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Menopause

Many women arrive at their menopause transition years without knowing anything about what they might expect, or when or how the process might happen, and how long it might take. Very often a woman has not been informed in any way about this stage of life, it may often be the case that she has received no information from her physician, or from her older female family members, or from her social group. In the United States there appears to be a lingering taboo over this subject. As a result, a woman who happens to undergo a strong perimenopause with a large number of different effects, may become confused and anxious, fearing that something abnormal is happening to her. There is a strong need for more information and more education on this subject.

Management

  • Perimenopause is a natural stage of life. It is not a disease or a disorder, and therefore it does not automatically require any kind of medical treatment. However, in those cases where the physical, mental, and emotional effects of perimenopause are strong enough that they significantly disrupt the everyday life of the woman experiencing them, palliative medical therapy may sometimes be appropriate.
  • Menopause is the cessation of a woman's reproductive ability, the opposite of menarche. Menopause is usually a natural change; it typically occurs in women in midlife, during their late 40s or early 50s, signalling the end of the fertile phase of a woman's life.
  • Menopause is commonly defined by the state of the uterus and the absence of menstrual flow or "periods", but it can instead be more accurately defined as the permanent cessation of the primary functions of the ovaries. What ceases is the ripening and release of ova and the release of hormones that cause both the build-up of the uterine lining, and the subsequent shedding of the uterine lining (the menses or period).
  • The transition from a potentially reproductive to a non-reproductive state is normally not sudden or abrupt, occurs over a number of years, and is a consequence of biological aging. For some women, during the transition years the accompanying signs and effects (including lack of energy, hot flashes, and mood changes) can be powerful enough to significantly disrupt their daily activities and sense of well-being. In those cases various different treatments can be tried.
  • Medically speaking, the date of menopause in a woman with an intact uterus is the day after the final episode of menstrual flow finishes. "Perimenopause" is a term for the menopause transition years, the time both before and after the last period ever, while hormone levels are still fluctuating erratically. "Premenopause" is a term for the years leading up to menopause. "Postmenopause" is the part of a woman's life that occurs after the date of menopause; once a woman with an intact uterus who is not pregnant or lactating has gone a year with no flow at all she is considered to be one year into post menopause.

Signs and symptoms

  • During the menopause transition years, as the body responds to the rapidly fluctuating and dropping levels of the body's own hormones, a number of effects may appear. Not every woman experiences bothersome levels of these effects; the degree to which they occur varies greatly from person to person.
  • The majority of women find that their menstrual periods are gradually becoming more erratic, and the timing of the start of the flow usually becomes more and more difficult to predict. In addition the duration of the flow may be considerably shorter or longer than normal, and the flow itself may be significantly heavier or lighter than was previously the case, including sometimes long episodes of spotting.
  • It is not uncommon to have a 2-week cycle when an ovulation has been skipped. Further into the process it is common to skip periods for months at a time, and these skipped periods may be followed by a heavier period. The number of skipped periods in a row often increases as the time of last period approaches. If a woman keeps a written record of all the erratic episodes of flow, she will know how many months have passed with no flow at all, and thus will be able to know at what date she reached postmenopause, which is important medical information that will subsequently frequently be requested by doctors.
  • Effects such as formication (crawling, itching, or tingling skin sensations), may be associated directly with hormone withdrawal. Effects that are caused by the extreme fluctuations in hormone levels (for example hot flashes and mood changes) will usually disappear or improve significantly once the perimenopause transition is completely over, however, effects that are due to low estrogen levels (for example vaginal atrophy and skin drying) will continue after the menopause transition years are over.
  • Hot flashes and mood changes are the most commonly mentioned symptoms of perimenopause, but in a 2007 study, lack of energy was identified by women as the most distressing effect.[3] Other effects can include palpitations, psychological effects such as depression, anxiety, irritability, memory problems and lack of concentration, and atrophic effects such as vaginal dryness and urgency of urination.

One way of assessing the impact on women of some of these menopause effects are the Greene Climacteric Scale questionnaire, the Cervantes Scale and the Menopause Rating Scale.

Skeletal

  • Back pain
  • Joint pain, Muscle pain
  • Osteopenia and the risk of osteoporosis gradually developing over time
  • Skin, soft tissue
  • Breast atrophy
  • Breast tenderness ± swelling
  • Decreased elasticity of the skin
  • Formication (itching, tingling, burning, pins, and needles, or sensation of ants crawling)
  • Skin thinning and becoming drier

Psychological

  • Depression and/or anxiety
  • Fatigue
  • Irritability
  • Memory loss, and problems with concentration
  • Mood disturbance
  • Sleep disturbances, poor or light sleep, insomnia, and daytime sleepiness

Sexual

  • Painful intercourse
  • Decreased libido
  • Problems reaching orgasm

Array

Cohort studies have reached mixed conclusions about medical conditions associated with the menopause. For example, a 2007 study found that menopause was associated with hot flashes; joint pain and muscle pain; and depressed mood. In the same study, it appeared that menopause was not associated with poor sleep, decreased libido, and vaginal dryness. However, in contrast to this, a 2008 study did find an association with poor sleep quality.

