Today, women’s health and longevity have improved significantly. Even as recently as a century ago, a large percentage of women did not live up to menopause. The women who did, did not live long after menopause. Improved nutrition and medical care have contributed to the longer life of women. Nowadays, women are encouraged to live in good health and happiness after their fertile years are over. Menopause might mean the end of fertility but there is no valid reason why a woman should not be well and comfortable in the years – or decades – ahead.

• What is menopause and when should you expect it?
• What happens to a woman’s body at menopause?
• The psychological features of menopause
• Oestrogen replacement therapy
• Bleeding after menopause (post-menopausal bleeding)
• Premature menopause

What is menopause and when should you expect it?

Menopause is the cessation of menstruation, in women over the age of 45, for at least 6 to 12 months. Menopause is accompanied with some physical and psychological changes. It occurs over a few years. Ovarian failure also takes place during this time. Needless to say, once a woman stops experiencing the menstrual cycle, her child-bearing years are over. There is usually reduced ooestrogen level after menopause.

The age of menopause varies. In India, which has a warm climate, women reach menopause between the ages of 45 and 50. In colder climates, women experience menopause a few years later. In the USA, for instance, the average age of menopause is 50 to 52 years. Apart from climate, the age of menopause also depends on hereditary factors.

What happens to a woman’s body at menopause?

• Menstrual irregularity and cessation
• Hot flushes and sweating
• Changes in the vagina
• Changes in the uterus
• Changes in the breasts
• The possibility of osteoporosis
• Tendency towards increased body hair

Menstrual irregularity and cessation: Only in a few cases, menstruation ceases abruptly. In case of some women, the frequency of the menstruation reduces gradually as they approach menopause. Others get their periods at frequent intervals with scanty or prolonged flow. This is because of limited follicle maturation as the remaining follicles in the ovaries become less sensitive to gonadotropin stimulation.

Hot flushes (or flashes) and sweating: This is one of the most common uncomfortable symptoms associated with menopause. The sudden reddening of skin on the neck, chest and face marks a hot flush. A feeling of intense body heat, and sweating accompany the hot flush. It could last for just a few seconds or for several minutes. Hot flushes tend to occur more at night or during times of stress. Usually menopausal women get hot flushes over a period or 1 or 2 years, but they can last up to 5 years. Oestrogen replacement therapy helps to decrease the frequency and severity of hot flushes.

Changes in the vagina: The vagina becomes smaller around menopause. The opening to the vagina narrows. There is a reduction of fat in the labia majora. The labia minora become pale and dry. The vaginal pH increases and this can result in infection (senile vaginitis). Pruritis of the vulvovaginal area can occur. Dyspareunia (pain during sexual intercourse) is commonly reported.

Changes in the uterus: The uterus also decreases in size and the endometrial tissue becomes sparse. The vaginal part of the cervix becomes smaller as the muscle atrophies. The pelvic tissues and ligaments that support the vagina and uterus lose their tone and become weaker. This predisposes to prolapse of the uterus. If there are fibroids in the uterus, they become smaller, but do not disappear.

Changes in the breasts: The fat in the breasts gradually reduces. Nipples become smaller. In general, the breasts become softer, less full and lose the form they had in the child-bearing years.

The possibility of osteoporosis: Osteoporosis is the main health hazard associated with menopause. In this condition, the bones become more porous due to decalcification. It is associated with reduced levels of two hormones – estrone and androstenedione. The danger of osteoporosis is the possibility of fractures. Fractures can be of the vertebral body (compression fractures), humerus, upper femur, distal forearm and ribs. Regular exercise and a proper diet throughout the child-bearing years can do much to prevent osteoporosis at menopause.

Tendency towards increased body hair: Because of the loss of oestrogen, menopausal women tend to have more circulating androgens (male hormones). This results in a tendency towards increased body hair with a male pattern of distribution.

