Menopause is a part of a women’s natural ageing process when her ovaries produce a lower level of estrogen and progesterone and when she is no longer able to become pregnant. This article describes the phases of menopause, the changes that women go through throughout menopause and its management. 

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Menopause is the end of menstruation. The word menopause came from the Greek word ` mens ’ meaning ``monthly’’ and ` pause ’ meaning ``cessation ‘’. Menopause is the permanent cessation of menstruation at the end of reproductive life due to loss of ovarian follicular activity.

A woman not menstruating for one year after her last period is termed as being postmenopausal. Menopause is a natural and normal event, not a disease or disorder. Yet menopause symptoms may significantly affect the quality of life.

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Phases of menopause

Menopause is divided into two phases:

1. Perimenopause is when a woman begins to have symptoms but is still having periods, which can last for 4 to 5 years. She can still become pregnant during this time.
2. Postmenopause is when a woman does not menstruate for almost 12 months.
3. The term surgical menopause is used if both ovaries are removed for eg. Hysterectomy

As ovaries age, their response to the pituitary gonadotropins follicle-stimulating hormone (FSH) and luteinizing hormone (LH) decreases, causing:

• A shorter follicular phase (with shorter and less regular menstrual cycles)
• Fewer ovulations
• Decreased estrogen and progesterone production.

Around menopause, estrogen levels decrease by half. The most common menopausal symptoms due to decreased estrogen levels are vasomotor symptoms manifesting as hot flashes, night sweats and mood swings. The risk for depression rises during the menopause transition, especially in women with a history of depression.

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Changes in the general appearance

1. Skin: The skin loses its elasticity and becomes thin and fine. This is due to the loss of elastin and collagen from the skin.
2. Weight: Weight increase is more likely to be the result of irregular food habits due to mood swings. There is more deposition of fat around the hips, waist and buttocks.
3. Hair: Hair becomes dry and coarse after menopause. There may be hair loss due to the decreasing level of estrogen.
4. Voice: Voice becomes deeper due to the thickening of vocal cords.

The other symptoms associated with menopause are:

1. Increased abdominal fat and decreased lean body mass results in difficulty in losing weight.
2. Vaginal changes such as decreased lubrication and vaginal dryness.
3. Sometimes vaginal changes are more severe and progress to atrophic vaginitis causing pain during intercourse and speculum exams, as well as increased urinary symptoms such as urine leakage and frequent bladder infections.

Also with menopause, women lose the protective effects of estrogen and are at increased risk for osteoporosis and heart disease.

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Management

Menopause itself does not need treatment, however, it is important to treat associated symptoms and reduce the risk of long-term medical conditions, such as heart disease and osteoporosis.

As estrogen levels decline with menopause, women are at risk for osteoporosis. Hence, the need for calcium, vitamin D and magnesium supplementation to prevent loss of bone density. Poor calcium intake in early life can account for as much as 50% of the differences in hip fracture rates in postmenopausal women.

Management of Healthy Menopausal women with no symptoms:

• Education
• Counselling
• Documentation in mid-life OPD card and assessment of risk factors.
• Lifestyle modifications, weight control, and nutrition.
• Vitamin D 800–1200 IU
• Calcium 1200 mg
• Vitamin B12 supplementation
• Moderate alcohol, no smoking
• Exercise, aerobics, range of movement, resistance, and weight training, stretching, yoga, and meditation.

General management of vasomotor symptoms is wearing Loose clothing, dressing in layers, cool air and avoiding hot spicy food.

Non-hormonal treatments for relief of menopausal symptoms

• Gabapentin: 300 mg TID × 6 weeks–3 months
• Venlafaxine: 25–75 mg/day
• Paroxetine: 7.5–20 mg/day
• Fluoxetine: 10–20 mg/day
• Isoflavones: 70 mg–100 mg daily × 6 weeks–3 months (equal producer
• patients have to be identified)
• Lycopene: 18–24 mg daily
• Isoflavones, bioidentical hormones

Alternative therapy includes nutritional supplements like isoflavones, calcium, magnesium and vitamin D.Isoflavones improve menopausal symptoms without causing significant side effects. Isoflavones together with calcium, and vitamin D improve vasomotor disturbances as well as the quality of life and sexual function in menopausal women. Furthermore, this mixture ameliorates lipid profile and body composition toward pre-menopausal homeostatic condition. Isoflavones and vitamin D also exert a synergistic effect on bone metabolism.

According to the Indian Menopause Society (2013), International Menopause Society (2016), and the North American Menopause Society (2012):

1. MHT should begin within 10 years of menopause or <60 years of age.
2. Premature menopause: MHT up to natural age of menopause 3-5 years.
3. Continuation of therapy should be decided the Hormone replacement therapy (HRT), which consists of supplemental estrogen and progesterone, which were used to treat menopausal symptoms in earlier days. According to a 2002 study, the Women's Health Initiative (WHI), found women who took HRT for several years had an increased risk of breast cancer, stroke and heart disease.

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Types of Menopausal Hormone Treatment (MHT)

1. Estrogen alone when no uterus.
2. Combination of estrogen-progesterone.
3. Selective estrogen receptor modulators (SERMs).
4. Tibolone/selective tissue estrogenic activity regulator (STEAR).
5. TSEC–bezadoxiphene + CEE for osteoporosis and the risk of breast cancer.
6. Ospemifene for urogenital atrophy.

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Contraindications to MHT

Known or suspected estrogen-sensitive malignant conditions:

• Undiagnosed genital bleeding
• Untreated endometrial hyperplasia
• Previous idiopathic or current venous thromboembolism
• Active or recent arterial thromboembolic disease
• Untreated hypertension
• Active liver disease
• Known hypersensitivity to the active substances of MHT or the excipients.
• Porphyria cutanea tarda (absolute contraindication)

Indications for Dexa scan:

• All women 5 years beyond the age of natural menopause
• Women less than 5 years since menopause with a particular risk factor
• Women with fragility fractures
• Women in menopause transition with secondary causes
• Radiological evidence of osteopenia and presence of vertebral compression fractures
• Before initiating pharmacotherapy for osteoporosis
• The interval testing should be based on calculated individual risk, mostly be scheduled between 1 and 5 years

It is the progestogen component of MHT that is more significant in any increase in breast cancer risk and modern progestogens, natural progesterone and SERMS optimise metabolic and breast effects. Reduction in all-cause mortality when MHT is initiated around the time of menopause

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Menopause is a natural stage in the life of middle-aged women and can have a significant impact on quality of life. Menopause involves several somatic and mental changes in women. Unhealthy lifestyle habits, such as poor nutrition and physical inactivity, may aggravate the condition of perimenopausal women. Women who lack a positive attitude frequently experience mental and somatic symptoms associated with menopause, exhibiting lower esteem and a low degree of satisfaction with life.

However, some women underline positive aspects of their menopause, such as a sense of relief as menstruation stops and there is no longer a need for contraception. Women who regard menopause as a ‘normal physiological transition’ cope with it perfectly and even notice several positive changes. Identifying the information needs of menopausal women can help in the design of practical training programs, raise levels of awareness and improve quality of life.

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Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India. 

About the author of this article: Dr Komal Chavan is a Medical Director and Senior Consultant from Mumbai.