Menopause, also called the climacteric period, refers to the time in a woman’s life where there is an irreversible change from fertility to natural infertility. It is a natural biological process that occurs when the supply of ovarian follicles is depleted resulting in a permanent cessation or stoppage of menstrual period. Menopause is a clinical diagnosis confirmed when a woman has had no menstruation for a period of 12 months. This occurs naturally in a woman between the ages of 42 and 58. It tends to occur earlier in women who smoke or have never given birth before. Menopause can also be induced artificially through surgery, chemotherapy or pelvic radiation.
What are the symptoms of menopause?
Hot flushes are the hallmark of menopause. The hot flushes is usually characterised by abrupt onset of warmth and red skin blotching typically involving the chest, face and neck, with transient anxiety, palpitations and profuse sweating.
Most menopausal women begin to experience hot flushes usually 2 to 3 years before actual menopause and peaks within 2 to 3 years after menopause. Hot flushes may continue for many years after menopause in some women. The frequency, duration and intensity of hot flushes vary from woman to woman. They coincide with declining estrogen levels and the mechanism for hot flushes is attributed to dysfunction of the thermoregulatory centre in the hypothalamus likely due to complex neuroendocrine pathways involving norepinephrine, serotonin, estrogen and testosterone. Other conditions that can also cause hot flushes include thyroid dysfunction, infection, carcinoid syndrome, pheochromocytoma, autoimmune disorder, mast cell disorders, malignancies and seizure disorders.
Other post menopausal symptoms may include vaginal dryness and irritation, urinary urgency and frequency, painful sex, decreased libido (sexual urge), mood swings, sleeplessness, depression and cognitive changes like poor memory and lack of concentration. These symptoms tend to be more intensed after surgical induction than in a natural menopause.
The Peri menopausal period.
The perimenopausal period is the period just around the actual menopause. It is characterised by erratic hormonal levels and irregular menstrual periods. Symptoms such as hot flushes, vaginal dryness and sleep disturbances may be present even while the woman still sees her menstruation. Anovulation is common during this period and contributes to the irregular menstrual bleeding patterns typical of perimenopause.
Despite the decline in infertility, pregnancy is still possible until when the actual menopause is reached which is confirmed by 12 months of absent menstrual periods or consistently high FSH levels > 30mIU/mL. Menstrual changes during perimenopause may include lighter or heavier bleeding, shorter bleeding period less than 2 days or longer bleeding period more than 4 days or even skipped menstruation. Very heavy flow with clots lasting more than 7 days or uterine bleeding after sexual intercourse, as well as menstrual cycle less than 21 days must be further investigated.
Changes in the genital tract after menopause
These changes are of atrophic type and affect the external genitalia as well as the internal organs. They take time to occur over a number of years. Not only are the main pelvic structures reduced in size, the facial framework and intrapelvic ligaments supporting the genitalia and bladder are also weakened which leads to complications.
- The vulva : There is flattening of the labia majora and the labia minora becomes more evident. Sexual or pubic hairs become grey and sparsely distributed. The clitoris also shrinks and the opening of the vagina narrows.
- The vagina : Opening of the vagina narrows and the vagina diminishes in length. Vaginal secretions are also limited leading to painful sex. The epithelium wall becomes atrophic and there is loss of rugosity which leads to petechial haemorrhages especially during sex.
- Uterus : The uterus becomes smaller in size with a relatively larger cervix.
- Fallopian tubes and ovaries : There is great shrinking of the fallopian tubes and they become thin, while the ovaries reduce in size to small white unwrinkled bodies of about 2cm to 3cm length.
Management of menopausal symptoms
Hormonal contraceptives are very useful in the regulation of dysmenorrhea, menorrhagia and hot flushes in perimenopausal women and the clinical signs of menopause are masked by taking hormonal contraceptives.
Estrogen is the most effective hormonal therapy for hot flushes and other troublesome menopausal symptoms but has some potential risk especially osteoporosis. There is increased risk of cardiovascular events, thromboembolism, stroke and breast cancer in women treated with a combination of estrogen and progesterone hormone. Post menopausal hormonal therapy is therefore advised only for women who have moderate to severe symptoms of menopause. Even at that, it should prescribed at the lowest dose needed for symptom relief and also for the shortest possible duration.
Contraindications for using estrogen-containing oral contraceptives
Absolute contraindications include
- History of deep vein thrombosis or pulmonary embolism.
- Active liver disease.
- Cardiovascular diseases such as chronic heart failure, myocardial infarction or coronary artery disease, atrial fibrillation, mitral stenosis and mechanical heart valve.
- Systemic diseases of the vascular system like systemic lupus erythematosis, diabetes with retinopathy or nephropathy.
- Women who smoke cigarettes and are older than 35 years.
- Uncontrolled hypertension.
- History of breast cancer.
- Undiagnosed Amenorrhea.
Relative contraindications include
- Classic migraine
A. K. Ghosh: “menopause ” Mayo clinic internal medicine Review (8th edition).
D. M. Hart: “menopause ” Gynaecology illustrated (5th edition).
S. Campbell, A. Monga : “menopause ” Gynaecology by Ten Teachers (18th edition).