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MENOPAUSE: -
Major endocrine changes occur in a woman around 45 and 50 years
of age. There is a marked decline in the ovarian function
resulting in a decline in estrogen production that leads to a
series of changes commonly known as menopausal changes. Fifty
years ago these changes were not considered significant as
average life expectancy of women was only 60 years and
postmenopausal population was small. Also at that time short and
long-term sequelae of estrogen deficiencies were not known.
Thus, menopause was considered as a process of normal aging and
though women had symptoms, they were not treated but either left
alone or given some symptomatic treatment, like good diet,
tranquilizers and psychotherapy. This thinking has changed now.
We definitely know the endocrine and metabolic changes that
occur with menopause and also the short and long-term sequelae
of estrogen deficiency. Also there is a profound change in the
birth and mortality rates, which has resulted in the aging of
the population all over the world. The enormous decline in
the maternal mortality in particular has meant that increasing
proportion of women are surviving to the menopause and several
years of active life beyond it. Women aged 55 years and above
now comprise 18% of the population of UK and 15% in USA. Average
life expectancy for women in developed countries today is around
83 reach the age of 80 years. If the average age of menopause is
50 years, most women will spend approximately one- third life in
post-menopausal period. In India also, the life expectancy for
women has increased from 31.7 years in 1940 to 60.7 years in
1993 and is expected to be 65 years in year 2000. The average
age of menopause is 47 years, which means even our women will
spend about 20 years of their life in post-menopausal period and
will develop symptoms due to estrogen deficiency requiring
definite treatment.
DEFINITION: -
Menopause means “ cessation of menstrual period”. (It is a
combination of Greek word menos meaning menstruation and
pause meaning stop). Sometimes this is confused with the
climacteric, but climacteric is the transitional phase during
which ovarian function ceases and which when complete leads to
the menopause.
The average age for menopause in Western countries is 50 years
and in India is 47 years. It occurs earlier in women who use
tobacco, and are heavy smokers, and those who live at higher
altitudes.
TYPES OF
MENOPAUSE:-
Menopause can be natural or spontaneous and artificial or
iatrogenic due to either surgical removal of the ovaries and the
uterus or due to irradiation or chemotherapy for malignant
diseases.
PREMATURE MENOPAUSE: -
Whenever menopause occurs before the age of 40 years it is
called as premature menopause, some authors consider 45 years as
age limits for premature menopause. Commonest causes for
premature menopause are surgery or radiotherapy and chemotherapy
for malignant diseases. Natural causes for premature menopause
are still not known but it is known to be associated with
chromosomal and certain autoimmune disorders.
Risks of
Premature Menopause:
These women will develop menopausal symptoms at an earlier age,
but more important is the fact that they are at a higher risk
for developing coronary artery disease as well as early
development of osteoporosis at an age of 50 to 60 years.
Starting HRT at an early age, and at least continuing till the
age of 50 years can prevent these complications.
SYMPTOMS: -
Menopause whether spontaneous, surgical or premature will
produce the following symptoms, mainly related to estrogen
deficiency. The symptoms can be acute, intermediate and
chronic or long-term sequelae.
Acute
Symptoms: -
Vasomotor disturbances host flushes and perspiration, night
sweats and insomnia.
Psychological Symptoms: -
Mood changes anxiety, irritability, poor memory, and poor
concentration loss of self-esteem and depression.
Intermediate Symptoms: -
1)
Those
associated with atrophy of the lower urogenital tract like
vaginal atrophy, recurrent vaginal infections, dyspareunia
painful sexual intercourse, and loss of libido and recurrent
urinary tract infections.
2)
Those
associated with loss of collagen from connective tissue like
thinning of skin, joint, aches and paints, prolapse and urinary
stress incontinence.
Chronic
Symptoms: -
Chromic symptoms or long-term sequelae are the most important
causes of mortality and morbidity. They are Arterial
cerebro-vascular accidents, coronary artery disease and skeletal
osteoporosis.
The symptoms very widely between individuals in the same
population as well as in different populations. Most women at
the age of menopause are more concerned about health issues in
their healthy “Disability Free Life Expectancy” (DFLE ) than
their total life expectancy.
Locomotor disorders rank first and circulatory diseases second
in the list of diseases which circumscribe DFLE. Not only
women have become health conscious now, but today they have
greater aspirations and are pursuing high profile careers
in all the fields and want to continue doing that even in
post-menopausal life Women today have greater expectations of a
higher quality life than their mothers and grandmothers and,
therefore, will pose challenges about their health care in their
7th
and 8th decades
MANAGEMENT OF MENOPAUSE: -
Proper and comprehensive management of women at menopause and in
post-menopausal period is very important and can be done
effectively by in-depth counseling. Management is
multidisciplinary and consists of relief of symptoms due to
estrogen deficiency as well as taking care of medical problems,
endocrine disorders, and genital malignancies and other health
problems like psychological and emotional problems that are
commonly seen at this age.
