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Menopause

 
INTRODUCTION

Women all over world now have to spend almost 1 /3rd of their lives in menopause years because average life expectancy is increasing. Average life expectancy for Indians is 68 years and 80 years for Americans, average age of menopause being 46-51years. So knowledge about menopause and various problems related to menopause is very important.

 

DEFINITIONS AND STAGING OF MENOPAUSE

Menopause is defined as the permanent cessation of menses. By convention the diagnosis of menopause is not made until the individual has had 12 months of amenorrhoea.
Menopause is not just cessation of menstruation it is "Depletion of Ovarian follicles" leading to decrease in ovarian hormones.
Menopause is thus characterised by the menstrual changes that reflect oocvte depletion and subsequent reduction in ovarian hormone production.

However the manifestations that occur around the time of menopause are caused by the underlying ovarian changes, rather than by the cessation of menstruation itself. Therefore, a woman who has undergone a hysterectomy but who retains her ovaries will experience normal menopausal symptoms as oocyte depletion leads to hypoestrogenism, even though cessation of menstruation occurred with surgery. In cases where we do hysterectomy but leave the ovaries behind the depletion of oocytes would occur earlier than expected and so woman will perceive menopausal changes earlier but not immediately after surgery.
Natural menopause occurs at or after 40 years of age and has no underlying pathologic cause.
Induced menopause may occur after:

  • Chemotherapy,
  • Pelvic radiation, or,
  • Bilateral oophorectomy.
  • Menopause is considered premature when it occurs before 40 years of age but is otherwise normal and not surgical
  • The climacteric, a term now used infrequently, refers to the time of waning ovarian function associated with menstrual irregularity and vasomotor symptoms.
  • Perimenopause is the time between the onset of the climacteric and the year after the last menses.
  • Premenopause is the entire reproductive span before onset of the menopausal transition, and postmeno-pause is the span of life after menopause.
 
AGE OF MENOPAUSE
Based on cross-sectional studies, the median age is estimated to be somewhere between 50 and 52 The Massachusetts Women Health Study found that the median age of menopause was 51.3 years while Treolar et al in their longitudinal study observed that 95% women reached menopause by 44 to 56 years, with an average of 50.7 years. Some of the Indian studies have found that average age of menopause is about 49-50 years.
 
Factors affecting age of onset of meno

Earlier onset of menopause

  1. Lower education
  2. Malnutrition
  3. Thinner women
  4. Low socio-economic status
  5. Vegetarians
  6. Growth retardation in late gestation if the woman has been a growth restricted and low birth baby
  7. Current smoking Late onset
  8. High parity
  9. Prior use of oral contraceptives
  10. Obesity
  11. Alcohol
 
So far 35 symptoms have been associated with menopause
  1. Hot flashes, flushes, night sweats and/or cold flashes, clammy feeling
  2. Bouts of rapid heart beat
  3. Irritability, mood swings
  4. Sudden tears
  5. Trouble sleeping through the night (with or without night sweats)
  6. Irregular periods; shorter, lighter periods; heavier periods, flooding; phantom periods, shorter cycles, longer cycles
  7. Loss of libido
  8. Dry vagina
  9. Crashing fatigue
  10. Anxiety, feeling ill at ease
  11. Feelings of dread, apprehension, doom
  12. Difficulty concentrating, disorientation, mental confusion
  13. Disturbing memory lapses
  14. Incontinence, especially upon sneezing, laughing; urge incontinence
  15. Itchy, crawly skin
  16. Aching, sore joints, muscles and tendons
  17. Increased tension in muscles
  18. Breast tenderness
  19. Headache change: increase or decrease
  20. Gastrointestinal distress, indigestion, flatulence, gas pain, nausea
  21. Sudden bouts of bloat
  22. Depression
  23. Exacerbation of existing conditions
  24. Increase in allergies
  25. Weight gain
  26. Hair loss or thinning, head, pubic, or whole body; increase in facial hair
  27. Dizziness, light-headedness, episodes of loss of balance
  28. Changes in body odor
  29. Electric shock sensation under the skin and in the head
  30. Tingling in the extremities
  31. Gum problems, increased bleeding
  32. Burning tongue, burning roof of mouth, bad taste in mouth, change in breath odor
  33. Osteoporosis
  34. Changes in fingernails: softer, crack or break easier
  35. Tinnitus: ringing in ears, bells, 'whooshing' buzzing etc.
 
TREATMENT OF MENOPAUSAL WOMAN

The patient often fears a pregnancy and possibility of cancer at the menopause. The gynecologist should investigate her thoroughly: palpate the breasts, do a speculum examination, take a smear for cytology and do a bimanual pelvic examination. A histological evidence of the endometrial condition is recorded in women in whom 'hormone replacement therapy' is contemplated.
Blood pressure should be determined, and blood sugar levels be checked for diabetes, lipoprotein profile evaluated, and whenever feasible, tests undertaken to detect disturbed thyroid function by estimating serum TSH value as a screening test.
It is a good practice to document baseline recordings of the following investigations: pelvic ultrasound scan noting uterine size and myometrial texture. The pathologies like presence of fibroids, alterations inendometrial thickness and adnexal masses is to be looked for. A baseline mammography documentation is always desirable .

 
PATIENT CONCERNS ABOUT MENOPAUSE

Numerous emotions are often associated with hormonal and bodily changes characteristic of this period. The physician should be sensitive to the potentially significant emotional distress faced by women entering menopause and be prepared to offer psychological support. For some women in whom childbearing and childrearing have been a major source of status and self-esteem, loss of fertility may cause great distress.46 For other women who have delayed childbearing, menopausal symptoms may represent tangible evidence of their inability to have children.
In our society, young age is looked upon with great pride whereas maturity often is not; thus menopause, which symbolizes loss of youth produces distress, may be subtle yet disturbing. Hence family support at this time especially from the husband and grown up children is very important. Women peer groups, Mahila mandals and counselors also play a major role in influencing life style changes. Our society will certainly benefit if women get together and involve themselves in constructive activities which will allow them to be busy and at the same time to enjoy the work they do.

 
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