Menopause, also known as climacteric, refers to the stopping of menstruation and the end of the reproductive capacity of
a woman. This event usually occurs around age 50 but may happen prematurely in some individuals before age 45 or artificially by the removal of the ovaries (oophorectomy). As many as ten years before
menopause, the ovaries begin to cease normal function. During this time, many basic physiological changes occur, including failure to ovulate; a decreased number of developing follicles and oocytes; a decreased level of the ovarian hormones estrogen and progesterone; and a rapid rise in follicle stimulating hormone (FSH), a pituitary hormone, as well as a gradual rise in luteinizing hormone (LH). These ovarian changes eventually result in the cessation of menstruation (amenorrhea) and infertility. In the years before menopause a woman may have irregular uterine bleeding, heavy enough in some instances to produce anemia. Postmenopausal bleeding indicates a need for immediate medical attention, because the incidence of uterine or cervical cancer after menopause ranges from 15 to 30% of women.
SYMPTOMS
Most symptoms that occur during menopause result directly from the estrogen deficiency produced by the failing ovaries (see sex hormones). It can be difficult to distinguish these symptoms from those caused by the normal aging process or from the social and domestic pressures faced by middle-aged women. The major symptoms (and their possible causes) occurring around the time of menopause can be divided into four main categories: changes in blood vasculature, the musculoskeleton, emotional status, and sexual
activity.
Blood Vasculature
During menopause, for reasons not yet known, the body seems to lose some control of the regulations of the blood vessels, which expand and contract to cause hot flashes, night sweating, and tension or migraine headaches. These temporary symptoms contribute to the overall irritability and insomnia that normally occurs during this time. Also, before menopause nonsmoking women have a virtual immunity to coronary heart disease; after menopause the incidence of such disease rapidly approaches that in men.
Musculoskeletal Changes
Osteoporosis, caused by severe or prolonged bone loss as a result of estrogen deficiency, affects 35% of women after a natural menopause. Fractures can be caused by even minor stress on the weaker and more brittle bones. An increased laxity of ligaments and reduced muscle tone and strength contribute to backaches and pain in the shoulders, elbows, knees, and joints of the hands. Decreased muscle tone in the pelvic floor muscles, bladder, and urethra results in urine leakage and the need to urinate frequently. The vaginal and urinary tract linings become less acidic, making menopausal women more prone to infections.
Emotional Status
Psychological symptoms of menopause may include anxiety, depression, irritability, diminished energy, difficulty with concentration, and tension. These symptoms are probably a result of the interactive effects of endocrine changes with sociocultural and psychological factors of the individual. Many life changes seem to coincide with time of menopause, such as adolescent crisis in a child, departure or marriage of the children, declining sexual activity, career or age-related frustrations and anxieties of the woman and her husband or partner, and the death of a parent or increasing parental dependence due to aging or illness. Psychiatric therapy and help from an understanding sexual partner and supportive family members can be beneficial.
Sexual Activity
Many women experience heightened libido after menopause because they know they can no longer get pregnant. However, emotional problems can cause a decline in sexual activity in some women. The involvement of an understanding partner can help relieve some of these problems. About 20 to 25% of menopausal women experience pain during intercourse, called dyspareunia. Mostly,this is due to thinning of the vaginal wall and a lack of lubrication, both caused by estrogen deficiency. This problem can be solved by using a vaginal lubricant or estrogen cream during sex.
THERAPY
Hormone replacement therapy (HRT), with estrogen and sometimes progestin (synthetic progesterone), can reduce the discomfort of menopausal symptoms such as hot flashes, headaches, and irritability. HRT also protects women from some of the conditions that were prevented by the female hormones, such as osteoporosis and heart disease. However, HRT increases the risk for uterine cancer, although the risk has largely been offset by alternating low doses of estrogen with progestin, mimicking the hormonal cycle before menopause. A woman on HRT does not ovulate, but the progestin does cause a monthly shedding of the uterine lining, resulting in monthly bleeding, which protects against uterine cancer. Studies of the role of HRT in breast cancer have had opposing results, and there is no consensus on this issue. HRT or antidepressant drugs are not always the solution for menopause-related emotional problems. Exercise programs and proper nutrition are also recommended for postmenopausal women to help prevent osteoporosis and heart disease.