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Menopause

Menopause is an important milestone and may be one of the first times a woman seeks medical advice around issues of long-term health promotion and disease prevention.

Menopause is a normal part of life, just like puberty. It is the time of your last menstrual period. You may notice changes in your body before and after menopause. The transition usually has three parts: perimenopause, menopause, and postmenopause.

Women are born with about a million eggs in each ovary. At puberty approximately 300,000 eggs remain, and by menopause there are no active eggs left.

On average, a woman will have 400-500 periods in her lifetime. From about 35-40 years of age, the number of eggs left in your ovaries decrease quickly and you ovulate (release an egg from the ovary) less regularly until your periods stop.

Natural menopause is the permanent ending of menstruation that is not brought on by any type of medical treatment. For women undergoing natural menopause, the process is gradual and is described in three stages –

Perimenopause or “menopause transition” – Perimenopause can begin 8 to 10 years before menopause, when the ovaries gradually produce less estrogen. It usually starts in a woman’s 40s, but can start in the 30s as well. Perimenopause lasts up until menopause, the point when the ovaries stop releasing eggs. In the last 1-2 years of perimenopause, the drop in estrogen accelerates. At this stage, many women can experience menopause symptoms. Women are still having menstrual cycles during this time, and can get pregnant.

Menopause – Menopause is the point when a woman no longer has menstrual periods. At this stage, the ovaries have stopped releasing eggs and producing most of their estrogen. Menopause is diagnosed when a woman has gone without a period for 12 consecutive months.

Postmenopause – These are the years after menopause. During this stage, menopausal symptoms, such as hot flashes, can ease for most women. But, as a result of a lower level of estrogen, postmenopausal women are at increased risk for a number of health conditions, such as osteoporosis and heart disease. Medication, such as hormone therapy and/or healthy lifestyle changes, may reduce the risk of some of these conditions. Since every woman’s risk is different, talk to your doctor to learn what steps you can take to reduce your individual risk.

Hormones and Menopause

Hormones are chemicals made in your body, which relay messages through the blood stream. They alert the body that it is time to do something. They help control many body functions such as growth, energy, repair of cells, reproduction, sexual function, digestion and the body’s temperature. They alert the body to eat, to stop eating, to sleep, to wake up, to grow, or when hormone levels decrease, to stop growing.

 

The three hormones of particular relevance at menopause are –

  • Oestrogen – The hormone oestrogen is made up of a group of three hormones: oestradiol, oestrone and oestriol. It is produced from the cells around the eggs in your ovaries. Oestrogen acts in the vagina, uterus, skin, bowel, liver, heart, blood, brain and throughout most of the body. The production of oestrogen fluctuates during the transition to menopause (perimenopause).

 

  • Progesterone – Progesterone, another natural female hormone, decreases toward menopause. Progesterone is responsible for changes to mucus in the cervix, from thin to thicker. It reduces acidity levels in the vagina, works on milk cells in the breast, and also can make us more moody.

 

 

  • Testosterone – Testosterone is produced by the ovaries and in other parts of the body, such as the adrenal glands (which sit above the kidney). Rather than a sudden or dramatic drop at menopause, testosterone decreases gradually with age. In some women, levels fall by half between the ages of 20-40 years.

Menopausal symptoms are created by changes in the levels of these hormones. These changes usually happen over months or years as you approach menopause. If you have menopause induced by surgery or cancer treatment, there can be a sudden drop in some of these hormones, causing symptoms to be more severe.

Menopause, when it occurs between the ages of 45 and 55, is considered “natural” and is a normal part of aging. But, some women can experience menopause early, either as a result of a surgical intervention (such as hysterectomy) or damage to the ovaries (such as from chemotherapy). Menopause that occurs before the age of 45, regardless of the cause, is called early menopause. Menopause that occurs at 40 or younger is considered premature menopause.

Causes

Natural Menopause – Natural menopause occurs at the expected age of around 51-52 – it is considered a natural life event due to ovaries running out of eggs.

Induced menopause – Chemotherapy & radiotherapy induced menopause. Menopause may happen as a result of chemotherapy and/or radiotherapy treatment for cancer because the treatments can cause ovaries to stop working.

Primary ovarian insufficiency (POI) – When periods stop spontaneously, either prematurely or early, this is referred to as ‘primary ovarian insufficiency’. This can be the result of several conditions or an unknown cause.

