Menopause is an important phase in a woman’s life and can impact her in various ways. A woman is said to have attained menopause if she does not get a period for 1 year (12 months). It occurs due to a decline in the levels of female sex hormones estrogen (estradiol) and progesterone, reduced functioning of the ovaries, and cessation of the release of eggs (ovulation), with age. The age of attaining menopause can range from 45-55 years, with around 50 years being the most common.
Perimenopause refers to the years before attainment of menopause when a woman’s monthly cycles start becoming irregular, unpredictable, or different from her usual cycles in terms of the time interval between periods, duration, and amount of bleeding. The duration of perimenopause can be a few years, and it is also accompanied by other symptoms, in addition to irregular cycles.
In the perimenopausal years, the periods become irregular and their usual pattern changes. These changes include any of the following:
- Change in frequency of periods (more or less frequent)
- Unpredictable time of periods
- Skipping of periods in some months
- Increased or decreased amount of bleeding
- Increased or decreased duration of the period
It is important to note that pregnancy is still possible with irregular periods during perimenopause, so if one has skipped a period for 1 or more months, it is wise to rule out pregnancy.
Physical and Psychological Symptoms
There are other physical symptoms during perimenopause and menopause that can be distressing, and reduce the quality of life. These include:
- Hot flashes, sweating, chills, night sweats
- Weight gain, bloating, and gas (flatulence)
- Indigestion, constipation
- Vaginal dryness, irritation, bleeding (during intercourse)
- Loss of a full feeling of the breast
- Difficulty in sleeping, or sleep pattern changes
- Headache, dizziness, vertigo
- Dry skin or changes in skin texture
- Tingling, pricking, and abnormal sensations (paresthesia)
- Thinning of hair, or hair fall
- Fatigue, weakness, low energy
- Joint and muscle pains
- Frequent or involuntary urination (incontinence)
- Mood swings, irritability
- Depression (melancholia)
- Anxiety, palpitation
- Dissatisfaction, frustration, impatience
- Decrease in memory, work performance
- Reduced sexual desire
- Social avoidance
There are rating scales and indices available that estimate the overall severity of menopausal symptoms. These include the Menopause Rating Scale (MRS) and the Kupperman Scale.
ASSOCIATED MEDICAL CONDITIONS
Menopause can increase the risk of medical conditions, for which women should be evaluated. These include:
Menopause is a natural process and as such does not routinely need diagnostic tests or medical treatment. However, in certain situations, as in the case of risk or the presence of associated medical conditions, or in the case of some of the symptoms being severe and affecting the daily quality of life, medical intervention may be needed.
The doctor may do a general checkup including blood pressure and weight check, and advise some lab tests if needed like complete blood counts (CBC), blood sugar, lipid profile, thyroid function tests, female sex hormone levels, and a urine test. A bone mineral density (BMD) test may also be advised to check for bone thinning. Mammography screening may be advised 1 or 2 yearly, based on a family history of breast cancer.
Diet: Eat a nutritious diet rich in vegetables and fruits, whole grains, proteins, and curd. Reduce consumption of high-sugar foods/drinks, refined flour, and high-fat/fried items. Keep well hydrated with adequate water intake through the day. Hot or caffeinated beverages, spice foods, and alcohol can trigger hot flashes in some women.
Environment: Avoid hot, humid, and poorly ventilated stuffy places, and wear comfortable clothes, if experiencing hot flashes. Avoidance of active and passive smoking is also beneficial.
Exercise: Maintain a regular exercise schedule of 30-45 minutes/day 3-4 times a week. Exercises can include brisk walking, cycling, stretches and aerobics, yoga, swimming, dancing or sports. It is not advisable to start any new or unfamiliar strenuous exercise at this time. Exercise should have periods of initial warm-up and a cool-down towards the end. All exercises should be performed in comfortable clothing and footwear in a cool/airy environment. Specific exercises may be recommended by the doctor in case of urgency or urinary incontinence (involuntary urination during laughing, coughing or sneezing), called pelvic floor muscle exercises or Kegel exercises. Apart from physical exercises, breathing exercises are also beneficial for stress relief, lung function, and improving overall health.
Sleep: It is very important to get 8 hours of undisturbed sleep on most nights. If sleep is not adequate, it is important to assess lifestyle and environmental factors, in order to improve sleep.
Stress management: When stress is present, it can worsen many symptoms of menopause. Relaxing hobbies, time with family and friends, avoidance of too much social media and gadgets, and practicing mindfulness techniques can help manage stress. Open discussion and sharing with family and friends, and their understanding and support during menopause can help in reducing a woman’s psychological stress and symptoms.
Health and Nutritional Supplements
The most common health supplements prescribed in menopause are those of calcium and vitamin D, as bone loss and thinning occur due to a decrease in estrogen levels, and this can increase the risk of fractures. General multi-vitamin-mineral supplements containing folic acid, vitamin B12, B6 and magnesium, may also be prescribed to improve overall health and nutrition. Vitamin E, omega 3 fatty acids (DHA, EPA) supplements and primrose oil may also be prescribed especially when hot flashes are present.
