Menopause Made Easy: How to Make the Right Decisions for the Rest of Your Life
Premature early onset menopause is when periods stop before the age of 40 years. At birth, the ovaries contain a lifetime supply of eggs stored in small follicles. At puberty, hormones produced by the pituitary gland in the brain stimulate the ovaries to begin releasing eggs each month ovulation. This prompts oestrogen and progesterone to be released by the ovaries, which in turn stimulate the lining of the uterus endometrium to thicken in preparation for the implantation of a fertilised egg. If an egg is not fertilised the endometrium is shed and a period occurs.
This entire process is known as the menstrual cycle. As a woman ages the number of follicles in her ovaries decreases and the ovaries produce fewer hormones. Menopause occurs when the ovaries fail to produce enough hormones to stimulate the monthly growth of the endometrium, and periods stop permanently.
The timeframe from when symptoms first appear to when menopause occurs may be several years. This timeframe is medically referred to as the climacteric or the perimenopause. After menopause a woman's risk of coronary heart disease including high blood pressure , heart attack and stroke increases and becomes as high as it is for men.
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The risk of developing osteoporosis bone thinning is also increased. Premature early menopause is when periods stop before the age of 40 years. This can be due to many reasons including medical conditions such as diabetes or hypothyroidism , and surgery or medications that have affected the blood supply to the ovaries. Genetic factors may also play a part as premature menopause can run in families. Women who smoke are also more likely to go through premature menopause.
Sometimes, however, there is no identifiable cause.
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Artificial surgical menopause is a consequence of surgical removal of both ovaries or destruction of the ovaries by some cancer treatments. With artificial menopause there is a sudden drop in hormone levels and menopausal symptoms begin abruptly. Often the symptoms experienced are more severe than those experienced with natural or premature menopause.
Often the first symptom of impending menopause is a change in bleeding patterns. Periods may become lighter or heavier, longer or shorter, the time between periods may increase and there may be occasional missed periods. These changes may occur gradually in some women, yet are more abrupt in others. There are also a wide range of physical and psychological signs and symptoms associated with menopause.
In some women they are very mild while in others they are more severe.
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They may last for only a few months, or may continue for several years. The average length of time for menopausal symptoms to be experienced is three to five years. There is no one test to diagnose menopause. Symptoms may indicate that menopause is imminent but menopause can only be confirmed retrospectively after periods have been absent for one year.
A change in bleeding patterns, particularly where periods become heavier, and an absence of periods amenorrhoea can indicate various medical conditions. Also, if bleeding occurs after periods have been absent for a year, a doctor should be consulted, as this is not considered normal. The intensity and frequency of menopausal symptoms vary from woman to woman.
If symptoms are problematic, or a woman is at high risk of developing osteoporosis or heart disease, medical treatment may be recommended. Ultimately, the decision to have treatment is a very personal one and should be made by the woman only after receiving a full explanation from her doctor of the benefits and counter benefits of the various treatment options. It can be effective in relieving the symptoms of hot flushes, night sweats and dryness of the vagina.
MHT can also help to reduce the risk of heart disease and osteoporosis following menopause. Facial hirsutism excess hair growth can increase after menopause due to hormonal changes. This growth may be slowed with MHT. MHT can be given as tablets, skin patches and as vaginal preparations such as creams and pessaries.
Vaginal preparations can help to reduce symptoms of vaginal dryness, incontinence and bladder and vaginal infections. Some forms of MHT may increase the risk of endometrial cancer and using some forms of MHT for longer than 5 years may increase the risk of breast cancer. Potential risks of androgen therapy include hirsutism, acne, irreversible deepening of the voice, and adverse changes in liver function and lipid levels. As most androgens are aromatized to estrogens, androgen therapy may pose the same risks as estrogen therapy.
Sleep disturbances during menopause have been associated with estrogen deficiency, as exogenous estrogen has been shown to improve both subjective and objective sleep, attributed to a decrease in hot flushes. A recent study proposed elevated LH levels during late menopause produce poor sleep quality through a thermoregulatory mechanism, resulting in high core body temperatures.
Rates of a sleep apnea increase with age, rising from 6. The pathophysiology is not known, but theories include a relationship to postmenopausal weight gain or to decreased progesterone levels because progesterone stimulates respiration. Estrogen may be helpful in relieving vasomotor symptoms that disrupt sleep, or that may have a direct effect on sleep itself. In most cases, schizophrenia first manifests in young adulthood, with the rate of new cases declining in both male and female individuals after early adulthood.
