The anatomy as well as physiology of the female reproductive system is quite complex when compared with the male reproductive system. Menopause is a very prominent stage in the life cycle of all females. It can be simply defined as the absence of the menstrual cycle for at least 12 months. The transition of the menopause starts with varying menstrual cycle length and finally terminates into menstrual period. The menopausal transitional period is often referred to as perimenopause phase although it is not a medical term but is often used while dealing a layman. Postmenopuase period is known to commence after the last menstrual period. Menopause can also be described as a phase of the female’s life when the function of ovaries terminates. Ovaries are the female reproductive organs, located in the pelvis, one of each side of the uterus. Each ovary resembles an almond in its shape and size. They are known to produce ova as well as the female hormone estrogen.
A single egg or ovum is produced from either the right or the left ovary during each menstrual cycle. The egg then enters the Fallopian tube and finally reaches the uterus. The female hormones secreted by the ovaries participate in the development of secondary sexual characters in the female like development of breasts, body shape and body hair. These hormones also participate in the regulation of menstruation and pregnancy. Estrogens are also known to provide protection to the bones and osteoporosis develops in a female if ovaries fail to produce adequate amount of estrogen. Perimenopause is different for each woman and researchers are still under dilemma about the factors governing this phase, so study is under execution.
Commencement of menopause
In general menopause is known to enter a female’s life at the age of 51 but no one can predict that when a female is going to enter menopause. The age at which menstrual cycle starts in the life of a female is also not correlated with the onset of menopause. Majority of the females are known to enter menopause between the ages of 45-55 but menopause can also occur at the age of 30, 40 or 60 years. Perimenopause is characterized by irregularities in the menstrual cycle followed by typical symptoms of early menopause and can commence 10 years prior to last menstrual period.
Conditions affecting menopause
Certain surgical as well as medical conditions are known to cast their spell on the timing of menopause. These conditions will be dealt one by one.
1. Surgical removal of ovaries
Surgical removal of ovaries from an ovulating female is known as oophorectomy and it results in immediate menopause and the condition is sometimes also designated as surgical or induced menopause. In this condition there is no perimenopause and the female automatically experiences the signs and symptoms of menopause. The ovaries can often be removed along with the uterus and this procedure is known as hysterectomy. If uterus is removed without removal of ovaries then they function normally and produce female hormones but such a female is not able to menstruate. In this situation symptoms of menopause occur naturally. The woman can experience other symptoms of menopause like hot flashes and mood swings. These symptoms cannot be correlated with the cessation of menstruation. Such a female is liable to get affected with premature ovarian failure before commencement of menopause within 1-2 years after hysterectomy. If this condition arises then the female will not experience the symptoms of menopause.
2. Cancer chemotherapy and radiation therapy
Cancer is also known to affect ovarian function. Chemotherapy and radiation therapy are given to a female depending upon the type and location of cancer. If these treatments are given to an ovulating woman then they result in cessation of menstruation and symptoms of menopause come into play. The symptoms may arise during or after treatment.
3. Premature ovarian failure
This condition can be defined by the appearance of menopause before the age of 40. This condition is common among 1% woman population. The exact reason behind premature ovarian failure is although unknown but it is believed that autoimmune diseases and genetic factors are associated with it.
Symptoms associated with menopause
Each woman experiences a different set of symptoms. Some women experience few or no symptoms of menopause while some experience a wide variety of physical as well as physiological symptoms. The major symptoms are:
1. Irregular vaginal bleeding
Vaginal bleeding may become irregular at the onset of menopause. Some females have little problems with abnormal bleeding during perimenopause while others have excessive bleeding. Menstrual periods may occur very frequently within short intervals or may get farther and farther apart before terminating completely. There is no usual pattern of bleeding during perimenopause but it may vary from individual to individual. If a female is experiencing irregular menses then she must consult the doctor as whether the problem is due to perimenopause or some other clinical condition is associated. The abnormalities associated with the menstrual cycle during the perimenopause are also responsible for the declination of the female fertility as egg production in the ovaries also becomes irregular. However, a female under the perimenopausal state can become pregnant and should take contraceptives if she is not interested to become pregnant.
2. Hot flashes and night sweats
Hot flashes are very frequent in the females undergoing menopause. A hot flash may be defined as a feeling of warmth spreading throughout the body but is more intense on the head and chest region of the body. It is sometimes associated with flushing as well as perspiration. They may last from 30 seconds to few minutes. The exact cause of hot flash is although not known but it is believed that is the result of a combined action of hormonal and biochemical fluctuations brought about by the declining estrogen levels. One cannot predict when hot flashes will arise and for how long they will appear. Hot flashes are known to occur in 40% of females under the age group of 40 having normal menstrual cycles. So hot flashes can appear even before menopause. Hot flashes end up within 5 years in 80% of the females entering menopause and sometimes they can run for about 10 years. Sometimes hot flashes are coupled with night sweats resulting in awakening, difficulty in falling asleep again resulting in daytime tiredness.
3. Urinary symptoms
Urethral lining also undergoes changes just like the tissues of the vagina and becomes drier, thinner, loses elasticity due to declination of the estrogen levels. These changes increase the risk of urinary tract infections as well as urinary leakage. Urination may also occur suddenly with coughing, laughing and lifting of heavy objects.
4. Vaginal symptoms
The vaginal tissues also become thinner, drier and lose elasticity as the estrogen levels fall. The symptoms include vaginal dryness, itching or pain during intercourse. The vaginal changes also increase the risk of vaginal infections.
5. Emotional and cognitive symptoms
Women entering perimenopause experience a variety of emotional symptoms like fatigue, irritability, memory problems and rapid mood changes. It is difficult to explain which behavioral symptom is directly associated with the hormonal changes. Emotional and cognitive symptoms are very common among women so sometimes it becomes difficult to determine whether these changes are due to menopause or not. Night sweats during menopause can also result in fatigue and irritation.
