Menopause :
 

What is the Perimenopause?

The perimenopause used to be considered the time of life during which a woman was past having children, but not yet past the menopause. Generally, MENOPAUSE was defined as one year without a period.However, this definition is now obsolete. Women are postponing having children until they are older, and treatment for infertility means that women can still conceive at an age when their fertility is declining.The perimenopause is a stage of life in which there is a collection of changes to the endocrine, or hormone, system of the body. These changes indicate a decline, but not a complete loss, in fertility.There is no simple biochemical marker to indicate when a woman enters the perimenopause.However, there is some relatively simple defining moments in the transition to menopause.The first is a break in your normal cycle of periods. You may skip a cycle, or bleed in between when you would normally have a period. This sign is associated with several changes to the hormones involved in reproduction.This transition time generally takes two to four years, and begins around the age of 47, except in women who smoke, who may enter this transition time two years earlier.

In the so-called "late" perimenopause, most women have at least three months, but less than 12 months, without a period. Once this stage has been reached, there is a fairly rapid transition into menopause. The final menstrual period is defined as one year without a period, but even at this point, some 10 percent of women have one or two more periods.

What happens to your body during this time?

The definition of perimenopause is so imprecise because the transition is a time in which there is waxing and waning of ovarian activity, with even increased oestrogen levels at various times.We know that as women age, what is called their ovarian reserve declines. This determines the number of times you will ovulate, which is finite, and declines until you stop once you have reached the menopause.

This means that fertility declines as you age. The reasons for this appear to be changes in the eggs which are produced by the ovaries, and changes in the hormones which control the release of these eggs. There are also changes to the lining of the womb, which affect both hormone production, and the ability of an egg to implant.

Once irregular cycles become the norm, you are not necessarily ovulating with each cycle.All these changes mean very complicated changes in the hormones which control ovulation and the menstrual cycle. As yet, there is no test which will definitely say that you are in the perimenopause, although a hormone profile will give some indication of what is happening, when interpreted by an experienced doctor.

What symptoms are associated with the perimenopause?

These vary from woman to woman, depending on each person's individual physiology.The most common symptom during the perimenopause is the hot flush, which can be mild, or bad enough to disturb sleep.Most people think that hot flushes are a symptom of lack of estrogen, but research has shown that they are most common just before the menopause, when estrogen levels can be high.Many women also experience such non-specific problems as irritability, dry eyes, joint pains, and general aches and pains. Problems with the digestion are also common.All these symptoms can be confused with depression and hypothyroidism, so these must also be ruled out.

Can the perimenopause be treated?

Some of the problems with bleeding and symptoms which are related to hormone imbalance can be treated using a low-dose oral contraceptive pill. This is now regarded as safe up to the menopause in most women.However, if you smoke, this option will not be open to you.Many women experience very heavy bleeding in the perimenopause. Before simply treating this, such problems as fibroids, polyps and endometrial cancer need to be ruled out.Most women will have no apparent cause for their heavy bleeding, and treatment with a particular type of non-steroidal anti-inflammatory drug, mefanamic acid etc can reduce blood flow by up to 50 percent.If medical treatment fails, then dilatation and curettage is often helpful.

Lifestyle changes can also relieve many of the symptoms of the perimenopause. Hot flushes will often reduce if spicy foods, caffeine, and alcohol are avoided.Calcium intake along with Vit-D is important in the perimenopause. Calcium amounts of 800 to 1000 mg/day are recommended in the perimenopause, increasing to 1200 to 1500 mg/day after menopause.

The perimenopause is the time marking your transition from reproductive to post reproductive life. It is usually a time of life in which many other changes are also taking place which can be very stressful.Perhaps it is also a time in which to re-evaluate a lot of things.Is this the time to finally give up smoking?

Once in your mid-40s you start to lose muscle mass, so this may well be the time to start a regular exercise program, combining aerobic exercise with strength training.Wake-up call for 40-plus women

Show the world that life begins at 40! Look after your body and feel good about yourself.

