Menopause,
that biological milestone in our lives, typically announces its impending
arrival by menstrual irregularity, fatigue, hot flashes and night sweats. There
are also subtle physical and psychological symptoms that we experience,
culminating in the end of the familiar monthly menstrual cycle. If you are
experiencing any of these symptoms or are approaching 40 to 45 years, it is wise
to discuss these issues with your doctor.
Strictly defined, the very last day
of menstruation is called menopause after it has stopped for a period of twelve
months. This end of menstrual cycling usually occurs between the ages of 40 and
60 years, with the average age being 51. Menopause can be a welcome relief from
the fear of pregnancy and painful or irregular bleeding often accompanied by
menstrual migraine and premenstrual tension. Women are unique beings who,
unlike females of other species, continue to live long after the end of their
fertility. In the 1990s, a woman can look forward to another 30 years or longer
after her menopause, because of the advances in medical science and better
socioeconomic conditions.
This end of the reproductive years
is known by various names — the change, the climacteric and, most popularly,
menopause. The word menopause is derived from two words - the Greek meno
meaning month and pause meaning cessation. Although menopause technically
refers to that one day in a woman’s life when her periods stop, the effects of
that loss of reproductive (ovarian) function extend over years, both before and
after, that one day. The word climacteric is used to define these years of physical
and emotional changes.
Since the
duration of these midlife changes is about 20 years in the context of chronic
illness, endocrine disorders, menstrual problems, fertility problems; about ten
years ago 2001 it was decided to study the changes of the reproductive aging.
The scientists of five different countries and multiple disciplines sat to
classify them into different stages. After ten years a more comprehensive basis
for assessing reproductive maturity is described. The first stages are like
normal reproductive function with regular menstrual cycle, later in this stage
the cycles can sometimes be irregular, the fertility decreases and the main
pituitary hormone for the maturation of the egg (FSH) can increase. At this
stage the patient can have some symptoms such as hot flashes in the
premenstrual stage, and premenstrual tension. In the following stages often called
perimenopause when the menstrual cycle varies the fertility decreases. The
hormone studies are often done especially in women who are anxious to have a
baby late in life. The FSH is variable. The two other hormones which we have
not elaborated on are called Antimullarian and Inhibin B are low. The number of
maturing follicles in the ovary is low. The women start having hot flashes. In
the later part of this perimenopause the FSH is usually high( Should be done on
the second day of the cycle) and the symptoms become pronounced.
In the
final stages of this menstrual cycle stops and when it has stopped for one year
it is called menopause and the FSH is usually high, and Antimullarian Hormone
and Inhibin B is very low. The chances of pregnancy are almost nil. Personally
I have seen two women having a baby at 54 and 56 years of age. Later on these
women start getting symptoms related to external genitalia (Painful dry vagina,
painful sex) and urinary symptoms, such as poor control and repeated urinary
infections. Recently this has been studied and called pelvic syndrome of
menopause, these late symptoms get worse and never improve. Many clinicians
call these changing years as menopause transition. I agree this system of
classifying the reproductive aging is very useful as we have no international
diagnosis of menopause syndrome. It is mainly based on menstrual cycle, ovarian
aging and supportive criteria. Depending on your menstrual cycle symptomatology
and supportive criteria you can assess when your menopause is coming
irrespective of your age and nationality.
Surgical menopause
The surgical removal of both
ovaries (called bilateral oophorectomy) is sometimes necessary in the treatment
of breast cancer or other conditions. Such removal of the ovaries results, of
course, in the sudden loss of a woman’s ovarian hormones, and produces a
surgical menopause. The symptoms that result from a surgical menopause can be
every bit as distressing as, and sometimes even more than, a normal menopause.
Hysterectomy
(the surgical removal of the uterus) does not induce a true menopause, because,
although the periods stop, the ovaries continue to manufacture the female
hormones in the normal cyclical way.
Menopause sometimes occurs about
five years earlier in women who have had a hysterectomy and in women who smoke.
For these women, menopausal symptoms, rather than the cessation of periods,
herald the start of menopause. For some women, a blood test may be needed to
confirm menopause.
