MENOPAUSE: POSITIVELY NOT THE END

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 soya beans -- 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.