MENOPAUSE AND SYMPTOMS OF MENOPAUSE

Menopause is a natural biological process. Every woman living on earth goes through it about the age of 45-55, the average being 51. When a woman stops having periods for at least 12 months it is called menopause. The period before this time also shows changes in our menstrual patterns being irregular in timing and amount, this is called Peri Menopause or Menopause Transitionor or Climactric a Greek word meaning 7.  This can often last for 6-7 years or some women may skip this phase. The menopause happens because our ovaries stop to function.  They no longer have any eggs left over to mature, we are born with a set number of eggs, when they finish, and that is it. Sometimes they finish when a woman is still very young say 30, then it is called premature ovarian failure or insufficiency or even premature menopause. Besides this natural menopause, it can be surgical, if a woman has a hysterectomy then no more periods. If the ovaries are removed at the same time the menopausal symptoms can be intense as they are sudden. Radiotherapy and chemotherapy can also cause menopause because of its effects on the ovaries.

Menopause is not a disease or a syndrome but once we are caught into it we are there forever. It is amazing how many women suffer from the effects of menopause in different phases of their lives, there is no coming back ,no artificial lens that can be implanted; like in your eye. Although some new research is being started in this area. The number of menopausal women is expanding exponentially. In 1990 there were 467 million (M) women worldwide, 47M new entrants each year, it is estimated  that by 2030 there will be 1.2 billion postmenopausal women. Although menopause is not a disease as already mentioned, it can cause innumerable problems in most women. Imagine the health cost to women herself and international health systems.

As mentioned the symptoms of menopause start long before true menopause sets in women start having irregular menstrual cycles, heavy periods or too little bleeding. Other causes of abnormal uterine bleeding such as fibroid cancer, pregnancy problems have to be ruled out.

Different women respond to menopause in different ways about 20% women do not suffer at all why we do not know?

Hot flush or flash is the main bother some symptom, along with anxiety lack of sleep, dizziness, fatigue, mood swings, weakness, and heart palpitations. Hypothalamus is a key nerve centre in the brain secretes, FSH LH under feedback from oestrogens, it controls the body functions, such as body temperature, metabolism, sleep, mood and stress response. Reduced ovarian function leads to impending peri menopause and menopause leads to decreasing oestrogen levels, irritates the neuroreceptors and hypothalamus. It goes into overdrive and secrets more FSH and LH hormones; this in turn sends signals to the blood vessels of the skin to dilate.  The increased blood flow through the skin raises the local temperature and woman get a hot flush/flash. It starts at the chest and spreads over the face, head and neck, and gives a feeling of hot a flush or flash, not only that the face appears flushed. The body temperature drops by a few degrees. There is a feeling of chill. The bodies stress response takes over. The adrenal gland relieves, adrenalin which constricts the blood vessels, hot flush/flash goes away. Hot flush and night sweats are an integral part of menopause and peri menopause. Often when hot flush  occurs during the night cold sweats occur following this, one may not notice the hot flush in your sleep, as much as you notice ,drenching cold sweats .However they are the part of the same activity. Hot flushes vary in different women.  They can undermine a woman’s confidence and if you are in a position of power and start happening at an in appropriate moment it can be very embarrassing. Fatigue can be a part of hot flashes, lack of sleep. Mood swings also happen, irritability starts as the ovaries fail there is irregular ovulation as a result women have irregular periods and can be very heavy, or very light. During this time the risk of pregnancy is still there, so take adequate care. I have discussed this in my previous blog. Menstrual cycles frequent become infrequent and then stop. If a woman has had no period for 12 months she is menopausal. During this time other causes of abnormal bleeding should be excluded such as, fibroids, polyps, cancer, and bleeding disorders.

Muscle and Joint Aches and Pains

With the decrease of oestrogen muscles and ligaments which connect our joints, lose their elasticity and strength as a result we start getting aches and pains. At the same time many of us start getting arthritis and may be osteoporosis (This is also a result of Menopause) all this together makes life painful and limiting. A lack of oestrogen, physical activity, obesity, can aggravate these symptoms.

Formication

Meaning a feeling of insects crawling under your skin is another strange feeling many menopausal women get. This is due to the changes in the blood vessels. Other symptoms women feel are tingling in the ears, dizziness, painful cramps in the legs and a bloated feeling. As at menopause there is more testosterone as compared to oestrogens, some women get acne, and mild hairiness. Elasticity of the skin decreases, the skin gets wrinkles and dryness. Some women get a male type of baldness.

As menopausal years progress, the symptoms of a dry vagina, frequency of urination and urinary incontinence increases; so are the psychosexual problems. This group of problems are now given a specific name of genitourinary syndrome. This is due to lack of oestrogens, the vagina losing its elasticity, and gets repeated infections. These can partly be due to lack of testosterone as well.  Emotional disturbances at this time are also common. This could be due to lack of oestrogens, as at other times of lacking oestrogen, women suffer these symptoms such as post partum and premenstrual. These feelings can also be due to stresses of life such as problems with children, parents, personal stress due to work, partner’s problems, divorce and separation. These are common and happen in almost 50 % of the population. Loss of self confidence, changing body shape, weight gain, and wrinkles worry many women; particularly women in upper socioeconomic groups. Loss of memory, forgetfulness also often happens; oestrogen alone cannot be blamed for this as this happens to men as well. Three main long term effects of menopause are increased risk of heart disease, osteoporosis and genitourinary syndrome.