While stocks last, grab your share of “fresh veggies” from the kitchen markets. Eating and living healthy should be everyone's top priority where the numbers of new diseases affecting people are constantly on the rise It's also a myth that heart disease is 'a man's disease'.

Check out these statistics. At menopause, a woman's heart disease risk starts to increase significantly one in 12 women aged 45 to 64 has heart disease while one in four women over the age of 65 has heart disease. Beginning at age 50, more women than men have an elevated cholesterol level and women are more likely than men to die within a few weeks of a heart attack.About 35 percent of women who have had a heart attack will have another within six years. Women having Type 1 diabetes or hypertension are at even a higher risk.You should also be aware of common cancers that most often affect women like uterine and breast cancer.Cancer of the uterus, or the womb, usually occurs around the time perimenopause begins. The occasional reappearance of bleeding should not be considered a part of perimenopause.

It should always be checked by a physician. And ignoring the possibility that we may develop breast cancer or avoiding the processes to detect cancer, can be dangerous. The fact remains all women are at risk for breast cancer.

Early detection of problems provides the greatest possibility of successful treatment, which is why it's crucial to follow the 3-step Plan for Preventive Care, outlined below:

Step 1.

Breast Self-Examination (BSE) should be practiced by women from their 20s and continued throughout their life. BSE should be done regularly at the same time every month. Regular BSE teaches you to know how your breasts normally feel so that you can more readily detect any change. Changes may include:
♦ development of a lump
♦ discharge other than breast milk
♦ swelling of the breast
♦ skin irritation or dimpling
♦ nipple abnormalities (i.e., pain, redness, scaliness, turning inward)

If you notice any of them, see your physician.

Step 2 .

Clinical Breast Examination by a physician or nurse trained to evaluate breast problems every three years is recommended for women between the ages of 20 and 39, and every year for those above 40.

Step 3.

Mammography, a low-dose x-ray of the breasts, finds cancer or other problems before a lump becomes large enough to be felt, as well as assist in the diagnosis of other breast problems.

However, a biopsy is required to confirm the presence of cancer.

Women in their 40s and older should begin having a screening mammogram every one to two years or even every year, as per their physicians' recommendations.

Imperative perspective?

One can stay youthful and active in the face of all these problems through simple lifestyle strategies. For hot flashes, avoid possible dietary triggers, such as spicy foods, alcohol, and caffeine. Add tofu, soymilks, and other soy products to your diet. Exercise and stress-reduction techniques, such as yoga, may improve mood swings and sleeplessness. Simple Kegel exercises (squeezing and releasing the muscles that control urine flow) can help with UI.For vaginal dryness try using natural moisturizers, such as vitamin E oil, sesame oil, and olive oil.

What about heart and bone health and protection against CAD and osteoporosis?

Well, in addition to lifestyle strategies, such as a healthy diet, regular weight-bearing exercises, not smoking, supplementary calcium, vitamin D, and other medications can help you manage beautifully.

But do remember one vital point.

The symptoms of many medical conditions may resemble these problems( as mentioned above ) in perimenopause/menopause , so always consult a physician for diagnosis and hence, accurate treatment. Also, if you're considering hormone replacement therapy (HRT) or estrogen replacement therapy (ERT) to treat perimenopausal/menopausal symptoms or for heart disease protection, Remember that there's still a great deal of controversy regarding these methods,So the decision to start should be made only after you and your physician have evaluated the risk versus benefit ratio based on your family medical history, current health problems, and current clinical evaluation occurs is 50 years (range between 45-55years)

HORMONAL CHANGES

Aging ovaries to fail.
Two ovaries produce estrogen. Gradually amount of estrogen decline.

The pituitary secrets more gonadotrophins .FSH levels increase 10-20 fold ( > 40 – 50 i.u. ) and LH levels by 3 fold and Plasma estradiol levels rarely exceed 20 - 25 pg/ml at menopause.

