Women and Postmenopausal Period
What is Menopause? What is Peri-menopause?
What is Perimenopause?
When I tell my patients “You are in peri-menopause”, they commonly ask in fear “Am I in menopause?”. Perimenopause simply means “a quarter to menopause” in which certain hormonal changes and differentiation occur. In academic point of view in some articles, it is a period of which biochemical basis is formed around 35 even if woman do not understand, but in some cases clinical symptoms may occur even around 38-40.
The most important character of perimenopausal period is that irregular menstruation and problems of high estrogenic activity occur in this period. The cause of this problem lays in basic physiologic information.
Then let’s talk about these basic information: Basic Pathophysiology Regarding Perimenopause
During the entire lifetime, woman has the highest number of eggs in her mother’s womb. Female fetus has 7 millions of eggs in 16-20th pregnancy weeks. Subsequently, a programmed cellular death begins in ovaries, which is called APOPTOSIS. At birth, there are 1 million of ovum and when menstruation begins there are only 300 thousands of ovum are present. Whether they give birth to 10 children, woman can only use 400-450 of these eggs. This process gets faster especially when the age gets closer to 40. Besides, qualified ova are used in younger ages and old ova which are difficult to provide pregnancy are left behind. Ovulation of these old ova is difficult. They begin to get damaged because they are old. Thus, high estrogen levels occur!
Progesterone cannot be secreted because ovulation does not occur or it is very few. This condition causes excessive effects of estrogen on the endometrium, thus causing excessive activation. Tissue begins to fall off irregularly. That is why irregular and severe bleedings occur in women around the ages 40-45. The reason for women getting surgery due to myomas in this period is also this hormonal environment. Myomas love high estrogen. They grow excessively!
The period in which this hormonal cycle occurs I told about is called “Perimenopausal period”. When hormones are checked, high estrogen and low FSH levels would be determined. IT is also a difficult period for gynecologists who try to solve the problems. Besides, it is a period showing constant hormonal changes.
In treatment of patient’s complaints, especially for treatment of excessive and irregular menstruation, progesterone replacement is applied. Oral drugs can be given as well as intrauterine devices with hormones can be used as local progesterone, which I prefer more, in order to remove the negative effect of high estrogen in the endometrium tissue.
BUT THE MOST IMPORTANT POINT IS THAT A PATIENT WHO HAS INTERMENSTRUAL BLEEDINGS IN THIS PERIOD MUST NOT BE TREATED WITHOUT SAMPLING THE ENDOMETRIUM AND TAKING A BIOPSY. BECAUSE UNDERLYING ENDOMETRIUM CANCER OR PRECANCEROUS FORMATIONS SUCH AS ENDOMETRIAL HYPERPLASIA MAY BE MISSED. BIOPSY MUST BE TAKEN BEFORE TREATMENT.
What is Menopause?
Menopause refers to the end of menstruations. A woman goes through; childhood, adolescence, reproductive age, menopausal period and climacteric period in her life. You can see different definitions of menopause below.
Different Menopause Definitions
Basically, menopausal period is the period in which ovarian functions of a woman is over after reproductive ages. Ovaries that begin to work with adolescence and secrete hormones basically secrete estrogen, progesterone and testosterone hormones. A major part of production of these hormones in woman occurs in ovaries. In menopausal period, ovarian functions stop and production of these hormones gets reduced. Therefore, a condition comes up that occur with lack of ovarian functions in menopause. This condition is called menopausal syndrome.
Here, you may see a slide showing how and when the symptoms of perimenopausal and postmenopausal period occur.
Menopause Types and Problems of Women in Menopausal Period
Symptoms in Menopausal Period
A woman entering in menopause after the age of 40 without any outside intervention and not having any menstruation for 12 months is called “natural menopause”. Condition which came up as a result of surgical removal of ovaries after the age of 40 due to any gynecological reason is called “surgical menopause”. What should be emphasized at this point is that women who got their uterus removed but have their ovaries intact are not in menopause. Women who had their uterus removed do not have menstruation but do not show any symptoms of menopause if their ovaries are functional. The condition which develops as a result of loss of ovarian functions before the age of 40 with any reason is called Early Ovarian Failure. Its frequency is %1 in the whole society.
Problems occurring in Menopausal period are subdivided into two as early and late problems. Most of the early problems occur right away when hormone production stops.
Early Period Symptoms:
- Vasomotor symptoms: The most common oens are hot flashes, sweating, throbbing and distressed feeling which we call vasomotor symptoms as a whole. These troubles which discomfort the patient severely are seen in %70 of women. Severe hot flashes are seen in %20 of women while mild and slight vasomotor symptoms are seen in %40-50. In %30, these symptoms do not occur or they occur shortly and weakly.
- Psychological Problems: Anxiety, lack of pleasure and depression are common psychological problems in menopausal period. Especially in this period, children growing up, getting married and/or having a job leading to separation from the house affects the woman negatively. This depressive condition is called “Empty house syndrome”. Lack of menstruation is another problem affecting her negatively. When woman loses her fertility, it affects her psychologically.
- Impairments in sleep routine: In %40-60 of women, irregular sleep is common especially in the beginning of menopause. They may complaint from not falling asleep or feeling tired and sleeping all the time.
- Urogenital complaints: Pain during urination, genital itching etc are considered as early period symptoms but they commonly occur 3-4 years after menopause.
- Impairments in sexual function: Both age and menopausal period affect sexual functions of a woman negatively. With increased age, a reduction in libido occurs.
