Menopause is defined as that time in a woman’s life when her menstrual cycles stop. This age is approximately 50 +/- 5 years across the globe. The average age is about 52 years. Many Indian women undergo menopause before the age of 50 years.
Menstrual cycles stop when there are few or no eggs left in the ovaries to be released each month. The cyclical hormone surges of estrogen and progesterone which cause the lining of the uterus (the endometrium) to grow and shed stop and so does the shedding of this lining.
This means that once periods have stopped for six months or longer a woman can be considered to have reached menopause. If menopause occurs before the age of 45 years it is called early menopause and if it occurs before the age of 40 years it is called premature menopause.
Premature menopause is of concern and needs special effort to diagnose and treat because it can have significant repercussions on a woman’s risk of developing heart disease, osteoporosis and a poorer quality of life as she ages. This is in comparison to those women who undergo menopause at the normal age of 50 years or more.
About 80% of women suffer with some symptoms relating to the declining levels of estrogen. Of these 30% suffer with symptoms that significantly affect their quality of life and in turn affecting their ability to lead productive and useful working lives. This group of women in particular need specialist guidance on managing their symptoms and some need medication to help them through this time.
You may find it useful: Menopause Treatment – How to Make it Work for You
The perimenopause is the period of 5 years before and after the cessation of menstruation when symptoms of estrogen deficiency are experienced. Appropriate management of symptoms during this period can help the woman have a smooth transition through the menopause.
Pre and Post Menopause Signs
Most women approaching the menopause experience a decline in the quantity and frequency of menses. Periods may come further and further apart and there may be a decrease in the amount of bleeding with each period.
Some women experience an abrupt cessation of periods. For about 30% of women periods can pose a problem. Periods may come more frequently, bleeding may be heavier and sometimes there is bleeding in between periods.
Heavy menstrual bleeding that is regular and has no other related symptoms is often benign. Basic gynaecological assessment and an ultrasound of the pelvis to rule out any significant problems usually is reassuring.
Where there is bleeding in between periods a further detailed assessment is usually required. A small percentage of these women (5%) will be diagnosed with endometrial cancer or its precursors. Therefore an early assessment of period problems is essential when approaching the menopause.
A small percentage of women 5 – 10% will experience post menopausal bleeding. As per definition any bleeding after six months of the cessation of menses is called postmenopausal bleeding. It requires further assessment with a detailed history and gynaecological examination.
This may also include an ultrasound and a sample of the endometrial lining which is nowadays done as an outpatient procedure. Depending upon the findings of these tests further evaluation is required in a small group of women – this takes the form of a hysteroscopy and biopsy done either as an outpatient procedure or under general anaesthesia depending upon facilities available.
Common menopause symptoms and how to assess them
Menopause brings with it several symptoms which are a result of declining estrogen levels. Their severity varies depending upon factors such as ethnicity, weight, physical fitness, diet, mental resilience and also geographic location.
Common symptoms which are easily recognizable include hot flushes and sweats, insomnia, irritability, mood swings, body ache and joint pains, vaginal dryness and burning, urinary frequency and recurrent infections.
Other less recognized symptoms include dry eyes, dry skin and hair, weight gain, muscle loss and difficulty maintaining previous fitness levels, change in sense of smell and taste, change in fat distribution, loss of classic female silhouette, loss of sexual desire and difficulty getting aroused or maintaining arousal, decreased ability or inability to orgasm with previous triggers.
There are several assessment tools used to determine the number and severity of symptoms a woman may present with. These tools can help with deciding whether hormone therapy is appropriate and also in monitoring its perceived benefits in improving quality of life.
These tools can take the form of a variety of questionnaires available online including the SF36, Menopause rating scale etc . Additional quality of life questionnaires can be used to assess the impact of specific medical problems on quality of life including the PISQ (pelvic organ prolapse), Kings health questionnaire (urinary incontinence), FSFI (female sexual function index).
Often symptoms do not correlate with the adverse health effects of declining estrogen levels and these are the ones that need medical assessment. For e.g. cardiac health, thyroid dysfunction, osteoporosis, obesity and metabolic syndrome, associated adverse effects of diabetes and hypertension on bone health, cardiac health and general fitness.
The effect of changing hormonal milieu on breast endometrium and bowel and the need to include screening for cancer as a part of general health check up also needs to be emphasized.
Women going through the menopause also find themselves in the midst of several relationship and social binds. They may be widowed or divorced or facing difficulties getting on with their partner who is also now looking to retire.
It can be difficult adjusting to changing career roles with more responsibility whilst going through physical changes that affect confidence and body image. The children may have left home and are now no longer dependent on the parents.
Their career and relationship choices or financial stability may continue to be a cause for mental and physical stress to parents. They may find that even within a happy and stable relationship the partner too suffers with sexual difficulties and this can complicate perceived menopause symptoms and feelings of inadequacy.
The use of quality of life questionnaires helps include these issues as part of the assessment and helps the doctor to deliver comprehensive care to the menopausal woman – not just limited to medication.
Suggested Readings:
Menopause and Bowel Health: Understanding and Managing Symptoms
What is Genitourinary Syndrome of Menopause and Which Symptoms Bother Women the Most?
Here is wishing you all the very best in your menopause journey! Do write to me at masterthemenopause@gmail.com about what you found useful in this article.
Continue to Part II