 

SIGNS AND SYMPTOMS

Menopause is cessation of menstruation for a period more than 01 year.The changes due to ovarian failure may be divided into two groups:

  • Short –term consequences causing a varied symptomatology
  • Long term sequelae which proceed for many years before they become clinically apparent

SHORT TERM SEQUELAE

VASOMOTOR- Hot flushes, night sweats, palpitations, headaches.
PSYCHOLOGICAL- Irritability,lethargy,Emotional distress, forgetfulness, Loss of libido
UROGENITAL- Vaginal dryness, painful intercourse, difficult to hold urine, uncontrolled loss of urine while coughing / laughing , increased frequency of urine etc
SKIN- Dry hair ,Brittle nailsSkin becomes thinner as collagen decreases , Skin becomes dry,flaky,transparent bruising easily.

NAILS –brittle.

HAIR –dry.Estrogen receptors are present in skin,sweat glands and hair follicles

Estrogen deficiency is responsible for this skin atrophy.

LONG TERM SEQUELAE

OSTEOPOROSIS–

Gradual thinning of bones which makes it more susceptible to fracture- Defined as decreased amount of bony tissue per unit volume of bone, leading to structural weakness, loss of bone when resorption outstrips new bone formation & age related decline in bone formation with superimposed increase in bone resorption. Lack of estrogen affects bone metabolism Common sites of fracture are wrist, femoral neck, and vertebrae.

CARDIOVASCULAR DISEASE –

Protective role of estrogen against heart attack is gradually withdrawn correlated with natural failure of ovaries at menopause.

MENOPAUSE IS A PRO-ATHEROGENIC CONDITION.

Below the age of 50 years men are at 2 to2.5 times grater risk as compared to females for cardiovascular disease in women after menopause a phenomenon of CATCHING UP with their male cohorts is observed.

CAD (Coronary Artery Disease) death slightly more common in menopausal women (42%) than in men (39%).Again a number of studies have shown that Estrogen Replacement Therapy (ERT) administered post-menopausal women causes 35% reduction in CAD risk.

ESTROGENS ARE KNOWN TO HAVE THE FOLLOWING EFFECTS

  • Increase HDL and lower LDL

  • Lower VLDL cholesterol/Triglyceride ratio.

  • Estrogens are known to prevent the penetration of lipoprotein into the arterial intima.

  • Estrogens delay the oxidation of LDL.

  • Estrogens are also known to have a direct effect on the myocardium and on the aortic wall.

  • Estrogens were found to increase cardiac contractility, stroke volume and lower the left ventricular mass.

  • Estrogens also decrease peripheral resistance

RISK FACTORS OF DEVELOPMENT OF OSTEOPOROSIS

Female sex Loss of ovarian function

Race-European or Asian Nulli parity

Low body weight Poor diet in childhood

Alcohol abuse Heavy smoking

SECONDARY CAUSES OF BONE LOSS

Steroids Thyrotoxicosis Hyperparathyroidism

MENOPAUSE AND CENTRAL NERVOUS SYSTEM DISORDERS

Stroke is the third leading cause of death in American and European women. A 50 year old white woman has 20% lifetime probability of developing stroke and an 8% probability of dying of stroke.

Estrogens play an important role in the maintenance of the dense network of neural fibers connecting one cell to another, and of the synaptic activity facilitating cognitive thought and memory.

TREATING THE MENOPAUSAL PATIENT

EXERCISE

Weight bearing exercise has a positive influence on the maintenance of bone density. For those unaccustomed exercise, a brisk walk twenty minutes three times in a week may be recommended. Smoking and excessive intake of alcohol should be discouraged.

CALCIUM

The national Osteoporosis Society (U.K) recommends a calcium intake of 1,500 mg daily in women over 45, and at least 1,000 mg in women on HRT.

National health and Nutritional Examination survey II study showed that more than 75% of all adult women get less calcium than even the required daily allowance (RDA) and that 25% get less than 300 mg

SODIUM ALENDRONATE:

It is known to increase bone density.It is used orally cyclically for the treatment of vertebral osteoporosis.In a three month regimen 40 mg of alendronate is given daily(on empty stomach) for 14 days, followed by 500mg of calcium every day for 76 days to ensure sufficient mineralization.

At present, this therapy is recommended for three years.

