INTRODUCTION AND PROLOGUE

Having undergone a surgical menopause before I was 35, my interest in menopause was aroused more than ever as persistent headaches were threatening my career as a gynecologist. Advice from my colleagues was not satisfactory. I had many challenges facing me: keeping my home, raising my children, looking after my elderly relatives and continuing the care of my patients.

            Besides the common challenges of life, many of my patients also shared another common link, that of being a migrant in a new land. As we overcame the problem of settling, we needed to enjoy the future years. According to life expectancy statistics, we have on average another thirty years to live after our menopause compared to our grandmothers and great-grandmothers that had only about 15.

            There has been a recent upsurge in interest in women’s health. The controversies surrounding many of the health issues for women may be confusing, weight control, exercise, recreation, sexuality, heart disease, diabetes, menopause and problems of muscular and skeletal systems. These issues affect all women regardless of profession, race, education or socioeconomic status.

            Many health care workers and medical practitioners were not well trained to deal with, or are not aware of, the problems of the growing number of older women who are keen to continue living a challenging and meaningful life. They are often ignored as being old or treated inadequately. Heart disease in elderly women is one such example. This is the highest cause of death in elderly women besides  the complications of osteoporosis. Many women are on antihypertensive and anticholesterol drugs when hormone replacement therapy (HRT) could have prevented the problem in the first place.

It is with these general questions of health for older women in mind that this book is written. It predominantly discusses menopause and menopausal concerns. Complex and confusing issues have been explained as clearly as possible using current scientific knowledge. Though it is not a medical book, Menopause and Beyond contains enough information to help health care professionals advise women with menopausal problems.

Several personal stories from my own medical practice have been used to illustrate various situations that women are likely to face. Pseudonyms have been used to protect the patients’ privacy. I thank these women for the contribution they have made to this book.

            The aim is to inform women and their partners about menopause and other health concerns of middle years. I hope that the information you find in the book helps you to make more informed choices about how you live through menopause and beyond.  

PROLOGUE  

This book was first published nearly twenty years ago, since then, Menopause has become a buzz word, this in part is due to the internet, menopausal women in the work force and articles associated with today’s media on women’s health, not only that but there are plays and even a musical on menopause. This is possibly due to the enormous increase in the number of menopausal and post menopausal women in the world, and in the USA alone 1million women join the menopausal club each year.

I often wonder along with other scientific people is it a disease or just a phase in a woman's life. A woman's sex gland the “Ovaries”, which you may have read, is quite magical, and it changes the phases of our lives. We are like little girls, then as we grow we become pubertal, menstruation starts, we become fertile and a few years later fertility is taken away from us and even the periods disappear, and then we are called menopausal. The time before the period stops has varying activity in our body and it is called pre, peri, post menopausal. It generally takes up to seven years for us to stop the periods completely. In the past this referred to Climacteric (A Greek word meaning seven).

It is called menopause when we have no periods for twelve months after the last period.

Each woman’s experience is unique in their own way during this time, hence the diagnosis is difficult to make.

Menopause has suddenly become like an epidemic, but this is probably due to our increased life expectancy and our desire to be healthy and happy during our menopausal years.

In 1900 the average life expectancy of a woman was 50 years, which is a very short life span after menopause,  Aristotle estimated the age of menopause was 40 years, so we had hardly any years left to live after menopause.

According to the World Health Statistics a girl born in 2014 is expected to live for an average of 73 years. Japanese women live the longest. The divide between the rich and the poor countries is still there, and in the rich countries the women live 7 years longer, and this is because they have the access to all the modern medical facilities that the women in the poorer countries do not have.

Therefore it is not surprising that wherever you go, be it a luncheon, a dinner party, a function or any gathering, middle aged women in their forties-80’s, discuss menopause, what is it, can it be prevented, what we need to do about it, what is the treatment for it, medical or natural.

A few years ago I went home to India where my mother's cook said to me "That she needs treatment for malaria, as she gets high temperature, and sweating, the treatment for malaria that the doctors are using is not helping me". Obviously she was menopausal having hot flashes and sweating which is the most common and distressing symptom of menopause. The modern treatment of HRT fixed her.

The attention paid to menopause is not new, as it started to be looked at in the 1930's by a French doctor who wrote one of the first books on menopause and he called it "The Problem as Menopause".

They called it the deficiency disease and they started to give extract of, crushed ovaries of cows and an extract from the amniotic fluid of cattle.

They also gave testicular extract. A product called Emmerin was prepared from pregnant women's urine and this was found to be useful.

In 1930 a German scientist Dr Zondek prepared an extract from the urine of a pregnant mare which was much cheaper than Emmerin and so it continued to be used.

Synthetic oestrogen was developed in 1938 and progesterone in 1937 and thus medicalization of menopause started.

