Symptoms Of The Menopause
Most women will experience menopausal symptoms. Some of these can be quite severe and have a significant impact on your everyday activities.
Common symptoms include:
- reduced sex drive
- problems with memory and concentration
Menopausal symptoms can begin months or even years before your periods stop and last around 4 years after your last period, although some women experience them for much longer.
Contraception In The Peri
A womans fertility declines naturally in her 40s and the risk of pregnancy after the age of 50 years is estimated at less than one per cent but women may ovulate twice in a cycle and as late as three months before the final period. Women are advised to keep using contraception until two years after their last period if they experience the menopause under the age of 50, and for one year after the last period if aged 50 years or more2. Women using combined oral contraception are generally advised to cease by the age of 51 years and switch to a non-hormonal or progestogen-only method. The risks of ethinyl oestradiol-containing methods increase with age, especially if the woman is a smoker over the age of 35 .
Mechanisms Of Hot Flashes
Estrogen has been studied and used to treat hot flashes for > 60 y, but the mechanism by which it works is still in question. This is due to relatively little examination of basic hot flash physiology, which has not received the research attention that has been accorded clinical trials of therapeutic agents. Thus, the body of knowledge on the endocrinology, neurophysiology, thermoregulatory physiology, and other aspects of hot flash biology is limited.
One long-standing assumption has been that hot flashes involve transient dysregulation of the thermoregulatory system, triggering homeostatic heat loss mechanisms to return the system to normal. During a hot flash, many of the easily observed physiological changes involve the thermoregulatory and vascular systems. This remains an area of incomplete research.
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Contextual Differences In The Experience Of Menopause
Attitudes toward menopause differ by gender, and are influenced by many contextual factors, including the attitude and response of health care providers. Additionally, the way menopausal symptoms are experienced, and the preferred management approach to address symptoms differs widely by context.
Attitudes Toward Menopause
The way menopause is perceived and therefore experienced and managed depends to a large extent on the social and cultural context in which women live . Although research points to menopause as a physiological process, some people perceive it as a disease process, especially in settings where people are ill-informed about menopause and how and why it occurs.
Attitudes of Women Toward Menopause
In studies among women in West Bengal, India, and Bahrain, researchers found that postmenopausal women had a more positive attitude toward menopause than their perimenopausal counterparts . A majority of highly educated Asian female teachers residing in Pakistan reported a positive attitude toward menopause . A qualitative study conducted in Singapore also reported a generally positive attitude toward menopause . One study among women and their spouses in Turkey reported that, in general, both groups had a positive attitude toward menopause .
Attitudes of Men Toward Menopause
Attitudes of Providers
Common Symptoms Associated with Menopause
Management of Menopause
Nonhormonal/Behavioral, Including Self-Care Strategies
Alternative Treatments/Natural Remedies
Deterrence And Patient Education
- Patients should be encouraged to stop smoking especially if considering starting hormone therapy.
- Women should try to obtain 150 minutes of cardiovascular exercise per week and 2 to 3 days of weight-bearing exercise.
- Women should eat a healthy diet to maintain a healthy weight.
- Sexual activity is normal, and women should feel comfortable speaking to health provider if having painful intercourse.
- Contraception is recommended for 1 year after the last menstrual period while having irregular menses.
- If having menopausal symptoms discuss with a provider because of the many treatment options available.
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Gaps In Knowledge And Future Directions
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 an issue for debate.
As recent data from the WHI establish the risks of long-term HRT use, concern about using HRT, even as a short-term intervention, has increased substantially. 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.
What Causes The Menopause
The menopause is caused by a change in the balance of the body’s sex hormones, which occurs as you get older.
It happens when your ovaries stop producing as much of the hormone oestrogen and no longer release an egg each month.
Premature or early menopause can occur at any age, and in many cases there’s no clear cause.
Sometimes it’s caused by a treatment such as surgery to remove the ovaries , some breast cancer treatments, chemotherapy or radiotherapy, or it can be brought on by an underlying condition, such as Down’s syndrome or Addison’s disease.
Page last reviewed: 29 August 2018 Next review due: 29 August 2021
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Enhancing Healthcare Team Outcomes
Even though menopause is a physiological condition and not a disease, it has significant morbidity. Besides the increased risk of osteoporosis and fractures, the women also regain their risk for heart disease. In addition, the symptoms of menopause are poorly tolerated and lead to poor quality of life. The majority of these women are seen in clinical practice by the nurse practitioner, primary care provider, or internist.
Healthcare workers including the nurse and pharmacist should educate the patient on the physiology of menopause. Only those who are not able to tolerate the symptoms should be treated. It appears that many clinicians have started to use menopause as an opportunity to prescribe all sorts of treatments without solid evidence. If there is osteoporosis, a better option is the use of bisphosphonates. Hormonal agents should only be used for short periods and at the lowest dose to avoid complications.
