DR. DURU SHAH
Program Director, Gynaecworld Assisted Fertility Unit(GAFU)
Medical Director, Gynaecworld
What does the word menopause mean?
The term “menopause” comes from the Greek words meno (month) and pause (to end). Thus, it literally means permanent physiological, or natural, cessation of menstrual cycles. The absence of menstrual periods for 12 months is usually used as the definition of ‘natural’ menopause.
What is menopause?
The word is commonly used to signal the end of the fertile phase of a woman’s life happening more or less in midlife. Menopause is perhaps most easily understood as the opposite process to menarche (first menstrual period). Menopause in women can simply be defined as the permanent ‘stopping of the monthly periods’.
Actually it goes back, as we say woman is menopausal only if she has not had her periods for 12 months. If she gets her periods after 3-4months then she is in perimenopause.
What is surgical menopause?
Due to some medical conditions, the uterus is sometimes surgically removed – a procedure called ‘hysterectomy’, due to which the menstrual periods will cease permanently and the woman will technically be infertile. But as long as one or both her ovaries are still functioning, the woman will not be in menopause. This is because even without the uterus the ovaries continue to release the reproductive hormones until the time natural menopause is reached. If the ovaries are removed only then surgical menopause truly occurs.
Why does natural menopause happen?
Menopause is triggered by the faltering and shutting down (or surgical removal) of the ovaries, which are a part of the body’s endocrine system of hormone production. During menopause the hormones that make reproduction possible and influence sexual behavior reach extremely low levels. There is actually depletion of eggs of follicles in the ovaries and that is the main reason of falling of female hormones estrogens.
The process of the ovaries shutting down is a phenomenon that involves the entire cascade of a woman’s reproductive functioning, from brain to skin. This major physiological event usually has some effect on almost every aspect of a woman’s body and life.
Does menopause occur only with age?
Menopause occurs when the ovaries ceases to secrete the sex-hormone (estrogen and progesterone). Usually it occurs as the age advances and ovaries mature. However, in certain cases like cancer – chemotherapy, radiation therapy or operative surgery on the ovaries or rarely, per-maturely the ovaries stop functioning and / or are removed leading to the symptoms of menopause. Other operative surgeries to remove uterus and the removal of uterus with ovaries (Hysterectomy) will also lead to menopause.
At what age does a woman typically reach menopause?
The average age of menopause worldwide is 51 years old. But there is no way to predict when an individual woman will enter menopause. The age at which a woman starts having menstrual periods is also not related to the age of menopause onset. Most women reach menopause between the ages of 45 and 55 years, but menopause may occur as early as the 30s or 40s or may not occur until a woman reaches her 60s! As a rough 'rule of thumb,' women tend to undergo menopause at an age similar to that of their mothers...
What is the age for menopause in India?
Mean age at menopause ranges in Indian women from 40.32 to 48.84yrs and I average is about 47 years. In the Western world from 48.0 to 52 yrs.
Why is knowledge about menopause important for me?
Menopausal health demands priority in the Indian scenario due to the increase in life expectancy and growing population of menopausal women. Large efforts are required to educate and make women aware of menopausal symptoms. This will help in early recognition of symptoms, reduction of discomfort and enable them to seek appropriate medical care to avoid disability in future.
What causes menopause?
Menopause is the time in a woman's life when the function of the ovaries ceases. The ovary, or female gonad, is one of a pair of reproductive glands in women. They are located in the pelvis, one on each side of the uterus. Each ovary is about the size and shape of an almond. The ovaries produce eggs (ova) and female hormones such as estrogen. During each monthly menstrual cycle, an egg is released from one ovary. The egg travels from the ovary through a Fallopian tube to the uterus. At birth a girl child has about 3 lac of ova and with each menstrual cycle a few ova develop to some extent and then die down and this depletions leads onto decreasing number of ova and at the time of menopause only about 500 ova are left and they are also non responsive.
What is estrogen?
