WRITE UPS - MENOPAUSE - Menopause And Its Gynecological Management



     Major endocrine changes occur in a woman around 45 and 50 years of age. There is a marked decline in the ovarian function resulting in a decline in estrogen production that leads to a series of changes commonly known as menopausal changes. Fifty years ago these changes were not considered significant as average life expectancy of women was only 60 years and postmenopausal population was small. Also at that time short and long-term sequelae of estrogen deficiencies were not known. Thus, menopause was considered as a process of normal aging and though women had symptoms, they were not treated but either left alone or given some symptomatic treatment, like good diet, tranquilizers and psychotherapy. This thinking has changed now. We definitely know the endocrine and metabolic changes that occur with menopause and also the short and long-term sequelae of estrogen deficiency. Also there is a profound change in the birth and mortality rates, which has resulted in the aging of the population all over the world.  The enormous decline in the maternal mortality in particular has meant that increasing proportion of women are surviving to the menopause and several years of active life beyond it. Women aged 55 years and above now comprise 18% of the population of UK and 15% in USA. Average life expectancy for women in developed countries today is around 83 reach the age of 80 years. If the average age of menopause is 50 years, most women will spend approximately one- third life in post-menopausal period. In India also, the life expectancy for women has increased from 31.7 years in 1940 to 60.7 years in 1993 and is expected to be 65 years in year 2000. The average age of menopause is 47 years, which means even our women will spend about 20 years of their life in post-menopausal period and will develop symptoms due to estrogen deficiency requiring definite treatment.




     Menopause means “ cessation of menstrual period”. (It is a combination of Greek word menos meaning menstruation and pause meaning stop). Sometimes this is confused with the climacteric, but climacteric is the transitional phase during which ovarian function ceases and which when complete leads to the menopause.


     The average age for menopause in Western countries is 50 years and in India is 47 years. It occurs earlier in women who use tobacco, and are heavy smokers, and those who live at higher altitudes.




     Menopause can be natural or spontaneous and artificial or iatrogenic due to either surgical removal of the ovaries and the uterus or due to irradiation or chemotherapy for malignant diseases.




     Whenever menopause occurs before the age of 40 years it is called as premature menopause, some authors consider 45 years as age limits for premature menopause. Commonest causes for premature menopause are surgery or radiotherapy and chemotherapy for malignant diseases. Natural causes for premature menopause are still not known but it is known to be associated with chromosomal and certain autoimmune disorders.


Risks of Premature Menopause:


     These women will develop menopausal symptoms at an earlier age, but more important is the fact that they are at a higher risk for developing coronary artery disease as well as early development of osteoporosis at an age of 50 to 60 years. Starting HRT at an early age, and at least continuing till the age of 50 years can prevent these complications.




     Menopause whether spontaneous, surgical or premature will produce the following symptoms, mainly related to estrogen deficiency.  The symptoms can be acute, intermediate and chronic or long-term sequelae.


 Acute Symptoms: -


     Vasomotor disturbances host flushes and perspiration, night sweats and insomnia.


Psychological Symptoms: -


     Mood changes anxiety, irritability, poor memory, and poor concentration loss of self-esteem and depression.


Intermediate Symptoms: -


1)       Those associated with atrophy of the lower urogenital tract like vaginal atrophy, recurrent vaginal infections, dyspareunia painful sexual intercourse, and loss of libido and recurrent urinary tract infections.

2)       Those associated with loss of collagen from connective tissue like thinning of skin, joint, aches and paints, prolapse and urinary stress incontinence.


Chronic Symptoms: -


     Chromic symptoms or long-term sequelae are the most important causes of mortality and morbidity. They are Arterial cerebro-vascular accidents, coronary artery disease and skeletal osteoporosis.

      The symptoms very widely between individuals in the same population as well as in different populations. Most women at the age of menopause are more concerned about health issues in their healthy “Disability Free Life Expectancy” (DFLE ) than their total life expectancy.


     Locomotor disorders rank first and circulatory diseases second in  the list of diseases which circumscribe DFLE. Not only women have become health conscious now, but today they have greater aspirations and are pursuing  high profile careers in all the fields and want to continue doing that even in post-menopausal life Women today have greater expectations of a higher quality life than their mothers and grandmothers and, therefore, will pose challenges about their health care in their 7th and 8th decades




     Proper and comprehensive management of women at menopause and in post-menopausal period is very important and can be done effectively by in-depth counseling. Management is multidisciplinary and consists of relief of symptoms due to estrogen deficiency as well as taking care of medical problems, endocrine disorders, and genital malignancies and other health problems like psychological and emotional problems that are commonly seen at this age.


