Cessation of menses: “Menopause” occurs as a natural process of ageing and is primarily caused by the depletion of the ovarian reserve as well as a consequent fall in the level of the ovarian hormones oestrogen and progesterone.
Let us break down the term “Menopause”: MEN+PAUEIN. The word “men” mean month, which is closely related to the word for moon “mene” as the months were measured by the moon. The word “pauein” means to cease or to stop.
In the western countries, the typical age of menopause is between 40-59 years and the average age for last period is 51 years. In India, the natural age of menopause is 44 years.
What are the causes of Menopause?
*If menopause occurs at the age before the age of 40, it is called as “Premature Menopause”. It is usually caused by premature ovarian failure and occurs in less than 2% of cases.
It can also occur due to:
- Surgery as in the case of hysterectomy (removal of the uterus) with or without oophorectomy( removal of the ovaries).
- Irradiation for malignancies can also lead to cessation of ovarian function and menopause
What is Perimenopause?
The term "perimenopause", which literally means "around the menopause", refers to the menopause transition years, a time before and after the date of the final episode of menstrual flow. This transition into menopause is referred to as the climacteric and can be divided into three phases - the pre-menopause, the menopause and the post-menopause. This transition can last for four to eight years and in some cases even up to 12 years. The menopause is diagnosed after 12 months have elapsed after the last period. Thereafter the period is the post-menopausal phase.
What are the Symptoms of the menopause?
Dr. Shishta Nanda Basu says, Perimenopause and menopause lead to many physical, emotional and psychological changes. In the months or years leading up to menopause (perimenopause), the woman may experience varying degree of various signs and symptoms.
The common problems of the perimenopause are:
- Irregular periods
- Vaginal dryness
- Hot flashes
- Night sweats
- Sleep problems
- Mood changes
- Weight gain
- Slowed metabolism
- Thinning of hair and dry skin and loss of breast fullness
Skipping periods during perimenopause is common; however, if you have irregular periods, pregnancy is possible. Hence if a woman misses her period pregnancy should be ruled out.
Another factor which needs to be borne in mind is that after menopause, the risk of certain medical conditions like a Cardiovascular disease, osteoporosis, weight gain, urinary incontinence, sexual dysfunction increases.
Is there any Diagnosis?
This can be made by taking a detailed history and excluding other causes of missed periods viz. pregnancy, thyroid disorders, elevated prolactin levels and use of antidepressants and other medications. Once the causes have been ruled out measuring the levels of hormones will help to confirm the diagnosis. The oestrogen levels fall and the FSH (Follicle stimulating hormone) level rises. If you have FSH levels of 35 ng/dl or more, then it is an indicator of menopause.
How can you Manage Menopause?
Menopause in itself does not require treatment as it is a natural process of ageing. The may treatments used are to alleviate the troublesome symptoms which might be affecting the life of the patient.
- Cardiovascular disease: When the oestrogen levels decline, the risk of cardiovascular disease increases. Heart disease is the leading cause of death in women as well as in men. So it's important to get regular exercise, eat a healthy diet and maintain a normal weight.
- Osteoporosis: The bones become brittle and weak, leading to an increased risk of fractures. Postmenopausal women with osteoporosis are especially susceptible to fractures of their hips, wrists and spine.
- Urinary incontinence: The tissues of the vagina and urethra lose elasticity, causing frequency, followed by an involuntary loss of urine (urge incontinence), or the loss of urine with coughing, laughing or lifting (stress incontinence).Urinary tract infections may occur more often.
- Strengthening pelvic floor muscles with Kegel exercises and using a topical vaginal oestrogen may help relieve symptoms of incontinence.
- Sexual function: Vaginal dryness from decreased moisture production and loss of elasticity can cause discomfort and slight bleeding during sexual intercourse. Decreased sensation may decrease the libido.
- Water-based vaginal moisturisers and lubricants may help. Choose products that don't contain glycerin because women who are sensitive to this chemical may experience burning and irritation. If a vaginal lubricant isn't enough, many women benefit from the use of local vaginal oestrogen treatment, available as a vaginal cream, tablet or ring.
- Weight gain: Many women gain weight during the menopausal transition and after menopause because metabolism slows. The diet needs to be modified to eat less and exercise more, just to maintain weight.
