Menopause literally means the “End of Monthly Cycles”

DEFINATION

Menopause is more accurately defined as the permanent cessation of the primary functions of the ovaries that is the ripening and release of ova and the release of hormones that cause both the creation of the uterine lining, and the subsequent shedding of the uterine lining (a.k.a. the menses or the period).
This transition from a potentially reproductive to a non-reproductive state is the result of a reduction in female hormonal production by the ovaries this transition is normally not sudden or abrupt, tends to occur over a period of years, and is a consequence of biological aging. Occurs in women in midlife, during their late 40s or early 50s, and it signals the end of the fertile phase of a woman’s life. Menopause has a wide starting range, but can usually be expected in the age range of 42–58.
Menopause can be officially declared (in an adult woman who is not pregnant, is not lactating, and who has an intact uterus) when there has been amenorrhea (absence of any menstruation) for one complete year.

Premature menopause

In rare cases, a woman’s ovaries stop working at a very early age, ranging anywhere from the age of puberty to age 40, and this is known as premature ovarian failure (POF).
Spontaneous premature ovarian failure affects 1% of women by age 40, and 0.1% of women by age 30. POF is not considered to be due to the normal effects of aging.
Known causes of premature ovarian failure include autoimmune disorders, thyroid disease, mellitus, chemotherapy, being a carrier of the fragile X syndrome gene, and radiotherapy. However, in the majority of spontaneous cases of premature ovarian failure, the cause is unknown, i.e. it is generally idiopathic POF is diagnosed or confirmed by high blood levels of follicle stimulating hormone (FSH) and luteinizing hormone (LH) on at least 3 occasions at least 4 weeks apart.

What are the symptoms of menopause and peri-menopause?

Technically, the menopause is confirmed when a woman has not had a menstrual period for one year. However, the symptoms and signs of menopause generally appear well before that one-year period is over. They may include:

Irregular Periods

This is usually the first symptom; menstrual pattern changes. Some women may experience a period every two to three weeks, while others will not have one for months at a time.

Lower Fertility

During the peri-menopausal stage of a woman’s life, her estrogen levels will drop significantly, lowering her chances of becoming pregnant.

Vaginal Dryness

This may be accompanied by itching and or discomfort. It tends to happen during the peri-menopause. Some women may experience dyspareunia (pain during sex). The term vaginal atrophy refers to an inflammation of the vagina as a result of the thinning and shrinking of the tissues, as well as decreased lubrication, caused by a lack of estrogen. The majority of post-menopausal women are uncomfortable talking about vaginal dryness and pain and are reluctant to seek medical help.

Hot Flashes

A sudden feeling of heat in the upper body. It may start in the face, neck or chest, and then spreads upwards or downwards (depending on where it started). The skin on the face, neck or chest may redden and become patchy, and the woman typically starts to sweat. The heart rate may suddenly increase (tachycardia), or it may become irregular or stronger than usual (palpitations). Hot flashes generally occur during the first year after a woman’s final period.

Night Sweats

If the hot flashes happen in bed they are called night sweats. Most women say their hot flashes do not last more than a few minutes.

Disturbed Sleep

Sleeping problems are generally caused by night sweats, but not always. Sleep disturbance may be caused by insomnia or anxiety. Difficulty falling asleep and staying asleep increase as women go through menopause.

Urinary Problems

Women tend to be more susceptible urinary tract infections, such as cystitis. Having to urinate may also occur more frequently.

Moodiness

This often goes hand-in-hand with sleep disturbance. Experts say that most mood disturbances are triggered by poor sleep.

Problems Focusing & Learning

Some women may also have short-term memory problems, as well as finding it hard to concentrate on something for long. Some women may not be able to learn as well shortly before menopause compared to other stages in life.

  • More fat building up in the abdomen.
  • Hair loss (thinning hair).
  • Loss of breast size

If left untreated, these symptoms will usually taper off gradually over a period of two to five years. However, symptoms can persist for much longer. In some cases, vaginal dryness, itching and discomfort can become chronic, and eventually get worse if left untreated.

What are Complications of menopause?

After the menopause it is common for the following chronic conditions to appear.
Cardiovascular Disease

A drop in estrogen levels often goes hand-in-hand with an increased risk of cardiovascular disease. Heart disease is not exclusively a male problem, it is the main cause of death among both men and women. In order to reduce the risk of developing cardiovascular disease a woman should quit smoking, try to keep her blood pressure within normal levels, do plenty of regular exercise, sleep at least 7 hours each night, and eat a well-balanced healthy diet.

Osteoporosis

A woman may lose bone density rapidly during the first few years after menopause. The lower a person’s bone density gets the higher their risk is of developing osteoporosis. The absolute risk of a second clinical fracture is highest in the five years after any first clinical fracture for post-menopausal women.

Urinary Incontinence

The menopause causes the tissues of the vagina and urethra to lose their elasticity, which can result in frequent, sudden, strong urges to urinate, followed by urge incontinence (involuntary loss of urine). Stress incontinence may also become a problem – urinating involuntarily after coughing, sneezing, laughing, lifting something, or suddenly jerking the body as may happen when we temporarily lose our balance.

Low Libido

This is probably linked to disturbed sleep, depression symptoms, and night sweats, a study found.

Overweight/Obesity

During the menopausal transition women are much more susceptible to weight gain. Experts say women may need to consume about 200 to 400 fewer calories each day just to prevent weight gain – or burn of that number of calories each day with extra exercise. The chances of becoming obese rises significantly after the menopause.

