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Introduction
Literally menopause is a word derived from two Greek words
men-month and pause meaning stop. To a lay man the word
menopause means cessation of menstruation. However, menopause is
an event in the series of changes that take place in women
wherein the ovarian function gradually ceases and begins to
withdraw. This entire phase is known as climacteric of which
menopause is an event. If one is to compare climacteric to a
ladder, menopause is just a rung of that ladder. Basically,
menopause is an event. It results from the depletion the stock
of ovarian follicles (which form ova subsequently) and a
resultant fall in estrogen progesterone hormone levels.
Natural Menopause
Menopause is a natural event in a woman's life that designates
the end of fertility, or her childbearing years. Menopause
results from the ovaries decreasing their production of the sex
hormones estrogen and progesterone. Most women can tell if they
are approaching menopause when their menstrual periods start
changing. "Perimenopause" or the "menopause transition" are
terms used to describe this time. Perimenopause is what some
describe as "being in menopause," but menopause itself is only
one day in a woman's life after she had not had a menstrual
period for twelve consecutive months, and no other biological or
physiological cause can be identified. Until twelve consecutive
months have passed without a period, a midlife woman may still
be able to get pregnant.
Induced Menopause
Although the majority of women experience "natural" menopause,
some women may experience "induced" menopause due to one of a
number of medical interventions. Surgically removing both
ovaries (bilateral oophorectomy) before natural menopause causes
surgical menopause. Induced menopause can also occur if the
ovaries are damaged by radiation, chemotherapy, or certain other
drugs. Due to their abrupt loss of ovarian hormones, women who
experience induced menopause will usually have a sudden onset of
hot flashes and other menopause-related disturbances such as a
dry vagina and a decline in sex drive. These women, as well as
women who experience early natural menopause (before age 40) or
prolonged time without menstrual periods due to excessive
exercising or dieting, may be at a greater risk later in life
for health problems such as heart disease and osteoporosis since
they spend more years without the protective effect of estrogen.
A woman who has a hysterectomy (uterus removed but not the
ovaries) prior to experiencing natural menopause should continue
to produce hormones and thus will not experience surgical
menopause. However, sometimes removal of the uterus will cause
damage to the nerves and blood supply to the ovaries. In this
case, a woman may experience some menopausal changes. These
changes will continue and may even worsen when the ovaries shut
down further and menopause occurs.
Timing of Menopause
In the Western world, the majority of women experience natural
menopause on average at about age 51, but it can occur as early
as in a woman's 30s and, rarely, as late as in her 60s. Indian
estimates have put the current age of menopause between 42 and
48 with the mean age around 45.5 years. Age of menopause is not
affected by the age of menarche, socioeconomic status of the
woman, her caste or creed, her socio epidemiological
characteristics like urban or rural origin, mental stresses and
strains, obesity, diet and nutritional status, number of
deliveries that she had or number of M.T.P. s she had in past,
oral pills taken for contraception or ovulogens taken, her
pattern of menstrual cycles, high altitude of living or living
at sea shore, whether she had sexual relations or not, whether
she had pelvic or urinary infections, etc.
Genetics are a key factor in determining the time of menopause.
Cigarette smoking can also influence the age of menopause;
smokers and even former smokers can reach menopause about two
years earlier than nonsmokers. However if a woman has an
inherited genetic predisposition she will have menopause early
or late as the case may be.
Menstrual patterns in natural menopause
Menopausal menstrual patterns are of three dominant types.
A) Abrupt cessation of menstruation.
B) Increase in the period between the cycles.
C) Reduction in the amount of blood loss
However, if menstrual cycles become heavy, it is not
physiological and requires investigations.
Typical Menopause-Related Changes
The six years or so immediately prior to natural menopause is
when menopause-related changes (sometimes mistakenly called
"symptoms") begin. This is the menopause transition or "perimenopause."
The perimenopausal years are a time of many changes.
Fluctuations in the levels of hormones produced by the aging
ovaries lead to normal, short-term physical changes such
irregular menstrual patterns (length of days, time between
periods, level of flow) and hot flashes (sudden warm feeling,
with blushing). These changes signal a need for a health checkup
to confirm their cause and consider ways to treat them, if
needed.
