Menopause

Menopause is a time of change for a woman. It signals the end of monthly periods and ovulation, and therefore fertility. Also called the "change of life", menopause is a natural event. Every woman experiences menopause in her own way. Many women may have little discomfort, but others may have a number of distressing symptoms. "Going through the menopause" is a common expression for the months or years that a woman may experience menopausal signs and symptoms. However, strictly speaking, menopause occurs only when monthly periods stop. Menopause is confirmed when a woman has not had a period for 12 consecutive months.

Most women reach menopause between the ages of 45 and 60, with the average age-for Indian women being about 52. After menopause, women can enjoy freedom from concerns about monthly periods and birth control. Many women find it beneficial to be well informed about menopause and the physical changes that gradually take place in their body. Knowledge of the treatment options for unpleasant symptoms helps a woman to make decisions about managing menopause and improving her quality of life.

EARLY OR PREMATURE MENOPAUSE: If menopause occurs before the age of 40, it is considered to be early or premature. Early menopause occurs in about one woman in every 100.

The cause in many cases is unknown, but some causes may have a genetic origin or be part of a multiple hormonal gland failure. In all of these women, the supply of eggs runs out earlier than expected.

Removal of the ovaries by surgery, radiotherapy to the lower abdomen, or chemotherapy may also bring on early menopause. A hysterectomy (removal of the uterus but leaving the ovaries in place) may lead to the menopause starting earlier than would be expected.

As menopause usually marks the end of the child-bearing years, its early onset will be distressing to younger women who may still want to have children. The long-term risks of an early menopause are an increased- risk of osteoporosis and heart disease. Hormone therapy is virtually always recommended for women with early menopause to replace the hormones that their bodies are no longer producing.

THE ROLE OF THE OVARIES: As shown in the above illustration, the ovaries are two organs on either side of the uterus. They begin to function between the ages of eight and 18 years. Each ovary contains a large number of eggs, the exact number being determined before birth.

In general, one ovary produces an egg (ovulation) each month in 'a complex series of events largely influenced by the female hormones oestrogen and progesterone. These hormones cause the lining of the uterus (the endometrium) to thicken with blood-rich tissue.

The flow of menstrual blood occurs when this lining is shed at the end of the monthly cycle, if pregnancy has not occurred. If a pregnancy does occur, ovulation is re-established at some point after the baby is born. The following month, another egg is produced, and the process is repeated. If the woman has only one ovary, it will produce an egg each cycle.

As a woman approaches menopause, the ovaries gradually make less oestrogen and progesterone. When oestrogen levels become too low to thicken the endometrium, monthly periods stop.

Low levels of oestrogen associated with menopause may cause a number of physical changes. The decrease in hormone levels has been linked to long-term health problems, including osteoporosis, which is the loss of bone density and strength.

SIGNS AND SYMPTOMS OF MENOPAUSE

Although all women go through the same basic changes in hormone levels during menopause, each woman experiences menopause in her own way. Signs and symptoms vary in intensity and duration from woman to woman, and include the following.

CHANGES IN THE MENSTRUAL CYCLE

One of the first signs of the onset of menopause is a change in the menstrual cycle. As the production of hormones begins to slow and levels in the blood fluctuate, cycles may become irregular, shorter or longer. Bleeding may be heavier or lighter.

HOT FLUSHES

This is the most commonly reported symptom of menopause. A hot flush is a sudden feeling of warmth or intense heat that spreads over the face, neck and chest and may last for several minutes. It may be accompanied by a red complexion, sweating, nausea, heart, palpitations, increased heart rate and sudden tiredness. A hot flush may last several seconds or several minutes, and can occur during the day or night. Many women have hot flushes for several years before and after menopause. However, most women experience them in the first two to five years after menopause and find they gradually diminish over time.

Night sweats often disrupt sleep, and some women awaken covered in perspiration. A hot environment, hot drinks, spicy foods, caffeine and alcohol may aggravate hot flushes.

Some women do not experience hot flushes.

VAGINAL AND URINARY SYMPTOMS

Oestrogen plays a major role in keeping the vagina and surrounding tissues healthy. Low oestrogen levels cause the lining of the vagina to become thinner, drier and to lose elasticity. The dryness may cause discomfort during intercourse, and the woman may be more susceptible to vaginal irritation and some types of infection.