The psychological features of menopause

There are some common psychological features of menopause. These include increased moodiness, irritability and greater anxiety and fearfulness. Some women undergo depression and experience insomnia (inability to sleep). Others report a decreased libido. All these psychological symptoms form part of the menopausal syndrome, which follows reduced oestrogen in the body. Menopause, like puberty, is another time when women require a lot of reassurance. Menopausal women also have to cope with a changing self-image. Emotional disturbances and insecurity only worsen the uncomfortable symptoms of menopause.

Oestrogen replacement therapy

To relieve menopausal symptoms in women, oestrogen replacement therapy is widely recommended. . However, it does have certain associated risk factors and has to be avoided under certain conditions A brief explanation of the advantages and disadvantages of oestrogen replacement therapy are given here:

Advantages of oestrogen replacement therapy

• Menopausal symptoms are relieved: Hot flushes and sweating become much less frequent and severe after oestrogen replacement therapy. This therapy also acts against and can reverse atrophic vaginitis, dyspareunia (pain during sexual intercourse) and degenerative changes in the urethra and urinary bladder. Psychological symptoms of menopause are also reduced with oestrogen replacement therapy.
• Osteoporosis can be either prevented or treated: If oestrogen replacement therapy is given within three years of the last period, there will be no bone loss. In fact, there will be new bone formation. If therapy is started more than three years after the last period, there is no new bone formation, but there will be no bone loss. Low back pain can also be reduced with this therapy. Along with the therapy, a regular exercise programme is recommended. This helps to maintain muscle tone.
• The risk of cardiovascular disease is reduced: Women who undergo oestrogen replacement therapy at menopause also undergo certain changes that protect them against heart disease. They have reduced levels of low-density lipoprotein in serum cholesterol and increased levels of high-density lipoprotein.
• The skin remains youthful: With oestrogen replacement therapy, a menopausal woman’s skin retains a youthful look.

Disadvantages of oestrogen replacement therapy

• Some conditions can worsen with oestrogen replacement: These include acutely diseased liver, impaired liver function, acute vascular thrombosis and neuro-opthalmological vascular disease. Those who suffer from seizure disorders, hypertension, familial hyperlipidemia and migraine should also avoid oestrogen replacement therapy.
• Suggested relationship with cancer: Some studies suggest that there is an association between unopposed oestrogen and breast cancer. The women who are particularly at risk are those who experienced late menopause, have been sterile or have had had a family history of breast cancer along with a history of infertility or chronic cystic mastitis.

Studies have also associated endometrial cancer with unopposed oestrogen. Women on oestrogen replacement appear to have a risk of endometrial cancer that is four to eight times greater than that of women who are not. The risk of endometrial cancer increases with the dose and duration of the oestrogen replacement and reduces once the therapy is over. It is also increased with continuous oestrogen replacement more than in cyclic replacement. The addition of a progestin to the therapy seems to reduce the risk of cancer.

Oestrogen replacement therapy should be avoided in women who are grossly overweight, have high blood pressure or are diabetic. Women with dysfunctional uterine bleeding or high endogenous oestrogen levels must also avoid this therapy.

Bleeding after menopause (post-menopausal bleeding)

Bleeding after menopause is called post-menopausal bleeding. This type of bleeding can be due to a wide range of causes. It can be caused by

• Ulcers caused by a pessary that has been left behind or by decibutus ulcers in the procidentia.
• Inflammatory causes like a urethral caruncle, tuberculosis of vagina, cervix or uterus, syphilitic ulcer of the vagina and cervix, senile vaginitis or senile endometritis.
• Benign growths like cervical polyps, a large benign ovarian neoplasm and uterine myomata and sarcomata.
• Malignant growths like carcinoma of the endometrium or cervix and cancer of the ovaries, vagina, vulva or fallopian tubes.
• Severe hypertension.

Treatment is based on the cause of the bleeding. If there appears to be no cause, a Dilation and Curettage is done. If the bleeding recurs, a hysterectomy with a bilateral salpingectomy may be advised.

Premature menopause

When a woman has permanent amenorrhea (absence of periods) before the age of 35, the condition is called premature menopause. This condition may be hereditary. The ovarian failure may also be caused by an autoimmune disorder that is secondary to rheumatoid arthritis. Another cause is an inflammatory reaction due to a mumps infection, which could affect the ovaries.