Menopause

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chapter 53 Menopause

INTRODUCTION AND OVERVIEW

The menopause transition can be a time of great change and disturbance for some women. Symptoms such as hot flushes, night sweats, mood swings and vaginal dryness can greatly affect quality of life and, in most Western countries, around a quarter to a third of such affected women will seek medical attention. More controversially, the postmenopausal phase of life may be associated with adverse long-term sequelae such as increased bone loss, and perhaps an increased risk of cardiovascular disease and even dementia.

One of the basic sex differences is that women obtain all their eggs in fetal life and then start to lose them, in contrast to males, who do not produce sperm until puberty and then continue to make them, even into advanced old age. Oocyte number peaks at around 6–7 million at 20 weeks of gestational age, and even by birth a baby girl has lost about half her eggs. The production of sex hormones is linked to the presence of oocytes and so menopause, or ‘last period’, signifies the permanent cessation of menstrual periods and the loss of the final egg.

DEFINING THE MENOPAUSE TRANSITION

Over the past two decades there has been much discussion about defining the terminology surrounding the last period. Sherry Sherman has aptly summarised some of the terminology, drawing together the WHO and International Menopause Society (IMS) recommendations (Box 53.1).¹

BOX 53.1 Menopause terminology

1. Natural menopause is defined as the permanent cessation of menstruation resulting from the loss of ovarian follicular activity. The final menstrual period (FMP) is recognised to have occurred after 12 consecutive months of amenorrhoea, for which there is no other obvious pathological or physiological cause.

2. Perimenopause should include the period immediately before the menopause (when the endocrinological, biological and clinical features of approaching menopause commence) and the first year after menopause. The term ‘climacteric’ should be abandoned, to avoid confusion.

3. Menopausal transition should be reserved for that period before the FMP when variability in the menstrual cycle is usually increased.

4. Premenopause is often used ambiguously either to refer to the 1 or 2 years immediately before the menopause or to refer to the whole of the reproductive period before the menopause.

5. Induced menopause is defined as the cessation of menstruation that follows either surgical removal of both ovaries (with or without hysterectomy) or iatrogenic ablation of ovarian function (e.g. by chemotherapy or radiation).

6. Postmenopause is defined as the period dating from the FMP, regardless of whether the menopause was induced or spontaneous.

7. Premature menopause ideally should be defined as menopause that occurs at an age two standard deviations below the mean estimated for the reference population. In practice, the age of 40 years is frequently used as an arbitrary cut-off point, below which menopause is said to be premature.

Source: adapted from Sherman 2005¹

EPIDEMIOLOGY

In Western countries, the average age at FMP is 51 years, with a normal range of 40–60 years.² The four or five years leading up to the FMP are characterised by menstrual irregularity, often initially cycle shortening, followed by cycle lengthening, although there is much normal variability. There are some minor variations in cycle patterns across different cultures but, as will be discussed later, quite marked differences in the symptoms are experienced across the menopause transition.

SYMPTOMS

Some of the symptoms experienced by women in the menopause transition are listed in Box 53.2.

BOX 53.2 Symptoms that might be due to the menopause transition

Aches and pains

Formication (a sensation of ‘ants’ crawling on the skin)

Vaginal dryness

Light-headedness

The Melbourne Women’s Midlife Health Project is a prospective, longitudinal study of healthy women passing through the menopause transition.³ The study began in 1991 and used random telephone dialling to recruit Australian-born women aged 45 to 55 years. One hundred and seventy-two women were premenopausal at the time at baseline, and by the end of the seventh year of annual follow-up had advanced to the peri- or postmenopausal interval.

By the postmenopausal period, almost all had recorded at least one symptom—the most common being hot flushes. As women transited from the premenopausal to the postmenopausal phase, they noted significantly less breast pain, but significantly more hot flushes, night sweats and vaginal dryness.

CULTURAL DIFFERENCES

There appear to be marked cultural differences in attitudes to menopause. In a study of Sydney women, Asian women generally appeared to view menopause in a more favourable light than Western women, who linked menopause with ‘getting older’. Asian women were also less likely to admit to a healthcare professional that they were suffering from vaginal dryness, but if a doctor raised the issue, they were very grateful.⁴,⁵

Among Indian women, only 34% complained of hot flushes; more were concerned about depression and memory loss.⁶ Unemployment was associated with more flushing and depression. Lebanese Muslim women reported high rates of feeling tired and worn out, as well as aches and pains, as they went through the menopause transition.⁷ Sixty-three per cent reported hot flushes and more than half had noticed vaginal dryness during intercourse.