     Hormone replacement therapy (HRT) forms the most important part in the management of menopausal symptoms related to estrogen deficiency. When HRT was introduced in 1960 it was mainly used as a therapeutic agent to relieve the acute symptoms like not flushes and vaginal atrophy and recurrent vaginal and urinary tract infections. Recently, it has been shown that HRT also plays a very important role in prevention of long-term sequelae of estrogen deficiency like cardiac and cerebro-vascular disease and osteoporosis. Currently, it is used extensively for both therapeutic as well as prophylactic or preventive purposes. Also some of the older myths and misconceptions regarding use of HRT have been cleared and it has been proved beyond doubt that benefits of HRT clearly outweigh the risks. Also by introducing better estrogen preparations and non-oral route of administration some of the side effects have been reduced. Addition of progesterone when estrogen replacement is used for over five years has reduced the risk of endometrial cancer and hyperplasia. In future, low dose combination patch of estrogen and progesterone will be available which will be an ideal form of HRT especially for a high-risk group. Before prescribing HRT to any woman, potential risks and benefits must be kept in mind and explained to the woman, as these prescriptions are apparently given to healthy women for prophylactic purpose and will have be taken for a long period of time to be effective. An informed consent is also necessary and long-term follow up is mandatory.




 Relief of Vasomotor Symptoms –


     Most important is relief of vasomotor symptoms. Hot flushes and night sweats occur due to estrogen deficiency and develop very early. 50 to 75% women experience them. HRT relieves them.


 Relief of Symptoms due to End-organ Atrophy: -


     Estrogen deficiency leads to atrophy of vaginal as well as urethral epithelium. This leads to recurrent vaginal infections, dyspareunia, recurrent urinary tract infection and urgency and frequency of micturition known as urethral syndrome. Estrogen replacement improves all the symptoms due to atrophy.


 Relief of Psychological Symptoms: -


     The effect is a “ snow ball” effect and is due to relief of hot flushes and night sweats. There is proper sleep and reduced irritability and mood disturbances. Major psychological symptoms are not cured and will require psychiatric opinion.


 The Mental Tonic Effect-


     Estrogen replacement improves mental awareness, produces sense of well being and euphoria.


 Effect on Skin Atrophy-


     By improving the collagen content HRT prevents skin atrophy prevents wrinkling and dryness and thus prevents aging to some extent.




      HRT also has potential risk of increase in the incidences of  genital cancers like cancer of uterus, breast cancer and ovarian cancer use of HRT is not so popular. Other risks are:

·        Endometrial hyperplasia,

·        Thromboembolism,

·        Gallstones,

·        Increase in blood pressure, and

·        Post-menopausal bleeding unnecessary surgery.


 Balancing the risk and benefits:-


     It is very important to balance the risks and the benefits. Aim should be to maximize the benefits and minimize the risk. Patients who are at high risk should not be given HRT or when given should be carefully followed up. Smallest dose should be used and combined estrogen and Progestogen should be given when uterus is still present. Detailed follow-up examination is very important.




      Post-menopausal women may have hypertension, cardio-respiratory problems, and chronic infection especially urinary tract infection due to prolapse as well as atrophy of urethral epithelium. All of these should be adequately investigated and treated.


Endocrine disorders like thyroid and parathyroid dysfunction and metabolic disorders like diabetes mellitus are common at this age and require careful management. Womb at this age are at an increased risk for developing cancer, therefore, cervical smear, endometrial aspiration cytology, and breast examination should be carried out frequently and regularly.


 Diet, Exercise And Change In Life Style: -


     All these form very important aspects of management. Healthy diet with adequate calcium supplement regular exercise, avoiding excess alcohol and smoking and avoiding excess weight gain or loss are equally important for a healthy life Women may feel lonely and unwanted at this period and may have depression. Good psychotherapy and advice to have a positive outlook and to develop some creative interest will go a long way for them. Let us not dismiss menopause as an aging process or an endocrine disorder, but call it a “ Golden Period” and provide these women efficient healthy care for happy and health life and help them to grow old gracefully.



Click here to view other articles in this section