This Sunday, we bring to you an old article from our archives. Dr. Kiran Guleria expounds on menopause, therapies that can be suggested to ensure a better quality of life. In addition, she talks in brief about the serious concerns during menopause and symptoms which require a physician's guidance.

---

Menopause is defined as the time in a woman's life, usually between age 45 and 55 years, when the ovaries stop producing eggs (ovulating) and menstrual periods end. Most women experience menopause transition first in the form of menstrual cycle variations like more frequent or infrequent periods or bleeding that lasts for fewer days than before, or skip in one or more menstrual periods before periods stop completely.

A woman is said to be post-menopausal only after one full year of absent menses. During this time, she may start to experience menopausal symptoms which result from declining levels of oestrogen in her body like hot flashes, night sweats, mood changes, sleep problems, skin and vaginal dryness and coital difficulties. The average age for a woman to stop having periods is 51 years.

Though it is mostly a natural phenomenon, there are some factors that can induce menopause. These include-

1. Chemotherapy (treatment with chemical agents) and radiotherapy (exposure to radiation) for cancer treatment which may knock-off ovaries and cause menopausal symptoms, and induce a temporary or permanent cessation of menstruation.
2. Autoimmune diseases or genetic factors may cause early failure of ovaries and primary ovarian insufficiency, thus leading to premature menopause.
3. Surgeries like total hysterectomy with bilateral salpingo-oophorectomy (removal of uterus and both ovaries), will immediately stop menstruation and induce surgical menopause.

Though menopause is a normal physiological phase of a woman's life and does not always need to be treated, a woman needs to take special care of her health in order to maintain optimum quality of life.

---

General care

1. Women should focus on healthy eating (fruits and vegetables, milk and milk products, nuts and seeds), meditation, relaxation exercises and yoga. Some of these lifestyle remedies can also help to reduce or prevent the symptoms of menopause.
2. Hot flashes can be cooled off by drinking cold water or staying in a cooler room. Women should be advised to identify factors that trigger hot flashes, like hot beverages, alcohol, caffeine and spicy foods, and avoid these.
3. Low-dose antidepressants may be used to manage hot flashes when hormone therapy is not advisable, and this will also help in improving mood swings.
4. Water-based vaginal lubricants can reduce vaginal dryness and discomfort. She should get adequate sleep, eat healthy, stay active, quit smoking and reduce overall stress.
5. Regular exercise helps to maintain weight, strengthen muscles and bones. Certain specific exercises like Kegel exercises can help strengthen pelvic floor muscles and improve urinary incontinence.

If menopausal transition and period beyond it become too disruptive, then there are effective treatments available for that. In general women should see a doctor if they experience heavy menstrual bleeding or spotting between periods or any of the postmenopausal symptoms as mentioned above.

---

Hormone therapy

Many women go through menopause with few or no symptoms. However, in some, presence of persistent vasomotor symptoms, vaginal dryness and genitourinary symptoms, and osteoporosis may mandate hormone therapy. Oral hormone therapy is highly effective in relieving hot flashes and night sweats whereas genito-urinary symptoms and vaginal dryness respond better to topical estrogens.

• Oestrogen-progestin therapy should be used for women with a uterus and unopposed oestrogen for that post-hysterectomy
• If oestrogen is contraindicated, a non-oestrogen drug, like Tibolone is prescribed
• Some women may respond to antidepressant medications such as SSRIs or SNRIs

According to various studies, women taking combined hormone therapy have a higher risk of myocardial infarction (MI) and venous thromboembolism after one year, stroke after three years, and breast cancer after five years. However, there is a lower incidence of fractures and colon cancer. In general, hormone therapy is used for clinical indications like moderate to severe menopausal symptoms or those at high risk of osteoporotic fractures.

Initiating menopausal hormone therapy (MHT) is considered a safe option for healthy, symptomatic women within 10 years of menopause or younger than age 60 years, who do not have contraindications to MHT (history of breast cancer, coronary heart disease, a thromboembolic event or stroke, or active liver disease).