ESTROGENAS HRT :

  • Lipid friendly
  • Cardiac friendly
  • They decrease the LDL and increase HDL in a dose dependant manner when used for a minimum of 3 to 4 years.

BENEFITS OF HRT

The benefits of HRT on bone metabolism need to be carefully weighed against the probable slight increase in the risk of breast cancer, which may occur only after more than ten years of use.

Women should be encouraged to continue with HRT as long as they feel the benefit, from a minimum period of five years and up to eight years.

INDICATIONS FOR HRT IN CAD

  • Women with angiographic ally proved CAD.
  • Women with Premature menopause (as a result of surgery, chemotherapy, radiation, or premature ovarian failure).
  • Women with risk factors for CAD such as :

 

Diabetes mellitus Hypertension Smoking

Family history of CAD Familial hyperlipidaemia

Total cholesterol/HDL-Cholesterol ratio more than five

RECOMMENDATION FOR DURATION OF USE

Patient choice to stop therapy

Reassure patient about benefits of long tem therapy

Judgment will depend upon presence of troublesome side effects and apparent beneficial effects.

 

INITIATING HRT -PATIENT MANAGEMENT

 

  • Height, weight and blood pressure to be recorded

  • Urine for protein and sugar

  • Breast examination ( Mammogram if indicated as discussed earlier )

  • Pelvic examination ( USG for ENDOMETRIAL THICKNESS in selected cases )

  • LFT(Liver function test)

  • Cytology( PAP’S Smear in Liquid/Slide )

  • Serum FSH helpful (a level of 50 iu per liter is diagnostic)

  • No place for routine endometrial biopsy or D&C (indicated if H/o intermenstrual, postcoital or postmenopausal bleeding present.)

  • First follow up should be after six weeks after HRT is initiated, further follow up every three months for first year and six monthly thereafter.

TREATMENT SHOULD BE STOPPED

  • If migraine appears or if headaches become severe and frequent.
  • Jaundice occurs.
  • Rise in the blood pressure
  • If trauma, illness or impending surgery is considered to entail a risk of thrombosis.

CONTRAINDICATIONS AND RISK OF HRT

Contraindications for Estrogen

A history of breast cancer

A history of endometrial cancer

Serious liver dysfunction

CONDITIONS IN WHICH HRT IS NOT CONTRAINDICATED

  • Prolactinoma Malignant melanoma

  • Liver adenoma Varicose

  • Diabetic mellitus Otosclerosis

  • Hyperthyroidism Sickle cell anemia

  • Hypertension Myocardial infarction

HRT AND CANCER RISK

Women using HRT do not seem to have an increased risk for malignancies of organs that do not belong to the female genital tract.

CARCINOMA OF THE ENDOMETRIUM:

  • Normal population/ never users of HRT have an incidence such that 1to3/1000 women develop carcinoma of the endometrial every year(Higher incidence in obese women).

  • Women using only Estrogens have an incidence such that 5 to 7/1000 women develop carcinoma of the endometrial every year.

  • If Progesterone is added to Estrogen therapy for at least 12 days (or more) the incidence of endometrial cancer is reduced to 0/1000 women per year.

CANCER RISK for breasts

HRT in a standard dose (estrogen 0.625 mg along with progesterone 2.5 mg) does not increase the chances of a women developing breast cancer when HRT is taken 8 to 10 years.

The High risk groups for breast cancer include women with:

  • Early menarche Late first pregnancy Late menopause

1st degree relative having breast cancer (mother, sister or daughter)

ADVICE FOR WOMEN WHO ARE AT INCREASED RISK FOR BREAST CANCER

A history of breast cancer or a family history of breast cancer has commonly been considered relative contra-indications for HRT.

At the moment, HRT in patients with a past history of breast cancer is controversial, since Estrogens may or may not active occult metastases lying dormant over a very long time–span in breast cancer.

CARCINOMA OF THE CERVIX:

No fear of this cancer developing with HRT.