Acute Symptoms in Menopausal Period
These early term symptoms of menopausal period are actually together with some changes and these changes add up to occurrence of those psychological and sexual problems. Due to lack of estrogen, collagen gets reduced each year which is a protein providing health to the skin.
This condition causes wrinkles on the skin and an old face and body. On the other hand, lack of estrogen causes a male type fat accumulation. Women complaint from their belly although saying that they did not put on weight. The cause is that male type fat accumulation occurs in menopausal period, their hip gets smaller and fat tissue accumulates around belly. Due to these changes in body shape after menopause, women do not like their body look and suffer from loss of self trust. This condition affects her psychology, sexual desires negatively.
Problems caused by Menopause in Late Terms (Late symptoms)
Long Term Negative Effects of Menopausal Syndrome
Some events in bone and cardiovascular system occur after menopause, which affect life duration and quality directly in women. Although patients are commonly focused on hot flashes and sweating, we are more concerned with bone and vascular system problems in late terms!
Long Term Negative Effects of Menopausal Syndrome
Women form %80-85 of their bone masses until the age of 20. The rest %15-20 is formed until the age of 30. After ovarian activity stops and menopausal period begins, a quick reduction in bone tissues occurs in the following 10 years. In the first years of menopause, bone loss is %3-10/year while age related loss is %1/year. This increases the risk of bone fracture in women above 50 to its double in each 10 years. One out of 3 women is diagnosed with vertebra fracture after the age of 65. On the other hand, similar loss does not occur in every woman, because some factors are very effective on bone metabolism. Women who are risky for osteoporosis are; thin, smoking, immobile woman whose nutrition lacks calcium. The risk for osteoporosis and fracture is high in these women. If a woman is not on estrogen treatment, calcium absorption from the bowels is very low and daily need is at least 1500 mg.
Cardiovascular System in Postmenopausal Period
In women, the risk of having a heart attack in reproductive ages is very low, 3-4 times lower than males. However, this risks gets even with male’s along with menopause. The most important reason is that protective effects of estrogen are no more. Additionally, risk may increase even more with personal factors such as nutrition and physical activity. The most important risk factors for cardiovascular diseases are: genetic predisposition, diabetes, smoking, obesity and bad nutritional habits, high blood cholesterols, hypertension etc. Most of these risk factors can be prevented an/ot kept under control.
What should be emphasized is that the risk of cancer increases along with age. We have told before that women enter into menopause around the age of 50. Unfortunately, the period in which many cancers are diagnosed is around 50-60. For example, the incidence of breast cancer is the highest in 50-55. Therefore, women should not miss their check-ups in this period.
Due to important changes we told until now and more importantly due to important increases in risks related to age which are not related to menopause, woman should be followed closely in menopausal period. In other words, whether there are hot flashes or not, hormone treatment or not, woman who entered in this state must be checked by a doctor with certain intervals. The earlier she begins to these controls the better for her.
Why Have Menopause and Treatment in Menopause Become so important in the last 30-40 years?
The shortest answer to this question should be “Because human life is extended”. Human life which was 40-45 years in 1920s became 80-85 years today. You may see life duration and expectation of humans below.
Old Female Population in Western Countries and Life Duration Expectation
Similar population is valid for our country. Old population is increasing in our country too. According to the data of 2004, %29 of female population in Turkey is above 40, %6 is above 65. As of 2002, female life expectation got up to 73.1. You may see population data of our country in the slide below.
Population in Turkey and Foresees Regarding Women in Menopause
However, the duration in reproductive ages, in other words, menopause age does not change. This age is reported to be 50-51 in western societies and it is 48 in our country. Therefore, the life period in menopause and climacteric period increases, which we may express as old ages.
Our aim is to help increasing the life quality of women in this long period.
What should a woman in menopause ask for and expect when she visits a gynecologist? Which tests should be conducted?
What should be done during routine examination?
A woman in menopause who consulted a gynecologist for the first time is interviewed in detail. Especially diseases in her family and in her past are questioned. Breast cancer and atherosclerosis history, steroid hormone use, malign disease presence must be asked. Exercise and nutritional habits must be questioned. Nutrition becomes more important with menopause.
Women who got breast cancer in first degree relatives must have mammography and ultrasonography at 35 apart from breast examinations on her own and continue with ultrasonography controls each year until 40 and have her routine mammography and breast ultrasonography each year just as any woman after 40.
Which Tests should be done?
During examination, cervical smear is taken and information about endometrium is gained which would not be gained with vaginal ultrasonography and examinations.
Patient’s blood lipids, sugar, liver and kidney function tests are ordered. Every woman after 40 must have yearly mammography. If there are no risk factors such as being too weak, use of steroid hormone, familial osteoporosis history and smoking there is no need to ask for bone intensity tests. If patient is in menopause for over 5 years, bone intensity should be checked whether or not there are risk factors.
Treatment Process of Menopausal Period Getting into a Shape
Menopausal period is an ongoing process of a woman’s life. Every woman should adapt to this process and take professional help in this direction.
Things that should be done for adaption to menopausal process
Patient’s menstrual cycle is questioned in order to understand whether patient is in menopause or not. Presence of vasomotor symptoms (hot flashes, sweating etc), especially distractibility, lack of libido, vaginal dryness, back and lumbar pain and such symptoms should be questioned.
Treatment of menopausal symptoms and complaints such as hot flashes of postmenopausal syndrome is managed according to the answers to these questions. Complaints must be understood clearly, thus gynecologist must spend some time on it. Doctor should focus on basic complaints of a woman in menopause and shape the treatment at this frame. For example while a group of women complaints more about hot flashes while others may be suffering more from lack of libido. Therefore, gynecologist must listen to the woman, understand and treat her.