  • Hormonal therapy
  • Non-hormonal treatment

Diet and Lifestyle Modification

Menopause is a key time in the life of a woman. The physiological changes that occur have a significant effect on the woman affecting numerous body systems. Women should keep themselves physically active by regular exercise, should avoid smoking, and decrease alcohol intake. Decrease weight if obese. To avoid osteoporosis and to improve general health calcium, Iron vitamins and a high protein diet should be taken.

Hormonal Therapy

Hormonal replacement therapy (HRT ) has been the mainstay of the treatment of menopausal symptoms for decades. It has rejuvenating abilities, in addition to long-term advantages for the prevention of cardiac disease and bone problems. The newer studies have either significantly reduced or removed the risks initially described in the past. HT includes Estrogens, progestogens, or testosterone hormones. Hormonal therapy improves the quality of life in symptomatic patients. Therapy is individualized depending on age and severity of symptoms balancing the benefits and health risks. For perimenopausal women with irregular or heavy menses and other symptoms, low-dose oral contraceptives are advised. As there is still some chance of getting pregnant. Non-steroidal anti-inflammatory medications can reduce bleeding if taken for 2-3 days. Increased menstrual blood flow should be investigated to rule out other uterine disorders.

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HT is advised for post-menopausal women. Doses of estrogen and progesterone in HT are lower than that in oral contraceptives so they do not prevent pregnancy. For women aged less than 60 or less than 10 years past menopause, the benefits outweigh the risks. For women aged more than 60 or more than 10-20 years past menopause, risks are more than benefits. HT should be taken in the lowest dose possible for a duration of fewer than 5 years depending on the symptoms with constant evaluation and health monitoring.

Non-Hormonal Therapy

Most of the symptoms improve with reassurance, sedative, or tranquilizers. Few women need hormonal therapy. If hormones are not wanted or contraindicated then other alternative treatments can be used. Antidepressants ( such as Venlafaxine, Gabapentin, Fluoxetine, and Paroxetine are moderately effective for hot flashes. For genitourinary symptoms, the efficacy of vaginal estrogen is similar to that of an oral or transdermal patch. For bone health, there are medicines that can prevent osteoporosis. 

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Complementary and Alternative Medicine

Complementary and Alternative Medicine (CAM) includes practices and products that can be used to alleviate menopausal symptoms. Herbal supplements like black cohosh, soy product, red clover, evening primrose oil, Dong Quai, Gingseng, kava, and phytoestrogens are claimed to have some benefits. Researchers keep studying the safety and effectiveness of CAM treatment. These herbal products may have weak estrogenic activity. Many women find them useful. Precautions should be taken while using them as they are not closely regulated as prescription drugs.

Mind and body therapies are helpful such as yoga, Hypnosis, magnet therapy, paced breathing (slow and fast breathing) relaxation techniques, Acupuncture, and reflexology are claimed to have some benefits.

Non-Physiological Menopause

Premature Ovarian Insufficiency

Premature Ovarian failure or Insufficiency (POI) is the cessation of menses (premature menopause) due to primary or secondary ovarian failure before the age of 40. Causes may be genetic or autoimmune. 1 % of women before 40 and 0.1% under 30 suffer from POI. It is a distressing diagnosis especially if it occurs prior to the completion of the family.

POI is usually permanent and progressive but can run a remitting course. Spontaneous ovarian activity can occur resulting in irregular periods and a small chance of pregnancy.

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Causes of POI are:

Primary causes

  • Chromosomal anomalies (5-10%) like Turner’s syndrome, fragile X premutation, and others
  • Autoimmune diseases (20%) (Hypothyroidism, Addison’s Disease, Mysthenia grevis, Type 1 diabetes mellitus, Systemic Lupus Erythemtosis)
  • Enzyme deficiencies: 17 alpha-hydroxylase deficiency, Galactosemia
  • Idiopathic:  ? environmental toxins

Secondary causes

  • Chemotherapy or Radiotherapy
  • Infections: e. g. Tuberculosis, Mumps, CMV, Varicella, Malaria
  • Pelvic surgery

Diagnosis of Premature Ovarian Insufficiency

POI is usually diagnosed following either primary or secondary amenorrhea. No cause was found in most cases.

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  • FSH level of more than 30 IU/L
  • Serum estradiol levels are usually low
  • Karyotyping
  • Screenings for autoimmune diseases
  • Thyroid function tests (T4 and TSH) as abnormalities of thyroid function can be confused with menopausal symptoms.
  • Pelvic ultrasound

There is an increased risk of osteoporosis and cardiovascular disease in women with POI. Estrogen replacement therapy is given till the average age of menopause 52 years. The co-existing disease may be detected and treated. Assisted conception is provided if needed or contraceptives are given if pregnancy is not required.

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