Menopause due to surgery

  • Removal of ovaries – Menopause occurs when a woman who is still having periods has surgery to remove both ovaries (oophorectomy). When the ovaries are removed, the levels of oestrogen and progesterone fall. These are hormones produced from eggs and ovulation (the release of an egg). Because ovaries are the main source of the hormone testosterone, these levels can also drop.
  • Hysterectomy – Sometimes there is confusion about whether having a hysterectomy (the removal of the uterus) will put you into menopause. If your uterus is removed but you still have your ovaries, you will not necessarily go straight into menopause. 10-12% of women who have a hysterectomy and keep their ovaries have menopause approximately one to four years earlier than their expected menopause.

Other Causes

Some women may experience premature menopause – their ovaries fail earlier than they are supposed to (before the age of 45). Ovarian failure can occur at any age – but very rarely – and often the doctor and patient will never find out why. Some who experience ovarian failure may still have periods and some degree of fertility for a while. Premature menopause may be caused by –

  • Enzyme deficiencies
  • Down’s syndrome
  • Turner’s syndrome
  • Addison’s disease
  • Hypothyroidism
  • Some infections – such as mumps or TB (tuberculosis), malaria and varicella. However, in all cases risk of ovarian failure is extremely small.
  • Genetic factors – scientists have been able to identify genetic factors that influence the age at which natural menopause occurs.
  • Being a twin – twins are more likely to have a premature menopause.

Smoking can lead to early menopause.

Symptoms

The hormone changes that happen around menopause affect every woman differently. Also, symptoms sometimes are not caused by menopause but by other aspects of aging instead. Some changes that might start in the years around menopause include –

Irregular periods – This is usually the first symptom; menstrual pattern changes. Some women may experience a period every two to three weeks, while others will not have one for months at a time.

Hot flashes (or flushes) – This is a sudden feeling of heat in the upper body. It may start in the face, neck or chest, and then spreads upwards or downwards (depending on where it started). The skin on the face, neck or chest may redden and become patchy, and the woman typically starts to sweat. The heart rate may suddenly increase (tachycardia), or it may become irregular or stronger than usual (palpitations). Hot flashes generally occur during the first year after a woman’s final period.

Trouble sleeping – Sleeping problems are generally caused by night sweats, but not always. Sleep disturbance may be caused by insomnia or anxiety. Difficulty falling asleep and staying asleep increase as women go through menopause.

Night sweats – If the hot flashes happen in bed they are called night sweats. Most women say their hot flashes do not last more than a few minutes.

Vaginal Dryness – This may be accompanied by itching and/or discomfort. It tends to happen during the peri-menopause. Some women may experience dyspareunia (pain during sex). The term vaginal atrophy refers to an inflammation of the vagina as a result of the thinning and shrinking of the tissues, as well as decreased lubrication, caused by a lack of estrogen.

Low Fertility – During the peri-menopausal stage of a woman’s life, her estrogen levels will drop significantly, lowering her chances of becoming pregnant.

Mood changes – Moodiness often goes hand-in-hand with sleep disturbance. Experts say that most mood disturbances are triggered by poor sleep.

Urinary Problems – Women tend to be more susceptible to urinary tract infections, such as cystitis. Having to urinate may also occur more frequently.

Changing feelings about sex – Lack of interest in sex.

Problems focusing and learning – Some women may also have short-term memory problems, as well as finding it hard to concentrate on something for long. Some women may not be able to learn as well shortly before menopause compared to other stages in life.

Women who are still in the menopause transition (perimenopause) may experience the above as well as –

  • Breast tenderness
  • Worsening of premenstrual syndrome (PMS)
  • Irregular periods or skipping periods
  • Periods that are heavier or lighter than usual

Some women might also experience –

  • Racing heart
  • Headaches
  • Joint and muscle aches and pains
  • Changes in libido (sex drive)
  • Difficulty concentrating, memory lapses (often temporary)
  • Weight gain
  • Hair loss or thinning

These symptoms can be a sign that the ovaries are producing less estrogen. Not all women get all of these symptoms. However, women affected with new symptoms of racing heart, urinary changes, headaches, or other new medical problems should see a doctor to make sure there is no other cause for these symptoms.

Complications

Osteoporosis – Day in and day out, your body is busy breaking down old bone and replacing it with new healthy bone. Estrogen helps control bone loss, and losing estrogen around the time of menopause causes women to lose more bone than is replaced. In time, bones can become weak and break easily. This condition is called osteoporosis.

Heart disease – After menopause, women are more likely to have heart disease. Changes in estrogen levels may be part of the cause. But, so is getting older. As you age, you may gain weight and develop other problems, like high blood pressure. These could put you at greater risk for heart disease.