Chinese women largely see menopause as a natural process.⁸ A group of Sydney-based Chinese women had more vasomotor symptoms (34%) than those women who live in mainland China (10.5%) or in Hong Kong (10–20%). The top three symptoms reported by Sydney-based Chinese women were poor memory (76.4%), dry skin (69.1%) and aching in muscles and joints (68.3%). Some told the interviewers that their vaginal dryness problem was so severe that they had given their husbands permission to have sex with someone else.

Among Greek women, most were more concerned about back pain, aches, pains and fatigue than about hot flushes.⁹ Seventy-nine per cent of the postmenopausal Greek women had vaginal dryness, and there was a high rate of sexual problems.

THE MENOPAUSE CONSULTATION

HISTORY

The initial menopause consultation is a long session and often takes at least 30 minutes. It might be facilitated by some pre-reading and by using one of the many menopause-scoring charts that are available, such as the MENQOL (Menopause-specific Quality of Life Questionnaire, Table 53.1).¹⁰

TABLE 53.1 Oestrogen deficiency symptom score, using MENQOL ¹¹

The following should be particularly considered while taking a ‘menopause’ history:

• The menstrual cycle. During the last 5 years of menstrual life, the cycle often shortens from 28 to even 21 days. Skipping months usually occurs during the last few years of menstruation. Variability is the norm. Some periods might be heavy with clotting, and others light. Bleeding lasting longer than seven days or continual bleeding needs to be investigated. Usually this means a transvaginal ultrasound scan and a referral for hysteroscopy and endometrial biopsy. Endometrial hyperplasia and cancer are increasingly common after the age of 40 years.

• Menopause symptoms (see Table 53.1)

• Contraception. Is the patient worried that she might ‘accidentally’ become pregnant? Has she used the oral contraceptive pill (OCP) in the past? If so, did she have any side effects? For example, if she became depressed on the Pill, this is a progestin side effect. Women who had ‘PMT-type’ side effects with levonorgestrel-containing OCP are usually also intolerant of other progestins such as norethisterone, cyproterone and medroxyprogesterone acetate (MPA), but may tolerate dydrogesterone.

• Sleep patterns. Sleep lightens with ageing, but at this time of life, sweats and flushes at night will often disturb sleep.

• Bladder and vaginal symptoms. Incontinence is common and, after menopause, vaginal dryness increases in prevalence; and apart from making vaginal intercourse uncomfortable and even painful, urinary tract infections increase in frequency.

• Mood. Severe depression and anxiety are not more common during the menopause transition, but those women with a pre-existing history of mood disorder commonly find that it worsens.

• Skin sensations. About one-third of perimenopausal women notice a peculiar skin sensation (no rash) called ‘formication’ or ‘ants under the skin’. Some describe it as like insects moving over the skin. It can be very unpleasant. The cause is not completely understood, but it does seem to be due to an effect of swinging hormone levels on nerve endings and usually passes after some months.

EXAMINATION

A woman may present to her doctor with a concern about menopause because of symptoms that she feels may be hormonally based. It is essential to have the diagnostic radar well-tuned for other possible explanations for symptoms. It is worth taking the opportunity to do a general physical examination and identify any possible risk factors for middle age and beyond. At the very least, it is prudent to check the woman’s blood pressure and weight, ensure that her Pap smears are up to date, and examine the breasts for abnormal lumps.

TESTS

A woman aged in her forties with amenorrhoea or slight periods should be tested for pregnancy. If a woman has ‘hot flushes’ and her blood pressure is elevated, a 24-hour ambulatory blood pressure monitor will reveal whether the flushes are symptomatic of hypertension.