Feeling Positive About The Menopause
Women may experience physical and emotional changes during menopause but that doesnt mean life has taken a turn for the worse! Many women are prompted at this time to take stock of their lives and set new goals. The menopause occurs at a time when many women may be juggling roles as mothers of teenagers, as carers of elderly parents, and as members of the workforce. Experts suggest that creating some me time is important to maintain life balance. Menopause can be seen as a new beginning: its a good time to assess lifestyle, health and to make a commitment to strive for continuing wellness in the mature years.
Sociocultural Issues In Measuring Hot Flashes
Hot flashes occur worldwide, and starting in the 1970s, research documenting such occurrence increased substantially. A wide distribution of the prevalence of hot flashes around the globe continues to be examined, with reports, particularly in Asian countries, of prevalence less than that in the US and other Western countries . Interest in understanding these differences has raised questions about whether these differences are due to genetic, cultural, environmental, or lifestyle factors such as diet and exercise.
Research in Japan has provided particular insight. Japanese women have a high dietary intake of soy and it was hypothesized that this might explain why they have fewer hot flashes than women in the US, Canada, and Europe. Basic science research has established that isoflavones have estrogen-like activity . Interest in the relationship between the soy consumption of different populations and hot flash prevalence led to epidemiological studies comparing level of dietary soy intake and frequency of hot flashes in countries such as Japan, where an inverse association between soy intake and hot flashes has been demonstrated . Clinical studies of soy foods and soy isoflavones to treat hot flashes proliferated, with mixed results, although there was a tendency toward a beneficial effect .
Menopause And Ovarian Function
Menopause occurs in most women between ages 45 and 55, although it may begin as early as age 40 or be delayed to the late 50s. The age of onset appears to be determined in large part by the hereditary background of the individual. In fact, genes associated with age variations in normal menopause have been identified on multiple chromosomes. However, nutrition and health habits can also influence the age of onset. Premature menopause, which takes place spontaneously before age 40, occurs in about 8 percent of women. The spontaneous onset of menopause before age 45 is sometimes referred to as early menopause. Early or premature menopause may be induced if the ovaries are surgically removed or incidentally damaged or destroyed .
The natural life of the ovaries is about 35 years, and thus the decline of ovarian function is a normal result of aging, though it is accelerated as menopause approaches. During the reproductive years, follicles in the ovaries mature and release their ova periodically under hypothalamic-pituitary stimulation. However, in the years immediately preceding menopause, a transitional phase known as perimenopause which can begin as early as 10 years before menopause, first some follicles and later all follicles fail to rupture and release their ova. In the last one or two years of perimenopause, estrogen levels decline quickly.
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Role Of Hormone Therapy
Gillian wonders whether hormone therapy would help.
Gynecologists have concentrated on determining which symptoms can truly be attributed to an estrogen-deficient state and are thus amenable to hormone replacement therapy. The most reliable way of determining response to hormones is via the randomized, double-blind clinical trial. To date, most trials that have assessed effects on mood and sexual functioning have had relatively small sample sizes. The stage of menopausal transition of the women participants has not always been clarified. There are also some difficulties in extrapolating results from studies of women who have undergone hysterectomy and bilateral oophorectomy to women who have retained their ovaries. Many of the trials failed to use validated and reliable assessments of mood and sexual functioning.
A review of six earlier double-blind studies found that all but one study reported that compared with placebo, there was a decrease in mood-related complaints, such as irritability, fatigue, insomnia, anxiety, and depression.42
To summarize, most double-blind studies have found that estrogens have beneficial effects on mood and sexual functioning. The addition of a progestin leads to less favorable results. Factors involved in determining the acceptability of progestins were reviewed.48 Personality variables, dosage, and type of progestins used, and individual patient vulnerability may be important in determining the response to treatment.
The Melbourne Women’s Midlife Health Project
This was the first major longitudinal study of the experiences of women transitioning from late reproductive age, with continuing regular menses, through the final menstrual period and beyond. It began with a cross-sectional survey of a randomly selected population of 2001 Australian-born Melbourne women, aged 4555 years at the time of the initial interview . Of these, 438 women who had menstruated within the preceding 3 months and were not using hormonal contraception or hormonal therapy, entered the longitudinal phase of the study, in which annual interviews were conducted in their homes, where early follicular phase blood samples were collected for subsequent hormonal and other analyses. Measurements of height and weight were recorded. Some aspects of the endocrine findings in this study are discussed in detail below. A summary of the major findings was published in 2004 . The accompanying paper presents a novel approach to modelling the longitudinal changes in FSH and E2.