The ovaries are the main source of female hormones or estrogen, which controls the development of female body characteristics such as the breasts, body shape, and body hair. The hormones also regulate the menstrual cycle and pregnancy. Estrogens also protect the bone.
What is the effect of less estrogen?
A woman can develop osteoporosis (thinning of bone) later in life when her ovaries do not produce adequate estrogen.
As part of the aging process the ovaries begin to produce less estrogen and progesterone. This decrease signals the beginning of the end of a woman's reproductive years. Eventually the menstrual periods stop and it is no longer possible for a woman to become pregnant.
Menstruation - What is it?
Menstruation is the periodic discharge of blood and other materials from the reproductive organs of women. A menstrual cycle usually lasts around 28 days, but different women can have different menstrual cycles.
When a baby is not conceived in the womb, the lining of the uterus is shed .during menstruation. Pregnancy is a phase when menstruation does not take place, because the lining is required to nourish the growing embryo.
What happens during the Menstrual Cycle?
The menstrual cycle does not take place only during the period when you are bleeding. It is an ongoing process, with different events happening during every week. By understanding what happens during each week of the menstrual cycle, you can understand what stage of the menstrual cycle you are in at any time.
• Week 1. Week 1 is considered to start from the first day of bleeding. After the bleeding has stopped, women may be more energetic and have less vaginal mucus.
• Week 2. The mucus becomes thinner and abundant as ovulation approaches.
• Ovulation. This occurs somewhere around day 14 of the ovulation cycle. The mucus is very wet. Breasts may be tender. There may be mood swings and cramps.
• Week 3. The mucus production slows down and the moods start to become more normal again.
• Week 4. This is the pre-menstrual phase. PMS symptoms may start, which can include bloating, cramps, headaches and mood swings.
What is menopausal transition or climacteric?
The menopausal transition starts with infrequent periods and ends with the final menstrual period. The transition can begin as early as the 30s and last even into the 60s. This span of time is also referred to as the change of life or the climacteric.
'Experiencing Menopause' is experiencing a transition in life for a woman. No more periods, no more childbearing, no more milk producing capability, are some of the changes that immediately hit a woman. There are also changes in physical appearance and a dry vagina.
Climacteric can be divided into three phases:
Premenopause: during this phase there is little disruption of ovarian function and the menstrual cycle remains regular. Some symptoms may begin to occur in this phase.
Perimenopause: represents declining ovarian function with menstrual irregularities and symptoms commonly start or become troublesome during this time.
Post menopause: when there have been no menses for 12 months, the post menopause phase is entered.
What is Premenopause?
Premenopause is a word used to describe the years leading up to the last period, when the levels of reproductive hormones are already becoming lower and more erratic, and symptoms of hormone withdrawal may be present.
What is perimenopause?
Perimenopause means "around the time of menopause." It is not officially a medical term, but is sometimes used to explain certain aspects of the menopause transition in lay terms. Peri menopause is different for each woman. In this stage women begin to experience the symptoms of menopause even though they are still experiencing ovulation and having menstrual periods. In this phase hot flashes and irregular periods begin to occur and it may be four to five years before full menopause sets in. It can begin up to 10 years prior to the last menstrual period.
What happens to our bodies during perimenopause?
During perimenopause, the production of most of the reproductive hormones, including the estrogens, progesterone and testosterone, diminishes. Periods become more irregular, often with wide and unpredictable fluctuations in hormone levels. During this period, fertility diminishes.
Not every woman experiences symptoms during her perimenopause. Approximately one third of all women get no noticeable symptoms other than that their periods become erratic and then stop. Another one third of women have moderate symptoms. The remaining one third of women has very strong symptoms that tend to have a longer duration. The tendency to have a very strong peri menopause may be inherited in some cases.
What is Post menopause?
Post menopause is the entire period of time that comes after the last menstrual period. When twelve months have passed with no menstrual periods occurring, a woman has reached full menopause. The ovaries produce significantly less estrogen and progesterone and no longer release eggs; consequently pregnancy is no longer possible.