Premature menopause
If menopause happens before 40 years
of age it is called premature menopause. If it happens very early, for example,
in the 20s, it is called ovarian failure rather than premature menopause. For
younger women who have no periods for any length of time and are having
symptoms, premature menopause is a possible explanation. Of course, pregnancy
is also a possibility and it is therefore essential to exclude pregnancy before
attributing the absence of periods to premature menopause.
Personal story
Premature menopause causing
psychological stress
Gina, a 22-year-old law student and
keen sportswoman of Italian descent, was a classic case of premature ovarian
failure. She had not had a period for five months and she had occasional hot
flushes. Her general practitioner who believed that her strenuous sports
activity had caused her periods to cease referred her to a gynaecologist.
Absence of periods often happens with excessively physically active young women
involved in sports, gynmastics and aerobics. Simple emotional stress which
affects young women can also cause infrequent or absent periods. However,
various hormone blood level tests showed that she was suffering from premature
menopause (premature ovarian failure). Gina took consolation from the rapid
strides being made by the IVF fertility program which may eventually provide a
solution to her problem. Immediately though, the answer was for her to go on
HRT
Gina is
having psychological counselling to cope with the devastating consequences of
possibly never being able to have a child.
Women
reaching middle age may experience several other problems unrelated to
menopause or oestrogen deficiency. Problems of ageing such as arthritis and
diseases such as diabetes and high blood pressure, often start at this time.
Many social and psychological barriers also arise. A lack of career fulfillment,
ageing parents to care for, marital disharmony and difficulties with growing
children all create additional stress. The problems at middle age are therefore
often a combination of biological (ageing and menopause), psychological and
social upheavals.
Specific
menopausal symptom
Menopausal problems can be short-term
or long-term. Hot flashes are the most obvious distressing symptom which brings
a woman to a doctor. Other symptoms are general sweating, night sweats, muscle
aches and pains, joint pains and a peculiar sensation of ants crawling on the
skin called formication. A second group of symptoms include urogenital changes,
manifested by dryness of the vagina, bladder problems such as the frequent
desire to empty the bladder, and the loss of bladder control. These symptoms
are due to atrophy (thinning) of the vagina and the urethra resulting from
oestrogen deficiency. A third group of symptoms embrace psychosomatic ailments
of confusion, loss of self—image, loss of memory, agitation, irritability,
headaches not previously experienced and depression.
Long-term, postmenopausal women
suffer an increased incidence of heart disease, a thinning of their bones
(osteoporosis) and atrophy of the genital organs. It has been shown in studies
that only 3% to 4% of women seek medical advice about these issues at this
time.For treatment to be effective, it is
important to distinguish between oestrogen deficiency symptoms and those caused
by other problems.
Hot
flushes
A hot
flush is a sudden transient feeling of heat over the head, neck and chest,
starting from the chest. It causes flushing of the skin which is obvious to
other people. What causes a hot flush is not clearly understood, but it is
likely to have something to do with the hypothalamus, a key nerve centre iii the brain. The reduced oestrogen levels irritate the neuroreceptors
in the hypothalamus and these in turn signal the blood vessels in the skin to
dilate. The increased blood flow through the dilated vessels heats up the skin,
and causes the flush, While the skin temperature is rising during the several
minutes of the flush, the body temperature drops by a few degrees. The cooling
effect is accentuated because a chill feeling follows the evaporation of the
newly formed perspiration from the skin. As a result of cooling, our body’s
defence mechanism takes over and the adrenal gland releases a hormone called
adrenaline. This stress response causes constriction of the blood vessels, and
the hot flush ends.
The
number of hot flushes women experience is variable. There may be several in a
day, several a night or they may be continuous, one after another. Night sweats
are the same phenomenon as hot flushes except that they occur during the night.
Because they occur during sleep, the hot flush is not felt as much as the
consequent cold sweat.
While hot flushes usually occur spontaneously, they may
also be initiated by external factors such as sudden unexpected noise or a
fright. A stressful work or home environment can greatly increase the frequency
and severity of hot flushes. They do not have any serious long-term effects,
although some of the insomnia and fatigue that occurs at menopause may be
caused by the night sweats.