ADVICE FOR HYSTERECTOMIZED WOMEN

Estrogen therapy may be administered continuously. These women can be prescribed HRT (in an adequate dosage with a view to preventing CAD and Osteoporosis) for a period of 5 years or less( till50yrs age) or maxm 8 yrs without an increase in breast cancer risk

THE BASIC RULES OF PRACTICAL HRT

  • Estrogen replacement therapy (ERT) should be prescribed continuously.

  • ERT must be combined with progesterone, unless the uterus has been removed.

  • In any combined (E+P) HRT regimen, progesterone should be prescribed for at least for ten days, and probably for 12-14 days.

  • The daily progesterone dosage should be as low as possible, but sufficiently high to prevent endometrial pathology.

  • Continuous /combined regimen is to be preferred.

THE ABC OF HRT

When starting all forms of HRT: The ABC of HRT to be observed

  • A for Attention and information

  • B for Basic Examination

  • C for Control scheme.

A. ATTENTION AND INFORMATION

Pay attention to:

  • Duration of medication

  • Bleeding pattern

  • Possible side effects (Fluid retention, mastopathy)

  • Breast cancer risk

  • Change in body weight.

B. BASIC EXAMINATION

  • Pelvic Examination including Cytology and USG.

  • Blood pressure and BMI recording.

  • Breast palpation.

  • Mammography if needed.

C. CONTROL SCHEME

  • Evaluation after first three months:

  • Blood pressure, bleeding pattern (based on menstrual calendar) and side effects.

  • Check-up every six months- therapy compliance and motivation, LFT.

  • Mammography every other year.

  • Cytology and USG (ET) yrly.

DIFFERENT FORMS OF ESTROGEN

All estrogen is not equal.

” Natural” estrogen types should be differentiated from synthetic estrogens which are taboo and are mentioned only to be condemned.

Of the numerous natural estrogen preparations available today, the principle plasma products available to the patient are limited to primarily one of the three.

ESTRADIOL, ESTRONE and ESTRIOL

Estradiol is the most physiological form of estrogen type since it is the predominant circulating estrogen in the premenopausal reproductive women.

On the other hand ESTRONE which is less potential than ESTRADIOL is the predominant circulating form of Estrogen in the postmenopausal women.

It would be well to remember that all the oral estrogens are metabolized in the gut mucosa and made into “ESTRONE” thus making it the principle circulating estrogen with all oral preparation, irrespective of the type ingested

Both ESTRADIOL and ESTRONE demonstrated to be cardio protective and osteoprotective.

ESTRIOL- is a less potent that has not yet been shown to be cardio protective or osteoprotective but has a good local action on Genitourinary tract and for control of vasomotor symptoms.

Menopause is more properly seen today as the gateway to a second adulthood, a passage to be approached with pleasurable anticipation, as women take control over their lives and living.

At the beginning of the century, many women didn’t live long enough to reach menopause. Menopause was not seen as an estrogen deficiency state.

But with the options available today, many thousands of women are finding that lives are transformed for the better. Attitude & understanding of living healthy in the right spirits of life after menopause empowered today’s women psycho-sexo-socio-somatically.

By the year 2015, approximately 46% of female population will be of the climacteric age or older (>45 years).

WHO NEEDS HRT?

All menopausal and post –menopausal women unless contraindicated to HRT exist.

If you do not question the need for thyroxin to replace the thyroid's-deficiency status in hypothyroid patients why is there a fuss when it comes to using HRT to replace the estrogens and progesterone in menopause an estrogen deficiency state that is Ovaries’ deficiency status?

Hence all “mature” and “sensible” women may be offered the choice of taking HRT once it is firmly established that they are indeed lacking in adequate quantities of “female” hormone.

DIAGNOSIS OF MENOPAUSE

  • Clinical:- cessation of periods for six consecutive months, hot flush and night sweats

  • Vaginal cytology:- MI 10/ 85/ 5 [low E2]

  • Serum E2:- less than 20 pg/ ml

  • Serum FSH and LH:- more than 40 mIU/ ml

When our mothers went through menopause they deserved medals. But for Today’s Women menopause seems to be victorious battle.