A second peak in the incidence of schizophrenia is noted among women aged 45—50 years; this second peak is not observed in men. Some researchers have observed a worsening of the course of schizophrenia in women during the menopausal transition. These observations may suggest that estrogen plays a modulatory role in the pathophysiology of schizophrenia. Exacerbation of mood symptoms during menopause has been noted in women with the pre-existing bipolar disorder. Research has suggested that women with bipolar disorder have higher rates of depressive episodes during the menopausal transition.
The frequency of depressive episodes in this population appears to be higher than during premenopausal years. Panic disorder is common during perimenopause. New-onset panic disorder may occur during menopause, or pre-existing panic disorder may worsen. Panic disorder may be most common in women with many physical symptoms of menopause. In a cross-sectional survey of postmenopausal women aged 50—79 years, panic attacks were most prevalent among women in the menopausal transition.
Panic attacks were associated with negative life events, functional impairment, and medical comorbidity. Fluctuations in OCD have been correlated with the menstrual cycle and with pregnancy, suggesting that hormone levels may contribute to the disorder. Assessment of the risks versus the benefits of HRT has become a challenging task for the physicians. Controversial issues have surrounded the status of HRT for postmenopausal women lately. Several randomized controlled trials present contradicting evidence and have raised questions about the short-term risks of long-term benefits of HRT.
The association of HRT with cancer, stroke, cognition, cardiovascular disease, venous thromboembolism, osteoporosis, gallbladder disease is under scrutiny. The latest controversial results of randomized controlled trials in recent years have posed newer challenges for the physicians in prescribing HRT for postmenopausal women. Controversial issues have surrounded the area of HRT for postmenopausal women in the past years.
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Many recent evidence-based studies have highlighted that HRT use led to a decreased risk of atherosclerosis, osteoporosis fractures, along with no significantly increased risk of breast cancer. However, in the past several years, evidence-based medicine has brought forward the results of several randomized double-blind placebo-controlled trials, especially the results of WHI study,[ 26 ] which have radically affected routine prescribing of HRT in clinics.
The randomized controlled trials present contradicting evidence and has raised questions about the short-term risks of long-term benefits of HRT. Some of the risks are mentioned below: Contradictory results have been reported in various studies for effects of HRT on the incidence of stoke. WHI study exhibited an increased risk whereas some other studies reported a protective effect. Estrogen is implicated in tumorogenesis in experimental animals.
A direct carcinogenic action of HRT on ovarian cells to induce proliferation of ovarian cells has been confirmed. Amongst evidence-based studies, HERS study had shown no decrease in colorectal cancer risk in women which was contradicted by the results of WHI suggesting a decrease risk of colorectal cancer by estrogen. The average age of menopause in India is Therefore, Indian women are likely to spend almost All women over 65 years have been found to suffer from osteopenia or osteoporosis Indian Menopause Society, A study[ 96 ] found that Indian women are now attaining menopause as early as at the age of It also puts them at a higher risk of being affected with osteoporosis, heart diseases, diabetes, hypertension, and breast cancer, says the study conducted by Bangalore's Institute for Social and Economic Change.
The report, which was presented in Parliament, has said that in India 3. The study said that there are a higher number of illiterate women who are in premature menopause as against those who are educated. There is a wide variation in the frequency with which women from different ethnic groups and different socioeconomic and educational backgrounds report the occurrence of symptoms associated with menopause. The variables that affect the socioeconomic status are different in the urban and rural population. Genitourinary symptoms like incontinence, frequency, urgency, difficulty in voiding etc.
The study showed that perimenopausal women showed greater symptoms when compared to menopausal women. Another study[ 99 ] also showed that menopausal symptoms peak at the perimenopausal period, followed by a decline in symptoms during the postmenopausal period. In contrast to the Srilankan study,[ ] an Indian study showed that vasomotor symptoms were more prevalent in the perimenopausal group, while musculoskeletal symptoms were common in the postmenopausal age group. One study[ ] showed that women of low socioeconomic status had a greater prevalence of biological and psychological symptoms.
Another study[ ] demonstrated that women of the lower socioeconomic group have more severe menopausal symptoms and poorer subjective adaptation to daily life than women of the higher socioeconomic class. This is in contrast to the Indian study, which showed a greater prevalence of musculoskeletal and psychological symptoms in the middle socioeconomic group, while vasomotor symptoms were found to be more prevalent in the lower socioeconomic group.
The difference found in the study could be due to sociocultural factors that are known to modify the experience of menopause and midlife. A study[ ] observed low to moderate level of anxiety, depression, social dysfunction and somatic symptoms as well as psycho-social stress in middle-aged women working as school teacher. It was noted that level of these factors was comparatively higher in postmenopause group than during menopause group. However, as far as these psychological factors are concerned this study could not find statistically significant difference between the groups.