Hormone replacement therapy (HRT) forms the most important part
in the management of menopausal symptoms related to estrogen
deficiency. When HRT was introduced in 1960 it was mainly used
as a therapeutic agent to relieve the acute symptoms like not
flushes and vaginal atrophy and recurrent vaginal and urinary
tract infections. Recently, it has been shown that HRT also
plays a very important role in prevention of long-term sequelae
of estrogen deficiency like cardiac and cerebro-vascular disease
and osteoporosis. Currently, it is used extensively for both
therapeutic as well as prophylactic or preventive purposes. Also
some of the older myths and misconceptions regarding use of HRT
have been cleared and it has been proved beyond doubt that
benefits of HRT clearly outweigh the risks. Also by introducing
better estrogen preparations and non-oral route of
administration some of the side effects have been reduced.
Addition of progesterone when estrogen replacement is used for
over five years has reduced the risk of endometrial cancer and
hyperplasia. In future, low dose combination patch of estrogen
and progesterone will be available which will be an ideal form
of HRT especially for a high-risk group. Before prescribing HRT
to any woman, potential risks and benefits must be kept in mind
and explained to the woman, as these prescriptions are
apparently given to healthy women for prophylactic purpose and
will have be taken for a long period of time to be effective. An
informed consent is also necessary and long-term follow up is
mandatory.
BENEFITS
OF HRT: -
Relief
of Vasomotor Symptoms –
Most important is relief of vasomotor symptoms. Hot flushes and
night sweats occur due to estrogen deficiency and develop very
early. 50 to 75% women experience them. HRT relieves them.
Relief
of Symptoms due to End-organ Atrophy: -
Estrogen deficiency leads to atrophy of vaginal as well as
urethral epithelium. This leads to recurrent vaginal infections,
dyspareunia, recurrent urinary tract infection and urgency and
frequency of micturition known as urethral syndrome. Estrogen
replacement improves all the symptoms due to atrophy.
Relief
of Psychological Symptoms: -
The effect is a “ snow ball” effect and is due to relief of hot
flushes and night sweats. There is proper sleep and reduced
irritability and mood disturbances. Major psychological symptoms
are not cured and will require psychiatric opinion.
The
Mental Tonic Effect-
Estrogen replacement improves mental awareness, produces sense
of well being and euphoria.
Effect
on Skin Atrophy-
By improving the collagen content HRT prevents skin atrophy
prevents wrinkling and dryness and thus prevents aging to some
extent.
POTENTIAL RISKS:-
HRT also has potential risk of increase in the incidences of
genital cancers like cancer of uterus, breast cancer and ovarian
cancer use of HRT is not so popular. Other risks are:
??
Endometrial hyperplasia,
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Thromboembolism,
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Gallstones,
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Increase in blood pressure, and
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Post-menopausal bleeding unnecessary surgery.
Balancing the risk and benefits:-
It is very important to balance the risks and the benefits. Aim
should be to maximize the benefits and minimize the risk.
Patients who are at high risk should not be given HRT or when
given should be carefully followed up. Smallest dose should be
used and combined estrogen and Progestogen should be given when
uterus is still present. Detailed follow-up examination is very
important.
TREATMENT OF C0-EXISTANT PROBLEMS: -
Post-menopausal women may have hypertension, cardio-respiratory
problems, and chronic infection especially urinary tract
infection due to prolapse as well as atrophy of urethral
epithelium. All of these should be adequately investigated and
treated.
Endocrine
disorders like thyroid and parathyroid dysfunction and metabolic
disorders like diabetes mellitus are common at this age and
require careful management. Womb at this age are at an increased
risk for developing cancer, therefore, cervical smear,
endometrial aspiration cytology, and breast examination should
be carried out frequently and regularly.
Diet,
Exercise And Change In Life Style: -
All these form very important aspects of management. Healthy
diet with adequate calcium supplement regular exercise, avoiding
excess alcohol and smoking and avoiding excess weight gain or
loss are equally important for a healthy life Women may feel
lonely and unwanted at this period and may have depression. Good
psychotherapy and advice to have a positive outlook and to
develop some creative interest will go a long way for them. Let
us not dismiss menopause as an aging process or an endocrine
disorder, but call it a “ Golden Period” and provide these women
efficient healthy care for happy and health life and help them
to grow old gracefully.
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