Other changes associated with perimenopause and menopause
include night sweats, fatigue (probably from disrupted sleep
patterns), mood swings, vaginal dryness, fluctuations in sexual
desire or response, forgetfulness, and difficulty sleeping.
Depression, headaches, dizziness, and heart palpitations have
not been proven to be related to menopause. As women move beyond
menopause into postmenopause, they may experience aging changes
which may or may not be related to prolonged periods of reduced
estrogen levels. Those include incontinence (involuntary leaking
of urine such as when coughing or sneezing ), as well as
increased risk of osteoporosis (thinning of the bones) and heart
disease.
Although there is a wide range of possible menopause-related
conditions, most women going through natural menopause have
minimal disturbances during the perimenopausal years. Indeed,
the majority continues to function well. Many disturbances
diminish or disappear over time.
Achieving Optimal Health
There are no pat or universal answers to help assure a
woman the best quality of life through perimenopause and beyond.
Although there is much research ongoing to help provide better
guidelines, today's woman -- with her healthcare providers --
must determine her own individual health status and risk factors
for developing diseases in later years. If therapy is needed,
there are many available options from which to choose: lifestyle
modification, nonprescription remedies, and prescription
therapies.
Healthy Lifestyle
Maintaining a healthy lifestyle can have an enormous impact on
health. Smoking is the single greatest preventable cause of
illness and premature death; women who smoke are strongly urged
to stop. Getting adequate exercise and eating a healthy diet
(especially with adequate vitamin D and calcium for strong
bones) are also important. Controlling weight and managing
stress are additional lifestyle factors that contribute to
optimal health.
Nonprescription Remedies
Many women find relief from short-term menopause-related
changes with nonprescription remedies. Products such as vitamin
E and vitamin B complex, as well as certain herbs such as black
cohosh, appear to have helped some women with hot flashes and
other changes. However, more studies are needed to fully
determine the possible benefits and risks of herbal medicines.
Foods made from soybeans -- such as soy milk, roasted soy nuts,
and tofu -- have also been helpful with hot flashes, and have
been shown to lower serum cholesterol (associated with lowering
heart disease risk).
Women with minor vaginal dryness can use special vaginal
lubricants. For severe vaginal changes, a vaginal prescription
estrogen product (such as a cream or ring) is the treatment of
choice.
Prescription Therapies
Prescription estrogen replacement therapy (ERT) has been
widely studied and used for over 50 years for a wide array of
menopause-related disturbances. ERT is available in many
convenient forms to help individualize treatment for each woman.
When ERT is taken in the form of oral tablets, skin patches, or
injections, it circulates through the body and reduces or stops
completely the short-term changes of menopause such as hot
flashes, disturbed sleep, and vaginal dryness.
Some of these ERT products have been shown to prevent
osteoporosis, a long-term consequence of lowered estrogen
levels. To keep bones strong, ERT should be taken from menopause
throughout a woman's life, since stopping treatment allows bone
loss to resume. In addition, evidence shows that by using ERT,
menopausal women can reduce the risk of heart disease by up to
50 percent. Vaginal ERT products help with vaginal dryness, more
severe vaginal changes, and bladder effects; since very little
vaginal estrogen enters the systemic circulation, it may or may
not help with hot flashes or the prevention of osteoporosis or
heart disease.
For women who have experienced natural menopause and still have
their uterus, the use of unopposed ERT (ERT alone) is associated
with an increase in the risk of endometrial cancer (cancer of
the lining of the uterus). However, by taking a form of another
prescription hormone (progestogen) along with estrogen, it is
well established that the risk of endometrial cancer is reduced
substantially, almost to the level of taking no hormones at all.
The combination therapy of estrogen plus progestogen is called
hormone replacement therapy (HRT).
Progestogen helps provide protection to the uterus by keeping
the endometrium from thickening (caused by estrogen). With some
women and some dosing schedules, the endometrial lining sheds
from the uterus through the vagina. Some women find this HRT-induced
bleeding to be an unacceptable nuisance, although with modern
dosage regimens the bleeding often dwindles or stops completely
over time.
