Menopause

Menopause is a part of the normal aging process, which refers to the termination of your monthly periods and marks the cessation of your fertility. You can have menopause around the late 40s to early 50s. It occurs due to the decreased production of female sex hormones estrogen and progesterone by the ovaries, so in people with surgical removal of ovaries, menopause occurs earlier than the normal age limit. Changes in the hormone levels tend to happen months before the actual cessation of bleeding, which is associated with symptoms like irregular bleeding, vaginal dryness, hot flushes, sleep disturbance, mood disorders, etc. Lifestyle changes and several treatment options are available to control these symptoms. 

Menopause occurs because the hormones responsible for the growth of eggs in the ovary can no longer do, owing to the insensitivity of ovaries towards them. Slowly and gradually, the eggs start to degenerate resulting in anovulatory cycles, which have a variable pattern of hormone production and sensitivity, leading to the final cessation of bleeding.

The causes of menopause are;

Age: It is a part of the normal aging process and occurs between the ages of 48-52. In some women, the normal process occurs earlier than this, known as premature ovarian failure. For some other women who undergo surgical removal of ovaries, uterus, etc., menopause can occur early. 

Premature ovarian failure: In some women, ovaries stop functioning before the age of 40. The reason for this in the majority of females is unknown. While in some, it happens due to diabetes mellitus, autoimmune disorders, thyroid disease, chemotherapy, and radiotherapy.

Surgical menopause: Some females who undergo removal of their sex/reproductive organs (ovary, uterus, fallopian tubes) due to other disorders undergo menopause earlier. 

Globally around 50 million women undergo menopause annually. The menopausal symptoms have occurred in around 85% of postmenopausal women once in their lifetime in the USA. The mean age of patients with maximum hormonal symptoms that needed HRT (Hormone Replacement Therapy) treatment is 54 years. The prevalence of symptoms varies with the race of women. The largest number of symptoms occur in African American women, and Asian women experience the minimum number of symptoms. The frequency of the symptoms most commonly experienced are; 40% - Hot flushes, 17% - Night sweats, 16% -  Insomnia, 13% - Vaginal dryness, 12% - Mood disorders,     12 % -  Weight gain.

Having the following risk factors can increase your chances of having menopause earlier;

• Smoking
• Medical disorders like thyroid, diabetes, endometriosis, PCOS.
• Surgical removal of uterus and ovaries
• Obesity
• Fragile X carrier
• Autoimmune disorders
• Living at a high altitude
• Exposure to chemotherapy and radiotherapy

The period before and after menopause is associated with a wide range of hormonal changes and is known as the menopausal transition (MT). You may have the following symptoms during this period.

• Irregular menstruation
• Hot flashes or flushes- sweating, reddening of the skin lasting from 30 seconds to 10 minutes.
• Sleep disturbance or inability to sleep
• Weight gain
• Bloating
• Mood changes
• Depression
• Breast pain
• Headache

Menopause is diagnosed when you have not had periods for at least 12 months. It can be confirmed by measuring the levels of sex hormones; FSH, LH, estrogen. The FSH levels are greater than LH during menopause. Your doctor may also check for thyroid hormone levels as their derangements can also cause menstrual problems.

FSH and LH levels are checked for 2-3 months to confirm the progression towards menopause. You may still have a baby in the transition period with increased FSH and continued periods, so contraception is still needed until complete cessation of periods.

Some medical disorders related to reproductive organs can also result in menstrual irregularities. Your doctor may suggest other blood tests, imaging tests, and endometrial biopsies to exclude those conditions. 

Some other disorders may also cause irregular bleeding or cessation of bleeding that must be ruled out to confirm the diagnosis of menopause.