These
symptoms are the commonest of menopausal problems. About seven out of every ten
menopausal women experience hot flushes and more than 60% experience hot
flushes for 12 months after menstruation stops. Hot flushes often continue for
several years after menopause. For many women, they start a few years before
their periods actually stop; that is, during the time when they are
experiencing menstrual irregularities.
Hot
flushes can be a very distressing condition. A general consensus is that hot
flushes undermine a woman’s self-confidence making her self- conscious of her
body in a negative way. They are a contributing factor to the psychological
symptoms accompanying menopause.
Formication
or the sensation of crawling under the skin is generally due to vascular changes
of the skin early in menopause. Some more unusual symptoms include tingling in
the ears and dizziness. Hormone replacement therapy (HRT) can bring dramatic
relief from these symptoms within days.
Fatigue
Fatigue
is a very common problem during menopause. There are several general causes for
tiredness which should be excluded before associating it with menopause. For
example, menstrual irregularities and heavy periods causing anaemia (lack of
haemoglobin in the blood) can cause tiredness. An often overlooked cause of
fatigue is poor diet and the stress of the daily demands of being a mother,
running a home and a job at the same time.
It is
important to evaluate your working hours and conditions before attributing
fatigue entirely to menopause. It is also important to exclude any other
disease or biological changes which may be responsible.
Urogenital
symptoms
These
symptoms occur three to eight years after menopause. They mainly affect female
urinary activity and genital function. Lack of oestrogen is the main reason for
changes in the urinary and genital tract. After menopause, there is a
progressive deterioration in these functions, ultimately causing a dry,
shrinking vagina which leads to diminished capacity and elasticity. Sexual
stimulation is also diminished and it takes longer to reach orgasm. Vaginal
atrophy and dryness varies from woman to woman. Larger women are less seriously
affected because their body fats continue to produce and store an oestrogen
called oestrone. Lack of oestrogen seriously affects urinary performance
because the urinary bladder is believed to be oestrogen dependent.
Initially, there may be repeated infections (cystitis),
frequency and urgency and some stress incontinence (spilling of urine under
stress such as coughing, sneezing, laughing or dancing). As the years go by,
these symptoms can become more serious and incontinence can become a great
handicap.
In
caring for the geriatric population, incontinence is a major determining factor
in finding accommodation in nursing homes. The most common urological complaint
a gynaecologist deals with is incontinence. For younger women, it is generally
stress incontinence and, for older women, it is generally due to overflow.
Difficulty in emptying the bladder completely is another problem experienced by
elderly women.
The important role played by oestrogen in the proper
functioning of the urinary system is not completely clear. The lack of
oestrogen, together with a generalised loss of muscle tone, are the major
factors in compromised urinary function after menopause. However, while
oestrogen replacement helps many women with such difficulties, it does not help
all. Thus, other causes of this particular symptom should be considered and
treated accordingly.
Irregular
or absent menstrual cycles
By
definition, menopause is the end of the menstrual cycle. However, before
menopause arrives, irregularity of cycles is common. Irregularity can be
frequent periods, infrequent periods, too much bleeding or too little bleeding.
The reason is that the failing ovaries are not ovulating;; there is no
progesterone produced to ripen the lining of the uterus (the endometrium) and
regulate the menstrual cycle. This is perhaps the earliest symptom of menopause
and is often not recognised as such.
In the past, many women in their late 30s and early 40s
who consulted their doctor about irregular periods were described as suffering
from dysfunctional bleeding. This term means abnormal uterine bleeding in the
absence of any uterine fibroids or other medical reason. The bleeding is
generally due to a hormonal imbalance.
Other causes of abnormal bleeding and absent periods
should be excluded before labelling this as menopausal. These problems can be
due to a range of causes varying in severity from simple fibroids to uterine
cancer or even pregnancy
Muscle
and joint aches and pains
After
the ovaries begin to fail, the ligaments and tissues which connect various
parts of the skeletal system become lax resulting in decreased muscle strength.