Similar changes occurring in the urinary tract can cause a need to pass urine more frequently and a vulnerability to infection.

SLEEP DISTURBANCE

Some women find it harder to get to sleep and do not feel rested when they awaken. Some women report persistent insomnia. Night sweats and the need to urinate more frequently are some of the causes of sleep disturbance. Lack of sleep causes fatigue, which can lead to a woman feeling irritable and unable to cope with daily activities.

EMOTIONAL CHANGES

Some women have wide mood swings and may have difficulties with memory and concentration. This may or may not be related to falling oestrogen levels. It may simply be due to increasing age or could be related to other major life changes. A woman may find her role in life changing; for example, children may be leaving home, or grandchildren and ageing parents may need substantial care, or she may have greater work responsibilities.

Emotional changes may also be due to lack of sleep and hot flushes associated with menopause.

SEXUALITY

Around the time of menopause, a woman's sexual feelings and desires may change. Some women may become less interested in sex.

There may be a number of reasons for this. A decline in sexual desire is normal for both women and men as they age. A woman's feelings about her body and the physical changes taking place can have an effect on her sexual feelings. Women may find intercourse painful or uncomfortable because of dryness. Feeling tired from sleep disturbances or stressed from daily life can also affect sexual desire.

It is common for women to have concerns about their sexuality at this time. Many women find it helpful to discuss their feelings with their partner, friends, doctor or a counsellor.

OTHER CHANGES

Some women may experience such physical changes as weight gain, aching joints and muscle pain. Skin may become dry and itchy, and hair may become coarser.

EXAMINATIONS

All women should have a physical examination by at least once a year, especially those older than 30. i will check blood pressure, examine the breasts, and may recommend a vaginal examination. For women who have been sexually active, a cervical (Pap) smear should be performed every two years to screen for abnormal cells of the cervix; some countries recommend three years. For women with no history of an abnormal Pap smear, the Pap smear can stop at age 70. For women who have had abnormal Pap smears, the doctor may recommend life-long Pap smears. Women older than 50 should have a mammogram every two years, or every year for women with increased risk factors.

Women with a family history of breast cancer may require an annual mammogram or other specialized testing.

Levels of follicle stimulating hormone and oestradiol can fluctuate considerably during the perimenopause and are unreliable in predicting the activity of the ovaries at this time.

A serum cholesterol test may be done to assess the risk of heart disease.

Birth Control During Menopause

A woman may become pregnant until menopause has been confirmed; that is, she has not had a period for at least 12 months. Until this time, she should continue to use a proven method of birth control or discuss other options with her doctor. Before menopause, it is safe to choose from one of the following methods of birth control.

• Oral contraceptives, also called "the Pill" or birth-control pills. These may have some health benefits as well as providing contraception. They may protect against ovarian cancer and endometrial cancer They may also help to make periods more regular and relieve hot flushes. Standard combination oestrogen-progestogen oral contraceptives are suitable for those women who do not smoke and who have no other significant risk factors for heart disease. For women with significant risk factors (including smoking), the progestogen-only oral contraceptive may be used.
• Vasectomy for men and tubal occlusion (tying or blocking of the Fallopian tubes) for women. These are surgical procedures and are permanent forms of sterilisation. 'Tubal occlusion does not cause menopause.
• Barrier methods — the diaphragm, condom and spermicides.
• Intra-uterine device (IUD).
• Hormonal implants and injections.

HEART DISEASE

Recent clinical trials have not shown a reduction in heart disease for menopausal women taking hormone therapy as compared to women not taking hormone therapy. This was a surprise finding that contradicted the previous thinking. Such conflicts among clinical studies are still a matter of ongoing debate and research.

To reduce risks of heart disease

• Do not smoke. Smoking increases the risk of heart disease, more than any other risk factor.
• Keep blood pressure within the normal range.
• Lose weight, if necessary.
• Maintain normal cholesterol levels.
• Eat a balanced, low-fat diet.
• Exercise regularly.

OSTEOPOROSIS

Osteoporosis is a condition where the bones become weak and brittle due to the loss of calcium and other minerals or connective tissue that are a part of the bone structure. Calcium loss is a normal part of ageing but happens more rapidly after menopause.