Any period-like flow that might occur during post menopause, even just spotting, must be reported to a doctor. The cause may be minor, but the possibility of endometrial cancer must be checked for and eliminated.
What is the effect of this "transition" period before menopause?
This transition can be the most traumatic and at times psychologically depressing but there are two sides to it: on one side there is sadness and gloom of losing youth but on the other side there is liberation and freedom from the monthly routine and a new found status of wisdom and maturity.
How does it affect me?
The symptoms of menopause are caused by changes in estrogen and progesterone levels. As the ovaries become less functional, they produce less estrogen / progesterone and the body subsequently reacts. Some women experience no symptoms, while others experience mild to ever symptoms. This variation is normal. A gradual decrease of estrogen allows the body to slowly adjust to the hormone change, but in some women a sudden decrease in estrogen level occurs, causing severe symptoms. This result is often seen when menopause is caused by surgical removal of ovaries (Surgical Menopause). Menopausal symptoms are part of a natural biological process experienced by all women as their child-bearing years come to an end.
Does menopause cause any symptoms/complaints?
The symptoms of menopause are no~ an illness, just a natural consequence of aging. All women experience "the change" in different ways. Some will have no symptoms or only mild issues while others will battle a range of annoying alterations in their body like hot flashes or mood swings, which can negatively affect their daily lives.
Does menopause cause complications?
After menopause there are chronic conditions that tend to appear in women. Declining estrogen levels increase the risk of cardiovascular disease. To combat this potential problem, women should stop smoking, maintain their blood pressure in normal limits, exercise regularly, and eat a diet rich in fruits, vegetables, and whole grains and low in saturated fats.
Bone density decreases at a rapid rate after menopause and some women develop osteoporosis. In this condition brittle or weak bones break easily, especially those in the hip, wrist, and spine. Adequate amounts of calcium at dosage of 1500 mg a day as well as 400-800 mg of Vitamin D will help to decrease this risk. Strength training and walking or jogging are extremely important ways to decrease the risk of fractures.
What are the signs that menopause is starting?
Menopause manifests at different times and in different ways for individual women. Some are lucky enough to get through the experience with no significant problems but for others, menopause disrupts both their lives and their interpersonal relationships.
There are a number of signs and symptoms to indicate the onset of menopause beginning with irregular menstrual periods. The irregularity may be apparent with increased or decreased frequency or in the amount of flow present. As ovulation begins to get erratic, a woman is less likely to get pregnant. The possibility of conception is almost nil after menstrual periods have been absent for a year.
What happens to the genitals and urinary area with menopause?
The linings of both the vagina and of the urethra (urinary outlet) become drier, thinner, and have less elasticity with the onset of menopause. Consequently women tend to experience burning and itching and have an increased chance of urinary or vaginal infections. A frequent urge to urinate is common with minor incontinence or leakage occurring especially when laughing, sneezing, or coughing. (These problems can continue after full menopause.) In addition, sexual intercourse may become increasingly uncomfortable or even painful.
What is a "hot flash"?
One of the most common menopause symptoms, the hot flash, is a consequence of dropping estrogen levels that cause blood vessels to expand rapidly with an attendant increase in skin temperature. Generally women experience sweating and a flushed appearance during a hot flush. This can last from 30 seconds to several minutes and can occur as often as once an hour. Although hot flashes can occur at any time of the day or night, night sweats are a related problem that severely disrupt the sleep cycle. Women report waking up from a deep sleep to find their nightclothes and bedding soaked with sweat.
Will my appearance change with menopause?
Most women gain some degree of weight during the onset of menopause, usually an average of 2 - 3 kgs. The increased weight concentrates around the waist and abdomen. Other changes in appearance can include sagging of the breasts, thinning hair, wrinkles, adult acne, and coarse hair (usually on the chin, upper lip, and sometimes on the chest and abdomen).
How is menopause diagnosed?