Surgical menopause may have a negative effect on sex drive.
Another prescription hormone -- testosterone -- is sometimes
prescribed to help. Other prescription medicines are also
options for certain short-term menopause-related changes:
low-dose oral contraceptives, clonidine, belladonna-containing
products, and megestrol acetate. Still other prescription drugs
may not help with short-term complaints, but may help prevent
long-term effects of prolonged lower levels of estrogen. If
lifestyle changes are not enough, drugs such as alendronate or
raloxifene will help prevent osteoporosis; many drugs can help
to prevent heart disease by keeping blood pressure and
cholesterol under control.
Weighing Benefits versus Risks
All treatments -- even those available without a
prescription -- have potential risks. For example, while
progestogen helps protect against an increased risk in
endometrial cancer from taking ERT alone, it may increase fluid
retention, cause headaches and breast tenderness, and alter a
woman's mood. An important disadvantage of taking progestogen
may be the lowering of levels of so-called "good cholesterol" (HDL)
that increases when taking estrogen alone. This means that
progestogen may reduce estrogen's protective effect on the
heart.
In some studies, ERT has been linked to an increased risk of
breast cancer. A few studies have observed as much as a 40% risk
increase when taking ERT for over five years. The relationship
between ERT and breast cancer remains a controversial issue. The
North American Menopause Society believes that insufficient data
prevent the Society from making a more definitive statement
about ERT and breast cancer risk. It is likely that an answer
will not be available for years. However, some epidemiologists
have pointed out that, for women at high risk for heart disease
or osteoporosis, the benefits of ERT may outweigh its risks.
Each Woman is Unique
Prescription ERT (or HRT if a uterus is present) appears to
be the treatment of choice for women who experience premature
menopause (either natural or induced) because it not only
prevents short-term disturbances but also helps protect against
increased risks of both osteoporosis and heart disease.
Similarly, women with a personal or family history of either or
both of these conditions should seriously consider ERT.
However, for most women experiencing natural menopause, the
decision to seek prescription treatment will be based on four
factors:
1. the severity of their short-term complaints,
2. their attitudes toward both menopause and medication,
3. if they are predisposed to developing heart disease or
osteoporosis later on, and
4. The potential risks and benefits of each available treatment.
When it comes to menopause treatment, one size does not fit all.
Each woman is unique and must make her own informed decisions
about her health. All midlife women are urged to consult their
healthcare providers at this time in their lives.
Hopefully, most women in the menopause transition will examine
and -- where possible -- improve dietary, exercise, and other
lifestyle factors. Stopping smoking as well as exercising and
eating right can reduce many short-term disturbances, and even
risk of serious disease later on in life. With proper treatment,
most if not all menopause-related disturbances decrease or
disappear. Many women in the menopause transition will find
ample help from lifestyle management and nonprescription
remedies such as vitamins and herbs -- knowing that the upsets
of menopause are temporary, and that a time of stability and
serenity waits.
"Natural" Products
Increasing numbers of midlife women with concerns about the
potential long-term sequelae of hormone replacement therapy are
looking to over-the-counter progesterone creams for a "natural"
solution. Claims made by the manufacturers of these "natural"
compounds range from "...7-8% bone mass density increase in the
first year [of use]," to "...relief of the symptoms of PMS and
menopause, as well as osteoporosis." However, this requires
scientific scrutiny before being put to mass use.
Menopause Management as a Public Health Issue
By the year 2030, 1.2 billion women in the world are
expected to be age 50 and above. In the 1990s, approximately
24.5 million women worldwide will reach menopause each year.
Proactively managing menopause is an opportunity for millions of
women to prevent disease, and improve their long-term health and
quality of life.
Epilogue
Menopause like pregnancy is a physiological event that
brings the patient and the clinician together. Contrary to
popular opinion, the menopause is not a signal of impending
decline, but rather wonderful phenomenon that can signal the
start of something very positive a good health program. Post
menopausal hormone therapy is an option that should be
considered by virtually all women as a legitimate part of their
preventive health programme.
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