Cause

  • Age
  • Normal range. In the Western world, the most typical age range for menopause (last period from natural causes) is between 40 and 61 and the average age for last period is 51 years. The average age of natural menopause in Australia is 51.7 years. In India and the Philippines, the median age of natural menopause is considerably earlier, at 44 years.
  • Youngest. In rare cases, a woman's ovaries stop working at a very early age, ranging anywhere from the age of puberty to age 40, and this is known as premature ovarian failure (POF). Spontaneous premature ovarian failure affects 1% of women by age 40, and 0.1% of women by age 30.
  • Oldest. Due to vagaries in records systems throughout the world, an oldest age for which menopause has occurred in a female of the human species is not exactly known. Reports of normal conception and child birth around the age of 70 exist, but are usually subject to controversy. Reports of normal conception beyond age 70 are almost nonexistent.
  • Additional factors. Women who have undergone hysterectomy with ovary conservation go through menopause on average 3.7 years earlier than the expected age. Other factors which can promote an earlier onset of menopause (usually 1 to 3 years early) are: smoking cigarettes, or being extremely thin.
  • Premature ovarian failure
  • Premature ovarian failure (POF) is diagnosed or confirmed by high blood levels of follicle stimulating hormone (FSH) and luteinizing hormone (LH) on at least 3 occasions at least 4 weeks apart.
  • Known causes of premature ovarian failure include autoimmune disorders, thyroid disease, diabetes mellitus, chemotherapy, being a carrier of the fragile X syndrome gene, and radiotherapy. However, in the majority of spontaneous cases of premature ovarian failure, the cause is unknown, i.e. it is generally idiopathic.

Women who have some sort of functional disorder affecting the reproductive system endometriosis, polycystic ovary syndrome, cancer of the reproductive organs can go into menopause at a younger age than the normal timeframe. The functional disorders often significantly speed up the menopausal process. An early menopause can be related to cigarette smoking, higher body mass index, racial and ethnic factors, illnesses,and the surgical removal of the ovaries, with or without the removal of the uterus. Rates of premature menopause have been found to be significantly higher in fraternal and identical twins; approximately 5% of twins reach menopause before the age of 40. The reasons for this are not completely understood. Transplants of ovarian tissue between identical twins have been successful in restoring fertility.

General

  • Hot flashes, also including night sweats, and, rarely, cold flashes. Technically known as vasomotor instability, the inability to regulate body temperature properly.
  • Possible but contentious increased risk of atherosclerosis
  • Migraine
  • Rapid heartbeat

Dysfunctional bleeding as part of menstruation. Women approaching menopause often experience this due to the hormonal changes that accompany the menopause transition. In post-menopausal women however, any genital bleeding is an alarming symptom that requires an appropriate study to rule out the possibility of malignant diseases, however, spotting or bleeding may simply be related to vaginal atrophy, a benign sore (polyp or lesion) or may be a functional endometrial response. The European Menopause and Andropause Society has released guidelines for assessment of the endometrium, which is usually the main source of spotting or bleeding.

Menopause

Clinically speaking, menopause is defined as a specific date; assuming the woman still has a uterus, the date is the day after the woman's final episode of menstrual flow finishes. However, this date can only be fixed retrospectively, once 12 months have gone by with no menstrual flow at all. In common parlance, however, the word "menopause" usually refers not to just one day, but to the whole of the menopause transition years. This span of time is also called the "change of life", the "change", or the "climacteric" and more recently is known as "perimenopause", (literally meaning "around menopause"). The word "menopause" is also sometimes used in common parlance to mean all the years of postmenopause.

Postmenopause

The term "postmenopausal" describes women who have not experienced any menstrual flow for a minimum of 12 months, assuming that they do still have a uterus, and are not pregnant or lactating.[26] In women without a uterus, menopause or postmenopause can be identified by a blood test showing a very high FSH level. Thus postmenopause is all of the time in a woman's life that take place after her last period, or more accurately, all of the time that follows the point when her ovaries become inactive. The reason for this delay in declaring postmenopause is because periods are usually erratic at this time of life, and therefore a reasonably long stretch of time is necessary to be sure that the cycling has actually ceased completely. At this point a woman is considered infertile, however the possibility of becoming pregnant has usually been very low (but not quite zero) for a number of years before this point is reached. A woman's reproductive hormone levels continue to drop and fluctuate for some time into post-menopause, so hormone withdrawal effects such as hot flashes may take several years to disappear. Any period-like flow during postmenopause, even spotting, must be reported to a doctor. The cause may be minor, but the possibility of endometrial cancer must be checked for.