Women are simply adequately attuned to their bodies to know when signs of menopause begin to appear. If irregular periods or hot flashes get out of hand, talk to your doctor to calm your concerns and to learn about some of the therapies available to alleviate your symptoms.
In some cases doctors will request for blood tests to check levels of Follicle-stimulating hormone (FSH) and estrogen. FSH increases and estrogen decreases at the onset of menopause. Additionally, a thyroid test may be in order as hypothyroidism can cause some of the same symptoms as menopause.
What conditions can affect the timing of menopause?
Certain medical and surgical conditions can influence the timing of menopause.
1) Surgical removal of the ovaries
Menopause can be surgically induced by bilateral salpingo-oophorectomy (removal of both ovaries and both fallopian tubes), which maybe done in conjunction with hysterectomy. Cessation of menses as a result of removal of the ovaries is called "surgical menopause". The sudden and complete drop in reproductive hormone levels usually produces extreme hormone-withdrawal symptoms such as hot flashes, etc.
2) Cancer chemotherapy and radiation therapy
Depending upon the type and location of the cancer, its treatment either chemotherapy and/or radiation therapy can result in menopause if given to an ovulating woman. In this case, the symptoms of menopause may begin during the cancer treatment or may develop in the months following the treatment.
3) Premature ovarian failure (Premature menopause)
Premature ovarian failure is defined as the occurrence of menopause before the age of 40 years. This condition occurs in about 1% of all women. The cause of premature ovarian failure is not fully understood, but it may be related to autoimmune diseases or inherited genetic factors.
Premature menopause is diagnosed or confirmed by measuring the levels of follicle stimulating hormone (FSH) and luteinizing hormone (LH). The levels of these hormones are higher if menopause has occurred. Rates of premature menopause have been found to be significantly higher in fraternal and identical twins; approximately 5% of twins reach menopause before the age of 40. The reasons for this are not completely understood. Transplants of ovarian tissue between identical twins have been successful in restoring fertility.
Does menopause occur in other species?
Menopause in the animal kingdom is somewhat rare, although this has not been thoroughly researched. However, it is already known that humans are not the only species that experience it. Menopause has been observed in rhesus monkeys, some cetaceans, as well as in a variety of other species of vertebrates including the guppy, the platy fish, budgerigars or "parakeets", laboratory rats and mice, the opossum, and all primates.
How did the evolution of menopause occur in humans?
The "grand mothering" hypothesis states that human female reproduction stops early so that the grandmothers can help out with their grandchildren, leaving the mother the ability to have even more children.
By provisioning grandchildren, grandmothers ensure the children's survival, boost their daughters' fertility and improve the chances that their own genes are passed on. With grandmothers providing food, daughters can breast-feed infants for a shorter period and so bear more babies during their fertile years. According to the theory, menopause helps aging females avoid the increased complications and risks of childbirth, freeing them to pitch in with child care.
But a new study finds no evidence for this "grandmother hypothesis"; three researchers suggest that menopause carries no evolutionary benefit or cost. Menopause, they say, is simply a consequence of aging, and how long females live after menopause depends upon how long a species needs to raise last-born infants to the age of independence.
Does education/ race/ethnicity affect menopause?
Studies have shown that women with is higher education are less likely to report symptoms such as hot flashes, suggesting that increased knowledge might help women to overcome them.
Vasomotor symptoms vary significantly by race/ ethnicity in various studies. Significantly more African Americans and Hispanics and significantly fewer Chinese women have reported vasomotor symptoms as compared to Caucasian women.
What is the Indian Scenario of menopause?
If adequate menopausal health services and awareness programmes are not available to the aging Indian women, the emotional and financial strain to the family, society and country will be significantly high. Unfortunately in India, the awareness and management of menopause has been limited. This is due to multiple factors such as inadequate understanding of menopause and its consequences by laypersons, primary care physicians and medical specialties. Indian women accept menopausal symptoms as physiological changes and have limited complaints related to menopause. This non-complaining attitude may be due to lack of awareness or more adaptability.
