Menopause

Menopause

The menopause is defined as the final episode of menstrual bleeding in women. The term is used commonly to refer to the transitional period up to and after the last episode of menstrual bleeding. During this period, there is a progressive loss of ovarian function and a variety of changes due to hormonal upset.The median age of women at the time of cessation of menstrual bleeding is 50 to 51 years. In the 5 years before menopause there is gradual increase in the number of anovulatory cycles – i.e. cycles without ovulation. During this period the estrogen secretion falls and there is increased pituitary secretion of LH and FSH hormones.  The age of menopause varies widely. Before the menopause the interval between the menses is variable and it becomes longer and longer.The menopause is the consequence of the exhaustion of folicles in the ovaries of a female. The decrease in the number of ova begins in the womb itself. By the time of the menopause, few ova remain, and these appear to be non-functional. Only a small number of ova are lost as the result of ovulation during reproductive life. The stopping of follicular development results in decreased production of estradiol and other hormones.Estrogen and androgen levels in plasma are reduced but not absent.
Clinical Features

About 3 of 4 women experience menopausal symptoms, but in 50 percent to 75 percent of sufferers they last a year or less. In about one-third of sufferers, they persist for up to five years, and in a small percentage, they last longer.

  •  Irregular periods commonly precede the menopause.
  • Hot Flashes and sweating. Hot flashes may start even when the paerson still has regular periods.
  • Nervousness, Anxiety, Emotional lability, Irritability, Depression.
  • Increased Vaginal Infection, Vaginal dryness, atrophy of urogenital epithelium.
  • Urgency of micturition.
  • Decrease in the size of breasts.
  • Approximately 40 percent of menopausal women develop symptoms serious enough to seek medical assistance.
  • Osteoporosis – reduction of Calcium in bones, is one of the crippling afflictions of aging, and there is a close relationship between estrogen deprivation and its development. Approximately one-fourth of aging women and one-tenth of elderly men sustain a vertebral or hip fracture between the ages of 60 and 90, and the incidence is highest in elderly white women. Such fractures are a major cause of death and morbidity. 

Many factors affect the development of osteoporosis, including diet, activity, smoking, and general health, and estrogen deprivation is of particular importance. White postmenopausal women are more predisposed to osteoporosis and its consequences. It is known that fall in the secretion of estrogen is associated with initial rapid loss of bone mass. Vertebral compression fracture, fracture neck femur and radius is seen more in females in  comparison to males. Those women who smoke are at a greater risk. Excessive alcohol and lack of exercise add to this risk. Earlier the menopause greater is the problem. Oestrogen started at the time of menopause is shown to prevent the bone loss. Many factors affect the development of osteoporosis, including diet, activity, smoking, and general health, and estrogen deprivation is of particular importance. White postmenopausal women are more predisposed to osteoporosis and its consequences. It is known that fall in the secretion of estrogen is associated with initial rapid loss of bone mass. 

  • After the menopause women experience an increase in the incidence of cardiovascular disease.

Management

  • Many women do not need any treatment. Explaining the problem and reassurance is what most of them need.
  • Imipramine, may be helpful to relieve anxiety and depression.
  • Hot flashes and sweating – may be helped by Clonidine 50 µg twice daily. But in many patients estrogen therapy is required.
  • Oestrogen Replacement Therapy

Oral Oestrogen – cyclical Ethinyl oestrogen 0.01-0.02 mg / day for 21 days with Medroxyprogesterone acetate 5 mg daily for the last 10  days.

Percutaneous Patches with reservoir of oestradiol 25-50 µg / day. Change every 3-4 days. Add oral Progestogen for 10 days per month.

Topical oestradiol – for Atrophic Vaginitis 0.01 % Dienoestrol cream.

  • Isoflavones: from plant sources esp. Soya, has oestrogen like activity. They do help to relieve symptoms to large extent in many women. They can be given in combination with Calcium, Magnesium and Vitamin D.

Hormone Replacement Therapy (HRT)~Risks

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