Breast Cancer

Women are at a higher risk of breast cancer after the menopause. Regular exercise after menopause significantly reduces breast cancer risk.

What are the treatment options for menopause or peri-menopause?

Only about 10% of women seek medical advice during the menopause. Many women require no treatment. However, if symptoms are affecting the woman’s daily life she should see her doctor. The kind of treatment the patient should have depends on her symptoms, her medical history, as well as her own preferences. Available treatments include:

HRT (Hormone Replacement Therapy) or HT (Hormone Therapy):

This is very effective for many of the symptoms that occur during the menopause, including vaginal dryness, vaginal itching, vaginal discomfort, urinary problems, bone-density loss, hot flashes and night sweats. HRT tops up the woman’s levels of estrogen. However, as with many treatments, HRT has its risks and benefits:

Benefits of HRT:
  • Effectively treats many troublesome menopausal symptoms.
  • Helps prevent osteoporosis.
  • Lowers colorectal cancer risk (cancer of the colon or rectum)
Risks of HRT:
  • Raises breast cancer risk
  • Raises ovary cancer risk
  • Raises uterine cancer risk (cancer of the womb)
  • Raises coronary heart disease risk
  • Raises stroke risk
  • HRT slightly accelerates loss of brain tissue in areas important for thinking and memory among women aged 65 and over.

“Not all women need HT, but many with troublesome symptoms were needlessly scared away from that option due to misunderstandings about the actual risks associated with it.”
Older women who take hormone therapy to relieve menopausal symptoms may get the added benefit of reduced body fat if they are physically active, a study revealed.
Hormone therapy in early menopause? – estrogen-progesterone hormone replacement therapy, if initiated soon after the menopause, not only improves symptoms considerably, but also improves some cardiovascular risk factors and mood.

  • Low-dose antidepressants – SSRIs (selective serotonin reuptake inhibitors) have been shown to decrease menopausal hot flashes. Drugs include venlafaxine (Effexor), fluoxetine (Prozac, Sarafem), paroxetine (Paxil, others), citalopram (Celexa) and sertraline (Zoloft).
  • Omega 3s – Researchers from the Universite Laval’s Faculty of Medicine found that Omega-3s ease psychological distress and depressive symptoms often suffered by menopausal and peri-menopausal women.
  • Gabapentin (Neurontin) – This medication is effective in treating hot flashes. It is commonly used for treating seizures (epilepsy).
  • Clonidine (Catapres) – Can be taken either orally as a pill or placed on the skin as a patch. It is effective in treating hot flashes. The drug is commonly used for treating high blood pressure (hypertension). However, unpleasant side-effects are common.
  • Osteoporosis Treatments :
  • Vaginal estrogen – may be applied locally using a tablet, ring or cream. This medication effectively treats vaginal dryness, discomfort during intercourse, as well as some urinary problems. A small amount of estrogen is released and absorbed by the vaginal tissue.
  • Soybeans – soy aglycons of isoflavone (SAI).
  • Exercise – a study found that slow exercise is better for post-menopausal women than fast exercise.

What is Post Menopausal Bleeding [PMB]?

Postmenopausal bleeding is defined as vaginal bleeding occurring over 12 months after periods have stopped in a woman of the age where the menopause can be expected. Hence it does not apply to a young woman who has had amenorrhoea from anorexia nervosa or a pregnancy followed by lactation. It can apply to younger women following premature ovarian failure or premature menopause.
It is common and represents 5% of all gynaecology OPD attendances.

Risk factors:

It is likely to occur if exogenous oestrogens are taken. Polycystic ovary disease increases risk. Use of combined oral contraceptives decreases risk.

Causes:
  • Non-gynaecological causes including trauma or a bleeding disorder.
  • Use of hormone replacement therapy.
  • Vaginal atrophy.
  • Endometrial hyperplasia – simple, complex, and typical.
  • Endometrial carcinoma usually presents as PMB but 25% occur in premenopausal women.
  • Endometrial polyps or cervical polyps.
  • Cancer of cervix (is cervical smear up to date?)
  • Ovarian cancer, especially oestrogen-secreting (theca cell) ovarian tumours.
  • Vaginal cancer is very uncommon. Cancer of vulva may bleed but the lesion should be obvious.
Management:

History and examination may possibly indicate cause but the dictum is that postmenopausal bleeding should be treated as malignant [cancer] until proved otherwise. This requires urgent evaluation by a qualified gynaecologist.

Investigation:
  • A transvaginal scan is used to measure endometrial thickness and 4mm is used as the cut-off point.
  • Hysteroscopy may be performed as this gives a view of the inside of the uterus.
  • D&C is performed along with the hysteroscopy or a hysteroscopic guided biopsy is taken.
Outcome:
  • Where pathology is found it needs to be treated and prognosis will depend upon the condition and, if malignant, the stage.
  • After an initial hysteroscopy and biopsy have excluded uterine pathology there is no need to repeat the procedure unless there are very strong grounds for suspecting an occult cancer. If transvaginal ultrasound measured endometrial thickness of less than 5 mm it provides additional reassurance that there is no sinister underlying pathology.
  • Most women who have negative investigations will have no further problems and failure to make a diagnosis is not uncommon.

Important points to keep in mind:

  • Most women with PMB will not have significant pathology but the dictum remains that postmenopausal bleeding is cancer until proved otherwise.
  • PMB in women on HRT still needs investigation.
  • An obvious lesion like atrophic vaginitis does not exclude another lesion.
  • Many women are unable to distinguish between vaginal and urinary bleeding and some are unable to distinguish rectal bleeding. This may need investigating.

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