What are the barriers in India in the treatment of menopause?
There are cultural barriers along with fears, concerns, and myths about the side effects of hormones in general. Improper compliance of patients on advice of life style changes and medication is another problem.
The high cost and non-availability of full range of therapy through the country make tailoring of treatment for individual women difficult at times. Moreover, there is lack of availability of diagnostic facilities for screening and monitoring of menopausal women including those on therapy. Many times, Indian symptomatic menopausal women are subjected to hormone replacement therapy based on Western experiences. Discontinuation rate is very high among Indian women due to myths and misconceptions.
Can diet influence menopause?
Yes, dietary factors may play a role in estrogen production and metabolism and in symptom occurrence. Asian women, who consume less fat with more soya and beans, report less vasomotor symptoms, as compared to Caucasian women whose diet is different.
What are some basic dietary guidelines?
Eat a variety of foods to get all the nutrients you need. Since women's diets are often low in iron and calcium, follow these simple guidelines:
• Get enough calcium. Eat and drink 2 to 4 servings of dairy products and calcium-rich foods a day to ensure that you are getting enough calcium in your daily diet. Calcium is found in dairy products, curds, pander, broccoli and legumes. You need to have calcium 1500 mg/day if you are not using any medication to increase your BMD but if you are then you need just 1000mg/day
• Increase your iron intake. Eat at least 3 servings of iron-rich foods a day to ensure that you are getting enough iron in your daily diet. Iron is found in lean red meat, poultry, fish, eggs, leafy green vegetables, nuts and enriched grain products.
• Get enough fiber. Help yourself to foods high in fiber such as whole-grain breads, cereals, pasta, rice, fresh fruits and vegetables.
• Eat fruits and vegetables. Include at least 2 to 4 servings of fruits and 3 to 5 servings of vegetables in your daily diet.
• Read labels. Use the package label information to help you to make the best selections for a healthy lifestyle.
• Drink plenty of water. Drink at least eight 8 to 10 glasses of water a day.
• Maintain a healthy weight. Lose weight if you are overweight by cutting down on portion sizes and reducing foods high in fat, not by skipping meals. A registered dietician or your doctor can help you determine your ideal body weight.
• Reduce foods high in fat. Fat should provide 30 percent or less of your total daily calories. Also, limit saturated fat to less than 10 percent of your total daily calories. Saturated fat raises cholesterol and increases your risk of heart disease. Saturated fat is found in fatty meats, whole milk, ice cream and cheese. Limit cholesterol intake to 300 milligrams (mg) or less per day/I
• Use sugar and salt in moderation. Too much sodium in the diet is linked to high blood pressure. Also, go easy on smoked, salt-cured and charbroiled foods - these foods contain high levels of nitrates, which have been linked to cancer.
• Limit alcohol intake. Women should limit their consumption of alcohol to one or fewer drinks per day (3 to 5 drinks per week maximum).
Can foods reduce menopausal symptoms?
Plant-based foods that contain isoflavones (plant estrogens) work in the body like a weak form of estrogen and may help relieve menopausal symptoms in some women. Some lower cholesterol levels and have been suggested to relieve hot flashes and night sweats. Currently, most research indicates that soy isoflavones are not particularly effective for treating several menopausal symptoms. Aside from soy products, isoflavones can also be found in foods such as whole grains and beans.
The phytoestrogens that have been isolated from a variety of plant food are phenolic (rather than steroidal) compounds; the major categories of phytoestrogens include isoflavones, Lignans, and coumestans. Soy, other beans, clover, and alfalfa contain isoflavones precursors, which are converted to genistein, daidzein, and equol by intestinal bacteria. Flax seeds, other seeds, legumes, whole grains, and some fruits and vegetables contain lignan precursors that can be converted to enterolactone and enteridiol by intestinal bacteria. Phytoestrogens can have estrogenic activity as potential dietary derived modulators with endocrine function.