Bone is living tissue that is constantly renewed as old bone breaks down and is replaced with new bone. Around menopause, more bone is broken down than is replaced. All bones in the body are affected by osteoporosis, but bones of the spine, wrist and hips are those most likely to fracture.

Factors that increase a woman's chance of developing osteoporosis include:

• Increasing age
• Being of Caucasian or Asian origin.
• Being small boned or of thin build.
• Lack of adequate exercise.
• having blood relatives who have had osteoporosis .
• Lack of calcium and vitamin D, which helps the uptake of calcium from the stomach and intestines.
• Early menopause.
• Smoking.
• Use of oral corticosteroids by mouth over a long period of time.

A bone-density scan may be recommended for some women at significant risk of developing osteoporosis.

HEALTH AND WELL-BEING DURING AND AFTER MENOPAUSE

Understanding menopause, having a positive attitude, and having a healthy lifestyle are likely to improve a woman's experience of menopause.

DIET: A well-balanced diet is important. This should include foods low in fat and high in fibre, with enough calcium and vitamin D to help strengthen bones. Dairy products such as milk, cheese and yoghurt contain calcium, and many foods have calcium added. Alternatively, calcium tablets can be taken. At menopause, the recommended dose of calcium is usually 1,000 to 1,500 milligrams per day.

Many women eat soy-based products and other foods rich in phytoestrogens. Limit caffeine and alcohol intake, stop smoking, and try to limit stress. Some women find that relaxation and meditation can be helpful.

EXERCISE: Get plenty of exercise. Regular weight-bearing exercise (such as walking, jogging or weight-lifting) can slow osteoporosis, improve fitness and promote feelings of well-being.

VAGINAL DRYNESS:If vaginal dryness causes discomfort, a vaginal cream or pessary containing oestrogen can be helpful; a number of brands are available: Vaginal dryness that causes soreness during sex can be treated with several commercial lubricants.

BLADDER CONTROL:Do pelvic floor exercises to improve bladder control.

HOT FLUSHES: For hot flushes, some simple remedies may help:

• Sleep in a cool room, or when a hot flush starts, go somewhere that is cool .
• Arrange clothing in layers that are easy to remove if you start to feel warm .
• Avoid hot, close environments; carry a fan.
• Avoid spicy foods, caffeine and hot drinks .
• When you feel a hot flush starting, have a cool drink + dress in cotton clothing or material that lets your skin "breathe".

Some women have more problems with their teeth and gums after menopause. Increased tooth loss has been associated with osteoporosis. For these reasons, good dental hygiene and regular dental check-ups are important.

Visit on a regular basis. You can review treatment options at any time.

Menopause is an opportunity for all women to assess their general health and to make important changes to their diet and lifestyle.

TREATMENTS FOR MENOPAUSE

To help relieve menopausal symptoms, hormone therapy (HT) may be useful. Combined HT involves oestrogen and a form of progesterone called progestin. These hormones reverse the effects of decreasing levels of oestrogen in the body. If oestrogen is taken alone, then the treatment is referred to as oestrogen therapy (OT). This is usually recommended only for women who have had a hysterec-tomy (removal of the uterus).

Most women report that menopausal symptoms, particularly hot flushes, ease when they take HT or OT. Long-term HT or OT may also protect against bowel cancer and the progression of osteoporosis. For some women, HT or OT may help with memory problems and concentration.

Oestrogen can be taken in many forms, including tablets, skin patches, skin gels, nasal sprays or implants (a small pellet placed under the skin which may last up to 12 months or longer). Progestin can be taken in tablet or patch form.

Women who are premenopausal (having menopausal symptoms but whose periods have not yet ceased) are often pre-scribed continuous oestrogen, with progestin added for 10 to 14 days each month. With these medications, periods continue, but menstrual flow usually becomes lighter the longer a woman takes HT.

Women who no longer menstruate and who are at least two years past the menopause are usually prescribed oestrogen and progestin to be taken every day. Otherwise, cyclic progestin for 12 to 14 days is combined with oestrogen in the perimenopause and in the first two years after menopause. A regular monthly bleed may occur with the cyclic therapy; the continuous regimen may have irregular spotting as a side effect, especially in the first six months. In eight out of 10 women, spotting will stop within six months. If it persists or becomes troublesome, contact .