Treatment modalities: The various treatments used for menopausal symptoms are:
- Hormone therapy: Oestrogen therapy remains, by far, the most effective treatment option for relieving menopausal hot flashes. Oestrogen also helps to prevent bone loss and may have beneficial effects on the cardiovascular system. If started within 5 years of your last menstrual cycle, it can significantly benefit your health. If a woman has an intact uterus, progesterone will have to be added to oestrogen to negate the risk of endometrial cancer with unopposed oestrogen. Adding testosterone to hormone therapy has a positive effect on sexual function in postmenopausal women, although it may be accompanied by hair growth, acne and a reduction in high-density lipoprotein (HDL) cholesterol. These side effects diverge depending on the doses and methods of using testosterone
- Vaginal Oestrogen: To relieve vaginal dryness, oestrogen can be administered directly to the vagina using a vaginal cream, tablet or ring. This treatment releases just a small amount of oestrogen, which is absorbed by the vaginal tissues. It can help relieve vaginal dryness, discomfort with intercourse and some urinary symptoms.
- Selective Oestrogen receptor modulators (SERMS): SERMs are a category of drugs, either synthetically produced or derived from a botanical source, that act selectively as agonists or antagonists of the oestrogen receptors throughout the body. The most commonly prescribed SERMs are raloxifene and tamoxifen. Raloxifene exhibits oestrogen agonist activity on bone and lipids, and antagonist activity on breast and the endometrium. Tamoxifen is in widespread use for treatment of hormone-sensitive breast cancer. Raloxifene prevents vertebral fractures in postmenopausal, osteoporotic women and reduces the risk of invasive breast cancer.
- Low-dose antidepressants: Certain antidepressants related to the class of drugs called selective serotonin reuptake inhibitors (SSRIs) may decrease menopausal hot flashes. A low-dose antidepressant for management of hot flashes may be useful for women who can't take oestrogen for health reasons or for women who need an antidepressant for a mood disorder.
- Gabapentin: Gabapentin is approved to treat seizures, but it has also been shown to help reduce hot flashes. This drug is useful in women who can't use oestrogen therapy and in those who also have migraines.
- Medications to prevent or treat osteoporosis: Depending on individual needs, doctors may recommend medication to prevent or treat osteoporosis. Several medications are available that help reduces bone loss and risk of fractures.
What should be the Lifestyle modifications?
- Medication may not always be required and making lifestyle modifications may be beneficial in alleviating many symptoms of menopause.
- Hot flashes: Dress in light layers of clothing, keeping the temperature cooler, avoiding too many hot drinks and tea and coffee, spicy food, alcohol, stress smoking will go a long way in helping women to cope with menopausal symptoms.
- Decreasing vaginal discomfort: Water-based vaginal lubricants (K-Y jelly, others) or moisturisers and use of natural oils can help. Staying sexually active also helps by increasing blood flow to the vagina.
- Getting enough sleep: Avoiding caffeine, which can make it hard to get to sleep, and avoid drinking too much alcohol, can interrupt sleep.
- The practice of yoga and relaxation techniques: Techniques such as yoga, deep breathing, paced breathing, guided imagery, massage and progressive muscle relaxation can help relieve menopausal symptoms.
- Strengthening the pelvic floor: Pelvic floor muscle exercises, called Kegel exercises, can improve some forms of urinary incontinence.
- Balanced diet: Including a variety of fruits, vegetables and whole grains and limiting saturated fats, oils and sugars are helpful in keeping you healthy.
- Avoid smoking: Smoking increases the risk of heart disease, stroke, osteoporosis, cancer and a range of other health problems. It may also increase hot flashes and brings on earlier menopause.
- Regular exercise: Regular physical activity or exercise on most days to help protect against heart disease, diabetes, osteoporosis and other conditions associated with ageing.
Are there Alternative medicines?
Many approaches have been promoted as aids in managing the symptoms of menopause. Some complementary and alternative treatments that have been or are being studied include:
Plant oestrogens (phytoestrogens). These oestrogens occur naturally in certain foods. There are two main types of phytoestrogens — isoflavones and lignans. Isoflavones are found in soybeans, chickpeas and other legumes and certain spices like turmeric, ginger and cinnamon. Lignans occur in flaxseed, whole grains, nuts and some fruits and vegetables.
However, since many of them have estrogenic properties these should be taken under the supervision of a doctor if consumed as a medication.
Bioidentical hormones. The term "bioidentical" implies the hormones in the product are chemically identical to those your body produces. However, these should also be taken under the supervision of a doctor.
Black cohosh. Black cohosh has been popular among many women with menopausal symptoms. But there's little evidence that black cohosh is effective, and the supplement can be harmful to the liver.
Yoga. Some studies show that yoga may be effective in decreasing the number of hot flashes in perimenopausal women. Tai chi and qi gong, which is a series of slow movements and meditation, may produce similar results. It's best to take a class to learn how to perform postures and proper breathing techniques.
Acupuncture. Acupuncture may have some temporary benefit in helping to reduce hot flashes.
Menopause is a natural process of ageing and should not be considered an illness. Women should be counselled and encouraged to adopt healthy, active lifestyle in order to lead happy fruitful lives.