Many herbal supplements are available for easing menopause symptoms, but it is important to take these under a doctor’s recommendation after review of clinical studies and research. Some of these herbs should be avoided by women with health conditions like allergy, breast cancer family history, epilepsy, high blood pressure, and if pregnant/breastfeeding. Plant estrogens, also called phytoestrogens, include isoflavones found in soybeans and lentils, and lignans found in flaxseed, whole grains, and some fruits and vegetables. These have estrogen-like effects in the body and can relieve menopausal symptoms without the risks and side effects associated with hormone replacement therapy. Other such herbs include sage, red clover, thyme-thistle, etc.
Hormone Replacement Therapy (HRT)
As menopause sets in, there is a decline in the hormones estrogen (estradiol) and progesterone. Our body produces 3 types of estrogen hormones: estradiol (the main estrogen during the fertile years, also called E2 or 17 beta-estradiol), estrone (the main estrogen produced after menopause, also called E1), and estriol (produced during pregnancy, is short-acting, also called E3).
Estradiol or E2 is the strong estrogen responsible for the functioning of the ovaries, the release of the egg (ovulation), and also for sexual development and maintenance of fertility during the reproductive years of the woman. E2 also helps bone development and protects against cardiovascular disease and injury to blood vessels.
E1 and E3 are weak estrogens. Estrone or E1 mainly produced in menopausal women is much weaker than estradiol and can thus not sustain ovarian function, ovulation, regular menstrual cycles, and bone health. E1 also increases blood vessel injury and cardiovascular risk.
Bioidentical hormones are hormones from plant sources, that are chemically identical to those of the human body. These are synthesized by chemically extracting a substance called diosgenin from plants such as yams and soy, that is chemically modified to yield bioidentical progesterone and estrogen. Only approved bioidentical hormonal products by the country’s regulators should be used.
Bioidentical hormones should be differentiated from customized compounded therapy, where local pharmacists combine ratios of bioidentical hormones into a particular recipe or mixture. Though these formulations may have ingredients similar to those in FDA-approved products, they are not regulated for safety, efficacy, and dosing consistency.
The gynecologist may prescribe hormones (estrogen and progesterone) in order to prevent severe menopausal symptoms like hot flashes and protect against bone loss.
Estrogen therapy can be given orally, vaginally (as creams, tablets, and rings), trans-dermally (as patches, gels, and creams), by injections, and in some countries by subcutaneous pellets or intranasally. However oral route remains the most common. Bioidentical estrogens include 17 beta-estradiol and estrogen valerate. Non-bioidentical estrogens include conjugated equine estrogen (ECC), ethinyl estradiol (EE), and mestranol.
Estrogen alone can be given in women who have undergone uterus removal (hysterectomy). In all other women, estrogen is given with progesterone that may be added throughout or in the latter half of the cycle with or without a hormonal break.
Bioidentical progesterone is available as micronized progesterone in oil to improve gut absorption. Non-bioidentical synthetic progesterone (also called progestins) includes medroxyprogesterone acetate (MPA), norethisterone, norgestrel, levonorgestrel, desogestrel, etc.
Alternatives to adding progestins include tibolone (metabolized to estrogen, progestogen, and testosterone in the body) or bazedoxifene (selective estrogen receptor modulator). The tissue-selective estrogen complex (TSEC) is a novel class of agents pairing a selective estrogen receptor modulator (SERM) with 1 or more estrogens.
Long-term hormone therapy especially with oral HRT or non-bioidentical hormones may be associated with some risk of CVD, hypertension, weight gain, thrombosis, and breast cancer; therefore, early initiation <60 years and the right dose of HRT is important. HRT should be taken under strict medical guidance and monitoring by a gynecologist.
Treating Vaginal Dryness
Vaginal gels, moisturizers, and lubricants are available for local application. Estrogen as vaginal creams/tablets when applied locally also helps protect against vaginal dryness, discomfort during intercourse, and degeneration, along with some improvement in urinary incontinence and urgency.
There is also alteration of the normal bacterial flora of the vagina after menopause. This, in addition to frequent urination, can increase the chances of vaginal infection (vaginitis) and urinary tract infections (UTIs). The use of probiotics alone or in combination with antibiotics may be prescribed to treat and prevent vaginal and urinary infections in postmenopausal women. Vaginal probiotics along with vaginal moisturizers can also help improve vaginal dryness, reduce degeneration (atrophy), along with normalizing bacterial flora.
Some medicines have been used to manage hot flashes especially when HRT is not recommended. These include SSRI antidepressants, gabapentin (mainly used for seizures, but useful in nighttime hot flashes), and clonidine (a drug for high blood pressure, but sometimes used to relieve hot flashes).
Menopause may also be caused unnaturally due to surgical removal of the uterus and ovaries (oophorectomy), or chemotherapy and radiation therapy for cancer. Menopause occurring before 40 years is called premature menopause for which often no obvious cause is found (may be genetic or immune-mediated).
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