6. Other physical changes
Weight gain is very common among women during menopause. The distribution of fat may also undergo change and may get deposited more in the waist and abdominal areas rather than the hips and thighs. Wrinkles may also appear on the skin. As the body continues to produce small levels of male hormone, testosterone, some females may develop some hairs on the chin, upper lip, chest or abdomen.
Complications associated with menopause
Osteoporosis is very common among the females undergoing menopause. Osteoporosis is the deterioration of quality and quantity of bone resulting in increased risk of fracture. However, the density of bone tends to decline normally in the females during the fourth decade of life but it declines rapidly during the menopause. Age and hormonal changes during menopause act together resulting in osteoporosis. The process can occur slowly for many years. Women may remain unaware of these changes unless and until she encounters a painful fracture. The treatment of osteoporosis includes slowing down the rate of bone loss as well increasing bone density and strength. The treatment includes lifestyle changes like cessation of smoking and drinking alcohol, regular exercise with adequate intake of balanced diet rich in calcium and vitamin D. calcium and vitamin D supplements are prescribed for those females who do not take a diet rich in these nutrients. Medications responsible for preventing bone loss include alendronate, risedronate, ibandronate and teriparatide.
2. Cardiovascular disease
Females before menopause are at decreased risk of cardiovascular diseases when compared with men but the frequency generally increases as they approach menopause. The incidence of heart diseases is very high both among men and women in the United States. Coronary heart diseases are two-three times higher in the women reaching menopause. This may be due to the declining levels of estrogen and the women in post menopausal stage are advised not to undergo hormone therapy in order to avoid the risk of heart attacks.
Treatments available for menopause
Menopause is a normal part of life that cannot be combined with a disease. However, the treatment of related symptoms is possible so can be taken into consideration.
1. Hormone therapy (Estrogen and progesterone therapy)
Hormone Therapy (HT) or Hormone Replacement Therapy (HPT) or Postmenopausal Hormone Therapy (PHT) is a treatment that administers doses of both estrogens and progesterone. It is administered in order to prevent the symptoms associated with declination of estrogen levels like hot flashes and vaginal dryness and is still the most effective treatment available but studies have indicated that the women receiving HT have increased risk of breast cancer, heart attacks. Women receiving only estrogen therapy also have higher risk of endometrial cancer. Hormone therapy is available in the form of oral pills and transdermal forms. Transdermal hormone products are already in the active form so they don’t have to get converted into activated form in the liver. As these products have no effect on the liver they are prescribed for majority of the females. There has been an emerging interest among the researchers for the use of a bio-identical hormone for the perimenopausal women. These hormones have same chemical compositions like those produced naturally inside the body. These products are prepared in the laboratory from the naturally derived plant products and are approved by the U.S.FDA so are in market. They are also used transdermal in the form of creams or gels. The use of hormone therapy is based on the decision of both the patient and the doctor.
2. Oral contraceptive pills
Oral contraceptive pills are other form of hormone therapy that is prescribed to the females undergoing perimenopause in order to treat irregular vaginal bleeding. Before prescribing these pills the doctor must check that whether the irregular vaginal bleeding is due to perimenopause or some other factors are associated with it. These do not provide relief from hot flashes but prevent a female from becoming pregnant.
3. Local hormone and non-hormone treatments
Vaginal estrogen deficiency is also treated with the local hormonal treatments. These include vaginal estrogen ring, vaginal estrogen cream or vaginal estrogen tablets. Local and oral estrogen treatments are sometimes combined. Vaginal moisturizing creams or gels or use of lubricating agents during intercourse are non-hormonal agents used to prevent vaginal dryness. Application of Betadine topically on the outer vaginal area or soaking in a bathtub or warm water may also relive the symptoms of vaginal pain or burning sensation after sexual intercourse.
4. Antidepressant medications
Selective serotonin reuptake inhibitors (SSRIs) are a class of drugs most frequently used to control the symptoms of hot flashes and have given positive results in 60% of the women. The common examples of these drugs include venlafaxine, citalopram, fluoxetine, paroxetine and sertraline. However, antidepressants are associated with some side effects like sexual dysfunction.
5. Plant estrogens or phytoestrogens or isoflavones
Isoflavones are chemical compounds present in soy and are plant derived estrogens. The structure of these plant estrogens is exactly similar to those produced in the body but their effectiveness is somewhat lower in comparison to the body estrogens. Their estrogen potency is estimated to be about 1/1,000 to 1/100,000 of that of natural estrogen. Two types of isoflavones namely, genistein and daidzein have been derived from soybeans, chickpeas and lentils that are considered to be the most potent phytoestrogens. Some studies have shown that these compounds help in relieving hot flashes and other symptoms of menopause. Women suffering from breast cancer are also prescribed these phytoestrogens if they do not want to undergo hormone therapy (HT) during menopause transition. Some researchers have however shown that excessive intake of these plant derived estrogens result in over-growth of the tissues lining the uterus which can result in the development of cancer.
6. Vitamin E
Some women have reported that intake of vitamin E supplements can also help in relieving hot flashes but this fact lacks scientific support. Taking a dosage of greater than 400 IU of vitamin E is not safe as it increases the risk of cardiovascular diseases.
7. Black Cohosh
Black cohosh is an herbal preparation popular in Europe often prescribed against hot flashes. The North American Menopause Society does not support the short term usage of this herbal preparation
8. Non-pharmaceutical therapies
Survivors of breast cancer or females not interested to take oral or vaginal estrogens are prescribed vaginal lubricants however, they are not very effective.
So it can be concluded that menopause is a natural state of body and the symptoms can be controlled by the medications mentioned above.