The looseness gives rise to a variety of aches and pains. Laxity of the muscles
is accompanied by loss of elasticity of the ligaments and the cumulative effect
is more aches and pains in the shoulders, elbows and back.
With
age, we can also expect some degree of osteoporosis and consequent pain.
Osteoporosis can cause fractures of the vertebrae and then curvature of the
spine. When the curvature is very marked, it is known as dowager’s hump and
results in loss of height.
With an
adequate amount of physical activity, these symptoms are prevented as exercise
enhances the wellbeing of the muscles, ligaments and the bones. Oestrogens are
also believed to have some benefic all effects as an anti-inflammatory agent
thus preventing pain as well as preventing osteoporosis.
A
combination of lack of oestrogen, poor physical activity and menopausal changes
exacerbate muscle aches and pains. Many women are treated as if they suffer
from osteoarthritis and are often given aspirin and other non—steroidal
anti-inflammatory drugs which can cause side—effects such as stomach ulcers.
Other
symptoms
As the
ovaries fail, there is a relative proportional increase of the male hormones,
androgens, mainly testosterone and androstenedione. These hormones can lead to
the appearance of pimples and facial hair, and the thinning and loss of scalp
hair. HRT can improve these distressing conditions. Sometimes, a drug,
Aldactone, can be used to neutralise androgens and decrease facial hair
Skin
and hair
The
skin constantly changes with age due to deterioration from excessive exposure to
sun. The ageing of the skin starts at about 30 years. These changes are
accentuated by the hormonal changes at menopause. At this time, the elastin and
collagen in the skin decreases although it is not yet understood why. The loss
of collagen, in the initial years of menopause is far more than in subsequent
years. The deficiency of elastin and collagen causes wrinkles and dryness.
Women who have been on prolonged corticosteroid therapy, or who suffer from adrenal
disease, have diminished collagen tissue. Corticosteroids, commonly used for
asthma, have an adverse effect on skin and bones.
HRT can
be beneficial. Oestrogen and testosterone help the skin by protecting the loss
of collagen and elastin, increasing the skin’s water content (called
“hydration”) and improving blood circulation. Recent research has shown that
skin changes often almost disappear within six months of starting HRT, after
which there is no further significant improvement as there is an optimum
collagen content that women achieve.
Acne at
menopause can be treated by general cleansing of the skin, by nutritional creams and by HRT which restores the hormonal balance
in favour of oestrogen. Some doctors use aldactone to neutralise the testosterones.
This may result in side—effects such as depression, diminished sex drive and a
tendency to a husky voice. These drugs have a place when acne is very severe.
At
menopause, new facial hair can commonly appear. HRT can lessen facial hair. In
severe cases, medication is prescribed for a few months at a• time. Simple
depilatory creams may be used. Baldness is rarely seen in menopausal women; if
it does occur, it is important for your doctor to:: exclude other causes of
hair loss.
Care of
our skin is important at any age. Australia has the world’s highest incidence
of skin cancer. Avoid unnecessary exposure to the sun by using a broad-brimmed
hat, wearing a long-sleeved top and using a SPF-15-plus protective sun cream
every day
Other
simple measures for skin care include correct diet and lifestyle factors such
as reducing your intake of fat and salt, eating plenty of raw fruits and
vegetables, drinking plenty of water, quitting smoking and cutting your alcohol
consumption. Other positive aids to the good health and wellbeing of your skin
are regular washing, gently massaging your skin with one of the many
specialised skin brushes and using moisturising creams.
Personal
story
Distressing
male pattern hair distribution and hair loss
Claire,
49, a shop assistant, cried as she took off her hairpiece concealing a large
bald patch. She described how she had been embarrassed and dismayed by her
creeping hair loss over two years from menopause and chronic emotional stress.
She was reassured that HRT could prevent the condition worsening and might even
improve it. She was prescribed a hormonal combination of oestrogen and
progestogen to combat the testosterone, the biological culprit. After eight
months of HRT, her hair loss stabilised.