By 1940 the medicalization of menopause became popular; they prepared drugs from the urine of pregnant women and pregnant female horse’s (Premarin). These drugs were available in the USA in high doses such as 1.25mgs.

Further down the track by 1948 smaller doses were available such as 0.625 mgs and 0.3 mgs.

In 1950 Ayrest Laboratories funded a big campaign to educate women on menopause, what it is and how it can be helped. After their public relations exercise, Premarin become the number one drug dispensed in the USA.

This got further promotion when gynaecologist Dr Robert Wilson in 1964 published an article on menopause called" Menopause" and a book called" Feminine Forever".

He did very extensive PR on the value of HRT; however by 1968 the side effects of oestrogen replacement therapy started to become obvious, such as endometrial cancer, breast cancer, deep venous thrombosis and the lack of any benefit to heart disease. There were some benefits, such as the prevention of osteoporosis and fractures.

Because of these complications several studies were set up to assess the benefit risk ratio of HRT (Oestrogen and Progesterone).

The main study was set up by the national institute of health, called Women's Health Initiative (WHI).

This was started in 1991 and to be completed in ten years on 160,000 women.

There were four arms to this study; one of them was continuous oestrogen progesterone with an intact uterus; however this had to be stopped after 7 years due to increased risk of breast cancer, heart attacks and deep venous thrombosis and strokes.

This group had women of all ages from early menopause to later age 50-79. They were more useful in younger women who took the HRT at the start of menopause.

The conclusion drawn from these controlled trials there was clear evidence of deep venous thrombosis, there was no clear benefit  on cardiac disease and there was no increase in coronary disease in women less than 10 years post menopausal.

After this study and many others the oestrogen was on trial and it seemed that the benefits of oestrogen were less beneficial than the side effects, this created a fear amongst women particularly the increased risk of breast cancer.

All of a sudden the sale of HRT plummeted; the stock market fell by nearly 20% and the sale of drugs from Wyeth namely Premarin fell from 1.2Billion to 984.Million.

People started to believe that these tablets were no more the magic bullet.

One of the problems with this study was that they included women of all ages and even those who had no symptoms.

As a result of this fear, millions of women suffered from severe hot flashes and problems with their sexual life. Their husbands also suffered during this period from their wives' mood swings, bad temperament and were devoid of any sexual pleasure with each other.

We have recently worked out that Pre menopause, Peri menopause and Menopause is a continuum of the same biological problem, process which is the lack of oestrogen due to the end of the biological cycle for women. This is now referred as Peri-Menopause, Menopause and Post Menopause. This has been studied under stages of reproductive aging, this makes it easier to understand women's menopause.

This period lasts for several years and that's why it was called "Climacteric". This in Greek meant seven years.

Currently we call it Menopause transition.

During this time some women have variable menstrual cycle both in duration and amount of bleeding, some of them still ovulate and can get pregnant. One of the hormones called F.S.H which comes from the brain increases.

Later on in menopause transition the menstrual cycles are delayed up to sixty days or more, F.S.H increases further. It’s called menopause when you have not had a period for one year.

During this time of menopause transition women suffer symptoms of menopause, such as hot flashes, lack of sleep, mood swings, irregular bleeding and many others.

During this time we need to treat them and also offer contraception.

Recently the Women's Health Initiative has published a new update on women's health along with the British Menopause Society, North American Advisory Committee and Royal College of Gynaecology have all published new guidelines on HRT, so we have come full circle.

WE should not let women suffer from any fear from menopause or HRT, always consult a professional and not be guided by the media frenzy about this subject.

The original WHI created a lot of confusion, the reasons being the selection of women for the study was incorrect. 160,000 women were selected with no consideration of their age, their symptoms, their medical history, obesity, smoking, and poor lifestyle factors. They mainly focused on the long term benefits of HRT; no attention was paid to their initial symptoms such as severe hot flashes, urinary symptoms, and lack of sleep, mood swings, and many other annoying problems.

The results were also analysed and expressed very poorly , for example they said that breast cancer risk increased by 26 per cent( 30-10,000 to 38-10,000 ), this frightened the life out of women and their care providers, they could have easily said, one extra patient in 1250 women who had been on HRT for 5 years was at risk.

The next worst thing was that these results were given to the media before they were published in any medical journal and analysed by the experts.

Many experts felt that the WHI conclusions needed a complete reassessment.

It is after ten years of muddy conclusions and many research trials the cloud over HRT has cleared.

We cannot say that HRT has no side effects, but the benefit risk ratio is in favour of the benefits

There are 37.5 million women in menopause or reaching menopause. Each year approximately one million will join the menopause club. Very soon there will be one billion women in menopause, we as a society cannot let them suffer or be miserable. There is enormous research in this area , There are many new drugs , which are very useful and with very little side effects and many new techniques to help this group of women, so lets us do it .time has come not to suffer in silence be well informed and live happily for the rest of our lives . I will discuss all this in detail in the relevant areas as I go along.