All that flushes is not menopause. Consider the differential diagnosis of ‘night sweats’ (see below) including viral infection, tuberculosis, neoplasm, hyperthyroidism, sleep apnoea, gastro-oesophageal reflux disease, alcohol excess and hypoglycaemia.¹²

There is no place for the routine measurement of hormone levels (e.g. FSH and oestradiol (E2)). During the normal menstrual cycle, E2 levels fluctuate from very low (below 100 pmol/L) to 500–1000 pmol/L at ovulation. FSH levels more than 20 U/L suggest that the patient is perimenopausal. The problem is that perimenopausal women can have even more variation than usual. It is not unusual for E2 levels to be greater than 2000 pmol/L and FSH levels can vary from less than 10 U/L to more than 40 U/L. The typical patient who is over 40 years of age with irregular periods and typical symptoms does not need her FSH and E2 measured.

If early menopause is suspected in a woman under 30 years of age, it might be prudent to measure her FSH levels three times over 2–3 months. In this way, the diagnosis is usually readily confirmed. Antimüllerian hormone (AMH) is a relatively new blood test that may give some information on ovarian reserve.

Use this opportunity to check the results of her last Pap smear, mammogram, bone density, lipids and blood glucose measurement, and ensure that a regular testing protocol is established for the perimenopause and postmenopausal phase.

MANAGING MENOPAUSE

There are a number of important issues for a woman and her doctor to be mindful of in managing the menopause but there are also a wide range of options available to a woman in managing those issues. The management objectives include ameliorating symptoms associated with menopause as well as making efforts to minimise the risk of other illnesses that become more common after menopause, such as heart disease, cancer and osteoporosis. The management approaches outlined below focus on lifestyle issues and specific medical and complementary therapies.

LIFESTYLE ISSUES: THE ESSENCE MODEL

Education

Being educated about the changes associated with menopause will be very useful in helping a woman to appreciate that many of the symptoms she might be experiencing are natural and that she is not alone. It will help to allay many concerns, may motivate her to consider the need for other lifestyle changes, and also help to improve her understanding of and compliance with any management strategies undertaken.

Stress management

Mental and emotional support is vital at such an important life transition as menopause. Such times are associated with an increased risk of mental and emotional problems. Emotional state will not only affect coping but can affect hormonal balance and exacerbate the effect of symptoms enormously. Poor mental health can also accelerate the progression of chronic illnesses including heart disease, metabolic syndrome, dementia and osteoporosis, due to the effects of allostatic load and its sequelae, such as elevated cortisol levels.

Spirituality

What meaning a woman makes of a life-changing event like menopause can affect how easy or difficult that transition is. It can be seen in a very positive light, as it has been for millennia in many traditional cultures, or it can be seen in a very negative light, particularly in our youth-obsessed contemporary society. Questions of spirituality or meaning can arise when one’s life role is being redefined, along with changes in relationships and life priorities. Also, for some, it is a time when ageing and mortality come into view.

Exercise

Regular exercise is particularly important during and after menopause, not only to help manage symptoms but also to help prevent a range of chronic conditions such as heart disease, cancer, dementia and osteoporosis. Regular moderate activity will help weight management and can help to improve sleep and maintain mental and physical vitality and performance in menopausal women.¹³,¹⁴ Vigorous aerobic exercise can precipitate hot flushes, in some women.

Nutrition

Apart from maintaining a healthy diet generally, a range of foods can be helpful for menopause. To reduce the incidence of hot flushes, advise women to try to avoid caffeine, spicy foods and smoking. Encourage soy foods such as tofu, miso and tempeh. Ensure adequate calcium and vitamin D either naturally or through supplementation. Advise on achieving a healthy weight range with a balanced, high-fibre, low-fat diet as well as calorie restriction (i.e. avoiding excess empty calories while maintaining a varied and nutritious diet).

Connectedness

As with any time of life, relationships matter enormously during menopause. Not feeling isolated and having the support of partner, friends, family, work colleagues and health practitioners can all make an enormous difference. Menopause corresponds with a time when many women find themselves with an ‘empty nest’, which can be a time of rejoicing for some, but grief for others. Staying connected to and engaging with one’s community as well as personal relationships can also help to provide new meaning and purpose at this important time.

Environment

Much has been said about environment in previous chapters. Particular things to note are the need for regular moderate doses of sunlight for mood and vitamin D, as well as helping to facilitate exercise. An unhealthy environment, physically or emotionally, can affect health in a variety of ways.

MANAGING HOT FLUSHES

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