---

Osteoporosis prevention

Bone mineral density screening should be performed in all women older than 65 years, and should begin sooner in women with additional risk factors for osteoporotic fractures. Adequate intake of calcium and vitamin D should be encouraged for all postmenopausal women to reduce bone loss.

The National Institute of Health (NIH) recommends 1,000 mg of calcium per day for postmenopausal women younger than 65 years who take oestrogen, and 1,500 mg per day for those who do not take oestrogen. The main dietary sources of calcium include milk and other dairy products, such as cottage cheese, yogurt, and hard cheese, and green vegetables, such as kale and broccoli.

Vitamin D plays a major role in calcium absorption and bone health. The recommended dose is 1000 U/day. Usually 10 to 15 minutes of sunlight exposure of hands, arms, and face two to three times per week satisfies the body's vitamin D requirement. Dietary sources of vitamin D include milk, salmon, orange juice, yogurt, and cereal. Regular weight-bearing exercises can reduce the risk of developing osteoporotic fractures in postmenopausal women.

---

Coronary heart disease prevention

Coronary artery disease is the leading cause of death in women. Postmenopausal women should be counselled regarding lifestyle modification, including smoking cessation and regular physical activity. All women should receive a periodic measurement of blood pressure and lipids (LDL, HDL, and total cholesterol levels; and triglycerides). Appropriate pharmacotherapy should be initiated when indicated. The American Heart Association recommends the use of low-dose aspirin in persons at high risk of coronary heart disease, especially those with a 10-year CHD risk of 20 percent or greater.

---

Cancer screening

Major guidelines concur that women at average risk of breast cancer benefit from screening mammography at least every other year from 50 to 74 years of age. Several effective options for colorectal cancer screening are recommended for women 50 to 75 years of age. Cervical cancer screening should occur at three- or five-year intervals depending on the test used, and can generally be discontinued after 65 years of age or total hysterectomy for benign disease.

Screening for ovarian cancer is not recommended. Clinicians should consider screening for sexually transmitted infections in older women at high risk. Postmenopausal women should be routinely screened for depression, alcohol abuse, and intimate partner violence.

---

Immunisation

Recommended vaccination for menopausal women includes an annual influenza vaccine, a tetanus and diphtheria toxoid booster every 10 years, and a one-time pneumococcal vaccine after age 65 years.

---

Primary care physician’s approach

A woman having persistent vasomotor symptoms not responding to general measures described above, having premature menopause (less than 40 years) and others having non-modifiable risk factors for osteoporosis (premature menopause, history of atraumatic fractures, family history of osteoporosis, loss of > 1-inch height, chronic steroid therapy, hyperparathyroidism, multiple myeloma etc.) should be referred to a specialist for further investigations and starting hormonal therapy or pharmacotherapy with bisphosphonates.

Another symptom of concern is postmenopausal bleeding which refers strictly to any uterine bleeding in a menopausal woman (other than the expected cyclic bleeding due to cyclic menopausal hormone therapy). Endometrial atrophy (senile endometritis) and endometrial polyps are the most common causes of postmenopausal bleeding, but these episodes are usually light and self-limited. History of medications like Tamoxifen, anticoagulants and use of foreign body like pessary should also be elicited. Further diagnostic evaluation is indicated for recurrent or persistent bleeding.

Exclusion of cancer is the main objective; which includes a good clinical examination, basic transabdominal and transvaginal scan, PP smear, endometrial sampling and in some cases tumour markers. Women having suspicion or diagnosis of malignancy should be referred to a specialist without any delay. In the rest of the patients, treatment is usually reassurance once cancer has been excluded.

---

Menopause is an unavoidable phase in every woman’s life. Its signs and symptoms can be often disturbing, but it is important to understand and learn ways to cope with these difficulties as various options are available to successfully manage them.

---

This article was originally published on February 23, 2021.

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.

The author, Dr. Kiran Guleria is the Director-Professor at Department of Obstetrics & Gynecology, University College of Medical Sciences & GTB Hospital, Delhi.