Should I avoid certain foods while I am going through menopause?
If you are experiencing hot flashes, you may find that consuming certain "trigger" foods and beverages - spicy foods, caffeine, and alcohol - may increase the severity and frequency of hot flashes.
Are there dietary supplements I can take to ease symptoms/prevent manifestations of menopause?
Because there is a direct relationship between the lack of estrogen after menopause and the development of osteoporosis, the following supplements, combined with a healthy diet, may help prevent the onset of this condition.
If you think you need to take a supplement to get enough calcium, check with your doctor first. Calcium carbonate and calcium citrate are good forms of calcium supplements. Be careful not to get more than 2,000 mg of calcium a day. That amount can increase your chance of developing kidney problems.
• Vitamin 03 (cholecalciferol)
Your body uses vitamin 0 to absorb calcium. People aged 51 to 70 years should have 600 to 800 IU each day and those over age 70 years should have 800 IU. More than 2,000 IU of vitamin 0 each day is not recommended because it may be too much for your body.
How can I cope with emotional changes?
Irritability and feelings of sadness are the most common emotional symptoms of menopause. Often, they can be managed through lifestyle changes, such as learning different ways to relax and reducing stress.
Here are some tips that may make it easier for you to handle your fluctuating emotions.
• Exercise and eat healthy.
• Find a self-calming skill to practice, such as yoga, meditation or rhythmic breathing.
• Avoid tranquillizers and alcohol.
• Engage in a creative outlet that fosters a sense of achievement.
• Stay connected with your family and community.
• Nurture your friendships.
Although depression is not caused by menopause, some women do exhibit the symptoms of depression during this time. If you are feeling increasingly unable to cope, see your doctor. He or she may be able to recommend medications, such as antidepressants, or hormone replacement therapy that can get you through this rough time.
I have a hard time concentrating and I'm forgetful. Is this a normal part of menopause?
Unfortunately, difficulty with concentrating and minor memory problems is a normal part of menopause. Doctors don't understand why memory changes occur with menopause and there are currently no treatments available to relieve these symptoms. If you are having memory problems, talk to your doctor. He or she can at least provide some reassurance and exercises to improve memory.
How does menopause affect your life?
Whether natural or iatrogenic, the menopause is associated with a symptom complex, arising because of hormonal deficiency. The socio-cultural and psychological factors contribute further in its manifestations.
Some of the symptoms are:
Vasomotor symptoms: hot flushes, night sweats, palpitations.
Atrophic tissue symptoms: thick skin, vaginal dryness, dyspareunia (painful sexual relationship), vaginal inflammation, postmenopausal bleeding, urinary dysfunction.
Psychological symptoms: depression, loss of concentration, irritability, poor libido, insomnia, lack of concentration, memory loss.
Others: Hypertension, Ischemic heart disease, Osteoporosis.
What are the menstrual cycle changes that occur in perimenopausal period?
Initially, menstrual cycle changes can be subtle with a wide variety of possibilities. Usually a woman's' cycle gets shorter, with periods occurring more often than the usual 28 days. Bleeding may last fewer or more days, and blood flow may be heavier, lighter or just spotting. Late in perimenopause, it is common to skip periods, and then resume a normal menstrual cycle again.
However, not all menstrual changes in midlife women are due to approaching menopause. That's why it's important to have an evaluation by a gynecologist to rule out other conditions that could cause menstrual abnormalities or abnormal uterine bleeding.
Which abnormal bleeding patterns require consultation with a gynecologist?
Women should consult a gynecologist right away if any of the following signs of abnormal bleeding pattern occurs:
• Periods that are extremely heavy, especially if they have not been that way in the past;
• Periods lasting more than 7 days, or 2 or more days longer than usual;
• Frequent periods, with interval shorter than 21 days from the start of one period to the start of the next;
• Spotting or bleeding between menstrual periods;
• Bleeding from the vagina after intercourse.
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