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Mood And Memory Effects
Menopause-related cognitive impairment can be confused with the mild cognitive impairment that precedes dementia. Tentative evidence has found that forgetfulness affects about half of menopausal women and is probably caused by the effects of declining estrogen levels on the brain, or perhaps by reduced blood flow to the brain during hot flashes.
Central Nervous System And Menopause
The association between estrogen and memory function is an intriguing area of research. Normal aging itself induces a decline in certain cognitive capabilities, and a lack of estrogen may contribute to this process. If this is the case, postmenopausal estrogen therapy may be able to preserve this function and slow or even prevent decline in certain cognitive functions.
An inherent difficulty in this area involves the limitations of objective cognitive testing for functions such as memory. Postmenopausal women receiving estrogen therapy have shown better performance on memory testing than postmenopausal control subjects not receiving estrogen therapy. The effect of estrogen is to slow the decline of preserved memory function. Womens Health Initiative data do not show improved cognitive function in women taking either hormone therapy or estrogen therapy.
Current data suggest that Alzheimer disease is more common in women than in men, even when the longer average lifespan of women is taken into account, because AD is primarily an age-related condition. In earlier studies, estrogen therapy appeared to reduce the relative risk of AD or to delay its onset. Estrogen therapy has not been shown to improve cognitive function in patients with AD it cannot reverse previous cognitive decline and therefore has no role as a sole treatment modality in AD. WHI data support this view.
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Endocrine Characteristics Of The Menopausal Transition And Menopause
Although some neuroendocrine changes may contribute to the onset of the menopausal transition , the major factor is generally thought to be the decline in the numbers of ovarian follicles to a critically low level. described follicle numbers in three groups of older women, those who were continuing to cycle regularly, those who were in the menopausal transition and those who were post-menopausal. In the menopause transition group, the mean number of primordial follicles per ovary was 100, whereas in the post-menopausal group the ovaries were virtually devoid of follicles.
The first major description of the circulating hormonal concentrations during the menopause transition was by , involving six women followed in detail up to and including final menses. The features included a monotropic rise in FSH levels, evidence of continued folliculogenesis and ovulation up to the FMP and periods of hypoestrogenemia concomitant with large FSH rises. These investigators first postulated that the FSH increase resulted from loss of inhibin restraint, though inhibin had not been characterized at that time.
Geometric mean levels of FSH, IR-INH, INH-A, INH-B and E2 as a function of menopausal status. Menopausal stages as given in text are regular menstrual cycles, early menopausal transition, late menopausal transition and post-FMP. Values with the same superscript are not statistically different values with differing superscripts differ, P< 0.05
Emerging Areas Of Interest
Brain imaging techniques such as functional MRI are being used to examine brain function during hot flashes. Initial studies of brain activation during hot flashes have found that the insula and anterior cingulated cortex are activated during hot flashes . Better understanding of the neural control of hot flashes will provide further insight into mechanisms.
Another area of growing interest is the relationship between hot flashes and polymorphisms of genes involved in estrogen function, such as sex steroid metabolizing enzymes and estrogen receptors. Given that estrogen plays some role in the hot flash phenomenon, investigators are examining variation in genes coding for enzymes involved in estrogen synthesis and hormone interconversion for a possible role in the variance in observed circulating hormone levels . Genetic polymorphisms are also being studied in an attempt to explain observations of race/ethnic differences in hot flash prevalences , such as seen in the Study of Women Across the Nation in the US. Two studies indicate that there are certain race/ethnicity associations between polymorphisms for sex metabolizing hormones . This line of research is in its infancy but may provide new insights into the often conflicting and variable results of studies examining factors that might predict who most is at risk for hot flashes.
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Scientific Definitions For Menopause Related Terminology
Established By The International Group
Throughout the world, misuse of terminology related to the field of menopause has caused a great deal of confusion and misinformation among healthcare providers, those in research, the media, and the public. To help ensure a standardized definition of key words used in the field, the International Menopause Society commissioned a project through its international policy organ the Council of Affiliated Menopause Societies .
Because terms such as premature menopause and perimenopause have not had specific scientific definitions, their use has caused confusion among those in the menopause field. In fact, even the definition of menopause itself is not the same around the world.
The following list of menopause-related definitions was approved by the Board of the IMS on October 11, 1999, in Yokohama, Japan. Wherever possible, current accepted definitions in the medical literature were left intact to avoid adding confusion to this area.
The IMS and CAMS organizations – including the North American Menopause Society – urge all those involved in menopause health care and research to adopt these refined definitions. Only through proper communication can we work together toward improving the health of women as they reach menopause and beyond.
CAMS Menopause-Related Definitions