Urinary incontinence – The menopause causes the tissues of the vagina and urethra to lose their elasticity, which can result in frequent, sudden, strong urges to urinate, followed by urge incontinence (involuntary loss of urine). Stress incontinence may also become a problem – urinating involuntarily after coughing, sneezing, laughing, lifting something, or suddenly jerking the body as may happen when we temporarily lose our balance.

Low libido – This is probably linked to disturbed sleep, depression symptoms, and night sweats, a study found.

Overweight/obesity – During the menopausal transition women are much more susceptible to weight gain. Experts say women may need to consume about 200 to 400 fewer calories each day just to prevent weight gain – or burn of that number of calories each day with extra exercise. The chances of becoming obese rises significantly after the menopause.

Breast cancer – women are at a higher risk of breast cancer after the menopause. Regular exercise after menopause significantly reduces breast cancer risk.

Treatment

Paroxetine for the treatment of hot flashes caused by menopause, the first non-hormonal treatment to be FDA-approved for hot flashes linked to menopause.

HRT (hormone replacement therapy) – Also known as HT (hormone therapy), this is very effective for many of the symptoms that occur during the menopause, including vaginal dryness, vaginal itching, vaginal discomfort, urinary problems, bone-density loss, hot flashes and night sweats.

Low-dose antidepressants – SSRIs (selective serotonin reuptake inhibitors) have been shown to decrease menopausal hot flashes. Drugs include venlafaxine (Effexor), fluoxetine (Prozac, Sarafem), paroxetine (Paxil, others), citalopram (Celexa) and sertraline (Zoloft).

Omega 3s – Omega-3s may ease psychological distress and depressive symptoms often suffered by menopausal and peri-menopausal women.

Gabapentin (Neurontin) – This medication is effective in treating hot flashes. It is commonly used for treating seizures (epilepsy).

Clonidine (Catapres) – This can be taken either orally as a pill or placed on the skin as a patch. It is effective in treating hot flashes. The drug is commonly used for treating high blood pressure (hypertension). However, unpleasant side-effects are common.

Osteoporosis treatments – Depending on individual needs, doctors may recommend medication to prevent or treat osteoporosis. Several medications are available that help reduce bone loss and risk of fractures.

Vaginal estrogen – Vaginal estrogen may be applied locally using a tablet, ring or cream. This medication effectively treats vaginal dryness, discomfort during intercourse, as well as some urinary problems. A small amount of estrogen is released and absorbed by the vaginal tissue.

Alternative Treatment

Black cohosh may work for hot flushes and night sweats but more studies are needed to see whether there is a real benefit. It can have minor side effects such as stomach upsets or rashes. Serious side effects affecting the liver are rare. You should stop taking black cohosh immediately if you have jaundice (yellowing of your skin and eyes), if you have severe stomach pains with nausea and vomiting or if you go off your food.

Chasteberry (agnus castus), selenium, vitamin C and herbs such as ginkgo biloba, hops, sage leaf, liquorice and valerian root are taken by some women but there are very few studies on whether any of these work for menopausal symptoms.

Dehydroepiandrosterone (DHEA) may have a positive effect on your sense of wellbeing, improving your memory, sexual libido and potentially reducing vaginal dryness. However, the longterm effects are unknown. Further studies are needed to see whether DHEA helps hot flushes.

Calcium, as estrogen levels decline with menopause, women are at risk for osteoporosis. Calcium citrate seems to be more easily absorbed by the body, but it has less elemental calcium than calcium carbonate. Calcium carbonate, however, needs an acid environment to be absorbed, so is best taken with a glass of orange juice.

Omega-3 fatty acids help reduce LDL (“bad”) cholesterol and lower the risk of heart disease. Women who are at greater risk of heart disease after menopause may want to ask their doctor whether they should take a fish oil supplement, or simply increase the amount of fish they eat.

Phytoestrogens are plant substances that have similar effects to estrogen.

Acupuncture – Several studies show acupuncture may help many women with symptoms of menopause, particularly with hot flashes and mood changes.

Reflexology: there have been very few studies of reflexology and whether it helps menopausal symptoms and more studies are needed to see whether it helps.

 

Reference –

https://jeanhailes.org.au/health-a-z/menopause/about-menopause

http://www.menopause.org.au/

http://www.medicinenet.com/menopause/article.htm

https://www.nhlbi.nih.gov/files/docs/pht_facts.pdf

https://my.clevelandclinic.org/health/diseases_conditions/hic-what-is-perimenopause-menopause-postmenopause

https://www.aace.com/files/menopause.pdf

https://www.womenshealth.gov/publications/our-publications/fact-sheet/menopause-treatment.pdf

https://www.womentowomen.com/menopause-perimenopause/am-i-in-menopause-2/

http://www.webmd.com/menopause/