In summary, menopause is not a transitory phase in your life; as it happens due to lack of oestrogen which continues forever. You cannot ever have a baby unless there is some freak anomaly. Menopausal symptoms are many and varied. The most important are hot flushes / flashes, dry vagina causing genitourinary syndrome, psychosexual, some alteration in brain activity e.g: forgetfulness, depression.  There is no conclusive evidence that oestrogen deficiency causes these symptoms, although many women claim that HRT helps them. The health of a woman’s skin, heart and bones, is related to her oestrogen levels and any other associated health problems. These menopausal like symptoms can occur for many other reasons. They should be excluded before HRT is started. The symptom of menopause is not a universal experience for all women. I will discuss the management of these problems in my next blog.

CONTRACEPTION AFTER FORTY

In the current world culture, there are many of us who are desperate to have a baby at a perimenopausal age. So far they have been studying and trying to make a career and suddenly they realize that the time is running out to have a baby as the biological clock is closing down. On the other hand many of us want to know how to stop having a baby as this will become a serious handicap with everything else happening. Perimenopause is a difficult time for women, as they have many peri menopausal symptoms such as irregular heavy menstrual cycles, hot flushes, tiredness and other menopausal symptoms. It is hard to keep a track of pregnancy risk time. This also called CLIMACTERIC can last up to 6-7 years. It is difficult to use natural methods of contraception as the menstrual cycles become irregular .Age does not preclude any contraceptive methods The choice depends on your , medical history(heavy periods fibroids and endometriosis)your weight, life style for e.g, if  you are a smoker or not .How active is your sex life. In a normal healthy woman, non-smoker, no blood pressure, no history of stroke, DVT personally or in the family, oral contraceptive pill is safe, it can be better if it has lower oestrogen levels. It also helps with your menopausal symptoms such as hot flashes night sweats, dry vagina , painful sex. If you are post menopaual and you are under 50, stop your pill  2 years after your last menstrual period, if you are over 50 then stop after one year of your last menstrual period. If you are taking O.C pill, your periods are generally bleeding following the use of the pill. If you do not know if you are menopausal to establish this, stop the pill for 2 months and test the Follicular stimulating hormone twice. During this time use condoms or abstain. If it comes high then you are post menopausal and do not need contraception. It is extremely rare to have a pregnancy after menopause, not that it never happens. I have delivered three post menopausal women in my career. Luckily the baby’s were normal and with uncomplicated pregnancies .The combined oral contraceptive pill (COC) is also very useful if a woman has heavy, painful and irregular periods. If they skip the sugar tablets, have a period ever 2-3 months, this may even prevent premenstrual tension (PMT).It decreases the risk of functional ovarian cysts, endometrial cancer. It has been shown in some studies that if a woman has been taking COC for more than 12 months she is protected from the risk of pelvic infections to some extent, this is being studied further. The other worry about oral contractive is about the risk of breast cancer, if a woman uses a pill less than20 micrograms of oestrogens, she has no family history of breast cancer, she personally has not had abnormal cells on aspiration, and she does not have abnormal genes for breast cancer, it is was not linked to higher risk of breast cancer. Women  who smoke, have high blood pressure have a BMI of more than 30, have diabetes, history of cardiovascular disease, personally or in the family,  increased waist circumference(limited clinical information on this). Combined vaginal ring is another alternative. It is inserted in the vagina for 3 weeks and removed for one week; some women prefer it, as it is used once a month rather than daily. It has slightly less oestrogen. It will have the same side effects as the COC, breast tenderness headaches (migraine), increased risk of breast cancer. The risk of DVT may be less. It works in the same away as the COC. In some women it can be expelled due to pelvic floor weakness. The clinical research evidence on this is limited.

Progesterone only contraceptives are often used, such as minipill (progesterone only pill), depomedroxyprogesterone acetate (DMPA) injection, progesterone implant (ETONODRYL). These do not benefit from the effects of menopausal symptoms, in addition cause irregular spotting and bleeding, which is already an existing problem in this age group. This is not good for bone health, as these cause amenorrhea, and a year of amenorrhea causes bone loss of 1%. The operation such as tubal ligation by key whole surgery is often performed. This is an operation and inherited risks of operations are all there. All these methods have a failure rate of 1%. Simple method such as condoms, male or female, withdrawal and a diaphragm   are also used. Diaphragm has to be fitted by a clinician and needs changing. If you loose or gain more than 5 kilograms. It is also not suitable if a woman has latex or spermicidal allergy. It is also not suitable for women with pelvic floor weakness. Intrauterine contraceptives are good for this group. There are copper, and hormonal IUCD’s, originally we had some plastic IUCD’s. The copper IUCD is fitted inside the uterus, it can remain there for 5-10 years these sometimes tend to cause heavy, painful periods. The most popular IUCD is hormonal called Mirena. It contains a hormone called levonogestral which is slowly released over 5 years. It is fitted by a clinician inside the uterine cavity initially for 2-3months. It can cause some irregular bleeding for the initial 2-3months they usually have amenorrhea it is effective for 5 years. It is useful for taking oestrogens with it for HRT. It can be left for another year or two for contraception, but if a woman is taking oestrogens as well, it needs to be changed after 5 years. These are not suitable for women who run the risk of STI’s. All women using these contraceptives need to protect themselves from STI’s. There is also emergency contraception with in 5 days of unprotected sex a copper IUCD fitted in, can work and loose the developing foetus or women can use the morning after pill.

For further information on Contraception/IUD’s please refer to my previous post Dated April 25th 2015.