According to the authors, one of the reasons of low and similar scoring between the groups may be due to the fact that these women were not psychological cases. In a study[ ] on 32 postmenopausal and 32 premenopausal patients aged between 40 and 55 years to investigate the anxiety and depression in postmenopausal women, the beck depression scale showed highly significant difference whereas, State-Trait Anxiety Inventory I and II showed no statistically significant difference and, therefore, concluded that depression rate is significantly higher in menopausal women. This study concluded that changes occurring in women during 40—60 years of age require proper attention.
Working women preferably may require more care due to dual role responsibility. It may become slightly difficult to manage all activities with the same efficiency as before. That may cause feeling of guilt, irritation, stress etc. Physical relaxation, emotional support, and essential care are needed for healthy living. Certain modifications in life-style and some programmed interventions can provide the enhancement of positive, healthy habits, reduce stress and can add quality to their life.
A study[ ] which analyzed a sample consisting of menopausal, premenopausal and postmenopausal women in the age range of 35—50 years using a two-stage screening procedure for identifying and screening psychiatric morbidity General Health Questionnaire and Standard Psychiatric Interview, found highest psychiatric co-morbidity in the menopausal group, in terms of age maximum number of cases with psychiatric co-morbidity were from 41 to 45 years. Menopausal women suffered more symptoms of menopause as well as psychiatric symptoms as compared to premenopausal women.
Both set of symptoms was found to be less in the postmenopause group also. The most common reported symptoms in the group were depression, depressive thoughts, anxiety, and excessive concern about bodily functions. Supporting the findings of the earlier study[ ] the predominant symptom in menopausal women was depression. Another study,[ ] including a sample of 30 married women in the age range of 39—52 years from middle socioeconomic group noted, mean age of menopause was This study was on the perception of women towards physiological problems faced at menopause.
It was revealed from this study that women who were undergoing menopause were suffering from more difficulties during the perimenopausal phase than the menopausal phase, this in turn can affect the mental health of women and thus may increase psychosocial problems in their life. It was also found that women complained more of backache, loss of sight, pain in joints and fatigue during the menopausal phase than the perimenopausal phase.
The women in the perimenopausal phase perceived more physiological difficulties irregular periods with the heavy menstrual flow as compared to the menopausal women. It has been difficult to distinguish between symptoms that result from loss of ovarian function and those from the aging process or from the socio-environmental stresses of midlife years. Symptoms which result from loss of ovarian function should resolve by hormone replacement, but it has not been found so.
Further research is required in this direction. Symptoms have variable onset in relation to menopause. Some women experience symptoms earlier during perimenopause while some experience them at a later time. When should treatment start is also prophylaxis or management an issue for debate. Although HRT remains the first-line treatment for hot flushes, the WHI findings have drawn attention to nonhormonal treatments of hot flushes and other menopausal symptoms.
Growing evidence to support the efficacy of serotonergic antidepressants and other psychoactive medications in the treatment for hot flushes suggests that nonhormonal interventions will prove important alternatives to HRT. As further evidence of the benefits of psychoactive medications for menopausal symptoms is established, the choice between using hormonal and nonhormonal therapies for the management of menopausal symptoms will continue to evolve. National Center for Biotechnology Information , U. Journal List Indian J Psychiatry v.
Dalal and Manu Agarwal. This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3. This article has been cited by other articles in PMC. Abstract Menopause is one of the most significant events in a woman's life and brings in a number of physiological changes that affect the life of a woman permanently. Hot flushes, menopausal depression, postmenopausal syndrome. Treatment Systemic estrogen therapy is the most effective treatment available for vasomotor symptoms and the associated sleep disturbance.
Hormonal changes Depression seems to be significantly linked to times of hormonal change in women. Life stressors Societal roles and expectations may contribute to the heightened rate of depression in women. Psychological or social conditions Numerous psychological and social theories have been proffered to explain why women may become depressed during perimenopause. Some of these are related to the following factors: Change in the childbearing role. The societal value of youth in societies where age is valued, women tend to report having fewer symptoms at the menopause transition.
Pre-existing tendency to develop depression A personal or family history of major depression, postpartum depression, or premenstrual dysphoric disorder seem to be a major risk factor for depression in the perimenopausal period. Treatment For major depression, standard antidepressants are first-line treatments. Bipolar disorder Exacerbation of mood symptoms during menopause has been noted in women with the pre-existing bipolar disorder. Panic disorder Panic disorder is common during perimenopause.
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The menopause is no joking matter - believe me
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