• Sheehan's syndrome
• Pituitary cachexia
• Hypothyroidism
• Hypogonadotropic hypogonadism
• Hyperprolactinemia
• Uterine fibroids
• Uterine polyps
• Endometrial hyperplasia
• Endometrial cancer

Usually, the treatment with medicines is not required by most women. Home remedies and lifestyle changes can help most of them. However, if your symptoms disturb your daily life, you may consult your healthcare provider. Some of the treatments that can help with the symptoms are;

• Hormone replacement therapy: This includes prescribing estrogen and progestin or only estrogen if the uterus has been removed before. It is most beneficial for hot flushes. It may also be effective to protect against osteoporosis and fractures, heart diseases, and endometrial cancer but can also cause breast cancer. The side effects are increased risk of strokes and blood clots. So it should be used in the minimum dose for the shortest time
• Selective estrogen receptor modulators: SERMs include drugs that act as an estrogen agonist at some places and antagonists at others. So it can be beneficial to protect against osteoporosis, improve good lipids, and also do not increase the risk for breast cancers. They include raloxifene and tamoxifen.
• Non-hormonal medicines: These include SSRIs and SNRIs. Low-dose paroxetine works well for hot flushes but can cause constipation, nausea, and sleeping problems. Gabapentin can also help to decrease the number of hot flashes. But it can cause side effects such as drowsiness and headaches. Clonidine is effective against vasomotor symptoms (hot flushes) but is associated with dizziness, constipation, nausea, and sleeping problems.
• Vaginal estrogen products: Low-dose estrogen creams applied topically are safe to use for vaginal dryness.
• Counseling: Some women can be benefited by joining support groups and acquiring cognitive behavioral therapy to reduce stress, manage mood disorders, depression, etc

Living the menopausal transition period can be difficult but manageable. You can cope with it using medicines, home remedies, lifestyle adjustments. Use medicines after consultation with the doctor, and the benefits of therapy should outweigh the adverse effects, including the possibilities of some cancers. Menopause can increase the risks of some important disorders, mainly osteoporosis and coronary heart disease. Estrogen has a protective effect on both bone health and heart health. After menopause, that protective effect is lost. You may be prone to bone loss (osteoporosis) with an increased risk of fractures. Talk to your doctor about the measures that can be taken to improve bone health. Likewise, the lipids levels in the blood also increase after menopause, increasing the risks of heart attacks. A well-balanced diet, exercise, and cholesterol-lowering drugs can prevent you from that. Some women tend to suffer from the problem of the weakened pelvic floor and urinary muscles (muscles that control the urinary bladder), leading to incontinence (leaking of urine). Pelvic floor exercises (kegel exercises) can improve these symptoms. 

The symptoms of menopause might be troublesome, but fortunately, they are temporary and can be managed by adopting some lifestyle habits;

• Hot flashes: Try to stay cool during the episode. Use a fan or cloth soaked in cold water. Try to figure out your triggers, such as stress, hot beverages, spicy foods, caffeine, alcohol, hot weather, or a warm room.
• For vaginal discomfort: You can try some vaginal lubricants that are available over-the-counter to treat vaginal dryness. Also, staying active sexually can improve the vaginal symptoms by increasing the blood flow to the vagina during sexual activity.
• Diet improvement: Take a healthy balanced diet that must have vitamins, minerals, amino acids, antioxidants, etc.
• Stress management: Try relaxation techniques or exercises and meditation therapies to manage stress.
• Exercises: Adopt a habit of exercising regularly, which can be a 30 minutes brisk walk or aerobics.
• Sleep therapy:  Try to learn about sleep hygiene and follow a regular sleep-wake schedule to control sleep problems.
• Avoid the triggers: Try to avoid alcohol and caffeine as they can worsen the other symptoms.
• Quit smoking: Try as hard as you can to quit smoking as it can not only worsen your symptoms but can also act as a risk factor for heart diseases, stroke, osteoporosis, and endometrial cancers.
• Osteoporosis management: Consult your doctor if you can use calcium and vitamin D supplements to improve bone health. You may need to cut back on smoking and perform regular exercise to prevent osteoporosis. Bisphosphonate is a drug that can be beneficial for women with a history of previous fractures and osteoporosis.