Formication
Formication is the sensation of
crawling under the skin. The feeling is caused by vascular changes in the skin
at the time of menopause. The condition usually improves or completely
disappears soon after starting HRT Some more unusual symptoms include tingling
in the ears, dizziness, painful leg cramps and a bloated feeling.
Emotional
disturbances
Psychological disturbances which many
menopausal women commonly complain of are depression, insomnia, panic attacks,
mood swings, irritability and lack of self-confidence. These feelings often
appear before the symptoms of hot flushes. Short-term memory loss is also
complained about but this may be more age related because it also affects men.
Although HT relieves these symptoms
for many women, there is no conclusive proof that these symptoms are the direct
result of oestrogen withdrawal. Many women seek to blame oestrogen withdrawal
when their real problems may be stress related at home or work. At this time of
life, women are prone to fretting about their changing body shape, weight gain,
sagging breasts, wrinkles around the eyes, career unfulfillment, problem
children and a disappointing marriage. Emotional symptoms from the time of
menopause are very difficult to classic and may be unrelated to lack of
oestrogen.
With our present state of knowledge,
we are unable to explain how and why HRT can give many of these women relief
from their emotional symptoms. Some of this improvement may be the result of
the tranquility they achieve from HRT’s correction of their hot flushes.
However, there is an equal number of women who pass through menopause without
any emotional trauma.
Premenstrual syndrome (PMT) is a
group of symptoms which affects women in their third and fourth decade,
ultimately merging with perimenopausal symptoms. It is a stressful combination
of physical and psychological symptoms which occurs regularly before the start
of menstruation. Symptoms can include headaches, irritability, depression, mood
swings, menstrual migraine and suicidal tendencies. There can also be poor
performance, clumsiness, changes in weight, tender breasts and fluid retention.
The exact cause of PMT is not known.
Personal
story
Persistent
headaches which, in reality, were hot flushes
Joan, a
hotel chef, who had a hysterectomy and removal of both ovaries at 36 because of
severe infection from the Dalkon Shield complained to her doctor of headaches.
Six months after her operation she began to suffer persistent headaches which
were actually hot flushes. Various doctors considered the condition to be
persistent headaches which were not relieved by pain killers. She was referred
to a dentist who believed the malalignment of her jaw was causing the
persistent pain.
Finally, she started taking HRT and within two weeks
felt better.
Personal
story - Hot flashes, insomnia and lack of concentration
Janet,
51, an architect, was worried about her mood swings, difficulty in
concentrating, lack of sleep and unpredictable hot flushes. Her menstrual
cycle, for the past 18 months, had become irregular and her last. menstrual
period was four months ago. Her past medical history was unremarkable except
that she had had varicose veins surgically removed from both legs.
She had
not taken any medication in the past. Her father died of coronary heart disease
at the age of 56 after several years of suffering from angina which had also
afflicted her mother. Her menopausal status was suspected from her irregular
menstrual cycle and symptoms and was confirmed with an elevated FSH level by
her blood test. HRT was recommended to control her symptoms and to prevent her
from developing heart disease because of her family history which put her in a
high risk category
Key
points
1.
After menopause the oestrogen
levels progressively decline, causing several permanent changes. Menopause is
not a transitory phase, but a permanent one in your life because the oestrogen
deficiency is permanent.
2.
Symptoms of menopause are many
and varied, extending from psychological to physical manifestations. The
commonest are hot flushes, irregular bleeding, vaginal dryness and mood swings.
Menopausal symptoms are not a universal experience for women.
3.
Symptoms can start many years
before and continue many years after your last menstrual period. If you are
experiencing any of these symptoms, it is wise to discuss them with your
doctor, particularly one with a special interest in menopause
4.
There’s no conclusive evidence
to suggest that menopause causes any psychological problems. Many women claim
that HRT helps their mood changes, energy levels and memory
5.
The health of a woman’s skin is
linked with her overall oestrogen supply, in a similar way to that of her
bones.
6.
These symptoms can occur for
many reasons. All possible causes should be looked for, and excluded, before
HRT is started.
7.
HRT 15 the focus of the
effective treatment of menopause. However, about 15% of women do not require
therapy because they are still capable of making some oestrogen.