Vaginal dryness and bladder symptoms . can be treated with oestrogen in the form of vaginal tablets, creams or pessaries.

The drug tibolone is an alternative to HT that may relieve symptoms of menopause but without some of the side effects.

Testosterone therapy may be prescribed for some women who have gone through an early menopause or who have a low testosterone level.

RISKS AND BENEFIIS OF HT AND OT

Side effects of HT may include breast tenderness, nausea, weight gain, irritability, spotting or the return of monthly bleeding, and an increased vulnerability to candidiasis or "thrush" infection.

With the exception of weight gain, side effects usually disappear after the first two to three months, and can often be con-trolled by minor adjustments to the timing and dose. HT may not be required or appropriate for every woman. All studies are unanimous in their demonstration that HT relieves the symptoms. However, it remains uncertain whether the benefits of long-term use of HT outweigh the risks.

The evidence is further confused by the use of varying forms of HT and OT, and by different routes of administration. Early studies involved oestrogen alone and showed benefits in preventing osteoporosis and heart disease. However, for women who have not undergone hysterectomy, the use of oestrogen alone carries a significant risk of uterine cancer as well as more frequent bleeding problems. So, for women who still have a uterus, a progestin is required.

By the 1990s, it was becoming apparent that the use of HT is associated with a small increase in the risk of venous thromboembolism (blood clots in the veins with a risk of travel to the lungs) and that long-term HT use (beyond five years) is associated with a small increase in the risk of breast cancer. More recently, a small increase in the risk of heart attack and stroke has been shown with HT use in women who have existing heart disease or risk factors for heart disease. For example, in a large clinical study of continuous combined oestrogen and progestin taken as tablets, for every 10,000 women on HT, there were seven more heart attacks, eight more strokes, eight more blood clots with lung effects, and eight more invasive breast cancers per year (but no increase in mortality). The overall excess risk of these events was 19 adverse events per 10,000 women treated per year.

Further, the overall risk of death from cancer is not increased; a number of studies have confirmed that women using HT have a lower risk of dying from breast or colon cancer. A possible explanation for this finding is that women using HT see their doctor more regularly and have more screening, thus leading to earlier diagnosis and treatment.

TREATMENT OF EARLY MENOPAUSE

A woman going through menopause before the age of 40 requires:

• Careful assessment to determine a cause .
• Counseling that may need to address symptoms, depression, grief, inability to have children or more children, feeling old, sexuality and relationships .
• Long-term follow-up of HT and other treatments.

As the ovaries are no longer producing oestrogen, progesterone and testosterone, the woman has an increased risk of devel-oping osteoporosis and heart disease at an earlier age. High doses may be recom-mended because the body needs higher amounts in a younger woman. The therapy includes testosterone, oestrogen and progesterone. Long-term HT is often recommended.

The risk of breast cancer due to long-term HT use does not seem to apply to women who go through an early menopause.

NATURAL REMEDIES

Some women turn to help them through menopause. These include vitamins, herbal preparations and plant compounds known as phytoestrogens.

Phytoestrogens are oestrogen-like substances found in cereals, vegetables, most beans, soya-bean products, and some herbs. They may relieve some menopausal symptoms in some women, but scientific studies have shown that plant oestrogens are no more effective than placebo in relieving symptoms.

An extract of the herb Black Cohosh may be effective in relieving hot flushes in some women with short-term use (less than six months). Although preliminary reports are encouraging, the research results are not yet sufficient to support a recommendation on the use of Black Cohosh for menopausal symptoms.

Some herbal remedies have been associated with adverse side effects. The effects of long-term use of herbal remedies have not been well studied. Research to confirm whether the various natural remedies are better than placebo is on-going. Tell me if you decide to take any herbal medicines. Use of any herbal preparation, without professional supervision, may have adverse effects.

SPECIAL CIRCUMSTANCES

Women who experience premature menopause or breast cancer or have other conditions that might prevent the use of oestrogen have additional health issues that need to be addressed by their doctor.

Some may benefit from referral to specialists who can explain the range of treatment options available for the control of symptoms and lowering the risk of long-term health problems.

Costs

I can advise you about the costs of examinations, tests, HT or other therapies. Due to unexpected tests or treatments, costs may vary from the original estimated cost. It is better to discuss costs with before receiving tests and treatment rather than afterwards.