The term means the ending of menstrual cycles which is the central
external marker of human fertility and occurs after six months of secondary
amenorrhea in women aged 45 years or older.
It is the transition from fertility to infertility state.
The cause of the menopause is depletion of oocytes and primordial follicles
from the ovaries and the subsequent cessation of estrogen production.
The cessation of cyclic bleeding takes many forms;
The menstrual cycle may stop abruptly or may cease after a stage of
polymenorrhea followed by a stage of oligo menorrhea.
Other causes of menopause :-
1- Surgical menopause :-
Surgical removal of both ovaries for any reason like ovarian cancer.
Studies have indicated the median age of menopause in hysterectomized patients
can be given at time of operation; indicating which patients may or may not
be affected.
2- Premature ovarian failure (POF) :-
Secondary amenorrhea due to ovarian failure may occur at any age and if below
age 45 years may be accounted as premature, these patients exhibit low plasma
estrogen, high levels of follicle stimulating hormone (FSH) and (LH). (POF)
is associated with other autoimmune endocrinopathies and in about half of the
patients other antibodies are present.
3- Radiation and chemotherapy:-
The management of malignant disease in young women may provoke menopause in
two ways; in women with breast cancer treated with radiotherapy, menopause may
still be used to suppress estrogen output and the use of chemotheraputic agents
in breast cancer or lymphomas may suppress and indeed arrest ovarian cyclic
activity.
Symptoms of menopause
1- Vasomotor symptoms :-
The most noticeable consequences of the drop in estrogen levels are vasomotor
symptoms in the form of hot flushes and night sweats. These are common and
occur in at least 70-80% of women.
Their frequency varies widely from a few to several dozen attacks per day and
the duration may be from a few weeks to many years.
2- Insomnia
Patient may experience repeated awakening from sleep with consequent loss of
sleeping -hour quantity and quality.
3- Psychological symptoms: including
Mood swings, anxiety, lack of concentration, depression and loss of short-term
memory.
4- Vaginal dryness :-
Estrogen deficiency results in epithelial and connective tissue atrophy in the
vaginal wall causing vaginal dryness and dyspareunia.
5- Urinary symptoms :-
Estrogen deficiency results in atrophy in the urethral wall predisposing to stress incontinence and atrophy in the trigone area of
the bladder resulting in urgency and urge incontinence.
6- Osteoporosis :-
In the early post menopausal years the density of bone in women decreases at
a faster rate than at any other time with greater bone resorption to formation
ratio.
In many women this process results in osteopenia which strongly predisposes
to fractures.
By the age of 70, 25% of women will have vertebral fractures, 15% will develop
hip fractures and 15% will develop fractures of the wrist.
Risk factor for osteoporosis:-
1- Family history of osteoporosis.
2- Smoking, alcohol abuse.
3- Early menopause.
4- History of prolonged immobilization.
5- Treatment with corticosteroids or heparin.
6- Medical conditions; hyperthyroidism, Cushing's disease, chronic renal failure
and hepatic insufficiency.
7- Black women are less likely to develop osteoporosis than white or Asian women.
Thin women are more likely to develop osteoporosis than fat women.
Cardio vascular system:-
The function of the heart and great vessels is now known to be affected by the
presence and absence of oestradiol.
It has been known for many years that the incidence of myocardial infraction
is much lower in pre-menopausal women than in men of the same age, the decline
in plasma estrogen results in changes in lipid profile with promotion of both
atherogenesis and vasoconstriction as estrogen exerts direct effects on the
vessel wall.
"Dietary changes and menopause"
Diet is thought to be one factor that helps in the explanation of the cultural
differences in the menopausal symptoms.
Asian women experience fewer menopausal symptoms and lower rates of hip fractures
than western women. This is related to their diets which contain high levels
of phytoestrogens (naturally occurring estrogens), about 200 mg daily as
compared to western
diet.
Phytoestrogens are structurally similar to oestradiol but much weaker than the
body's natural estrogen and have a cumulative effect when taken in sufficient
amounts.
Soybeans are the richest source of this substance. In the USA studies found
that foods and drugs containing specific amounts of Soya protein can lower cholesterol
and improve arterial function, reduce atherosclerosis then reduce cardiovascular
disease.
Studies have not shown any significant adverse effects due to phytoestrogens.
They are well tolerated and despite their cost, they remain a very popular supplement.
Some studies have suggested that multivitamins and mineral supplements can reduce
hot flushes but their effect may be partly dependent on the quality of the woman's
diet.
Supplementation of vitamin E 440-1200 I.U. daily reduces vasomotor symptoms.
Women in the menopause and not on HRT (hormone replacement therapy) are recommended to include 1500 mg of
calcium daily.
Some clinicians would recommend adding vitamin D 400 IU daily with calcium which
significantly reduces fracture risk.
Exercise in menopause :-
Exercise is effective in slowing the gradual long term ageing related bone loss
and is important to cardiac health , helping to reduce weight , blood pressure
and cholesterol levels.
Women who exercise regularly are less likely to suffer severe hot flushes and
depression and have less insomnia, together with providing a greater feeling
of well being.
The safest exercise to recommend to women is walking.
Women who walk for at least one hour per week experience about half the
coronary heart disease risk than women who do not walk regularly.
Hormone replacement therapy (HRT)
Hormone replacement therapy has now been available for more than 25 years and
its use is growing rapidly.
HRT can effectively reverse all the effects of the menopause but should be given
under medical supervision.
- Continuous estrogen- progestogen preparations
This type of therapy is taken every day without interruption and prevents endometrial
proliferation. Their use therefore does not cause withdrawal bleeding, and the majority
of postmenopausal women prefer a bleeding free hormone treatment.
- Cyclic estrogen- progestogen preparations
In this type of therapy estrogen is taken for 21 days and is combined with a
progestogen for the last 10 days following which there is a 4-7 day medication
free interval during which withdrawal bleeding occurs.
This type relieves the symptoms effectively and regulates the cycle.
- Tibolone (Livial) :-
This type of therapy is a synthetic steroid which exhibits estrogenic, progestogenic
and androgenic activity, given in a dose of 2-5 mg daily to women at least one
year after menopause and results in the suppression of symptoms and the prevention
of bone loss.
This preparation is well tolerated and the amenorrhea which is present in 80%
of patients by six months of use is usually warmly welcomed.
- Subcutaneous hormonal implants:-
This mode of treatment is restricted in the UK to patients who have undergone
hysterectomy with or without oophorectomy.
The procedure involves the positioning of a pellet of oestradiol in the subcutaneous
tissue , usually of the lower abdomen, under sterile conditions and local anesthetic.
This implant usually is reviewed at six monthly intervals.
They are very well tolerated and successfully treat menopausal symptoms and
protect against bone loss.
- Transdermal estrogen:-
This type of therapy is particularly used in older women. Patches are available
in varying strengths of 28 mg, 50,75 or 100 mg of estraodiol per day.
Seven day patches are now available.
Skin reactions are minimal and such treatment is well tolerated.
- Local estrogen:-
In this type of therapy estrogen is used in the form of cream, pessary or vaginal
ovules.
It is suitable for those women with local symptoms and in whom systemic
administration
of estrogen is hazardous.
Patients on HRT need a careful breast examination, pelvic examination and
blood pressure should be checked regularly along with a bone mineral density
scan to check for osteoporosis.
The patient may be reviewed every three months then at six monthly intervals
thereafter and then annually.
