About the Menopause
Menopause is defined as the cessation of menstruation as a result of the decline in ovarian function. Technically, you enter menopause following 12 consecutive months without a period.
“Menopause signals the end of fertility and the beginning of a new and potentially rewarding time in a woman's life.”
The menopause occurs in all women at some stage. Natural menopause occurs when the ovaries fail to produce the female sexual hormone estrogen and progesterone. Hormone production fails when the ovaries have few remaining egg cells.
Periods stop or become infrequent because the reduced levels of estrogen and progesterone do not stimulate the endometrium as they usually would in a normal cycle. Hormone levels can fluctuate for many years, before finally reaching a low, at which the endometrium remains thin and no longer bleeds.
The average age of the natural menopause is 51 years, but this can vary quite significantly. In rare cases, menopause can occur as early as the 30's or as late as the 60's. Menopause is classed as premature if it occurs before a woman reaches the age of 40. Radiation exposure, chemotherapeutic drugs and surgery can create what is known as an artificial menopause.
Several factors may contribute to the early onset of menopause, for example a history of smoking, poor nutrition or a co-existing medical condition.
Menopausal symptoms include a range of physical, psychological and sexual problems. Most common are hot flushes,night sweats,insomnia,irritability,mood swings,depression and dryness of the vagina. There are, of course, many more reported symptoms.
These complaints are due to an increasing deficiency in the body’s natural hormones (especially estrogen). A lack of estrogen also contributes to the increased risk of osteoporosis.
The first two weeks of the menstrual cycle are dominated by estrogen. It is their role to build the lining of the uterus (this is done in preparation for a potential pregnancy). It is on approximately day 14 of the cycle that an egg is released from the ovaries. This process is called ovulation.
After ovulation has taken place the ovary begins to produce progesterone. It is during the second half of the cycle that progesterone is dominant. The role of progesterone is to change the character of the uterine lining, (again in preparation for pregnancy) and stop any further buildup of the lining by estrogen. If, at the end of the cycle, the egg has not been fertilised, both estrogen and progesterone levels drop. This drop in hormone levels causes the uterine lining to be sloughed off (a menstrual bleeding occurs). The female body goes through this cycle monthly in preparation for a potential pregnancy.
At birth, a female has almost a million eggs, but by puberty they have only 300,000. During the 10 to 15 years before the menopause, the rate at which these eggs are lost accelerates.
Perimenopause is the term used to describe the transitional period between a woman's reproductive years and the time when menstruation ceases completely.
Generally perimenopause occurs between the ages of 40 and 51. Its duration can vary hugely; between six months and ten years. Hormone levels naturally fluctuate and decline, but the process is not necessarily a smooth and well-ordered one.
Changes in hormone levels are a major contributing factor in the occurrence of the physical, mental, and emotional imbalances that are common in many women’s menopausal experiences.
Eventually estrogens reach a level at which the lining of the uterus discontinues to builds up and menstruation finally stops. This point is the menopause.
“Although there are similarities in what happens hormonally, each woman's experience can be very different. Genetics may play a role in the timing, but lifestyle can certainly influence a woman's experience of menopause.”
Symptoms and complaints
Menopause symptoms affect around 70% women.
Symptoms such as hot flushes, night sweats, palpitations,dizziness, insomnia and headaches/joint aches are particularly common in the early stages of menopause.
In the later stages of the menopause, changes in the bladder and vagina occur due to the lack of estrogen. For example, increased urinary frequency/incontinence/discomfort, urine infection, vaginal dryness/discomfort/discharge and burning or itching.
Vaginal dryness can make sexual intercourse painful or uncomfortable. Women may also find their interest in sex decreases, and orgasms become less intense. This is again due to decreased levels of estrogens.
Such complaints can be very distressing and embarrassing.
Vaginal and bladder symptoms are very common and can cause significant distress yet are often under-reported and under-treated. Women are frequently too embarrassed to discuss these problems. Very effective treatments are available and should be discussed.
Other later menopausal symptoms stem from the decrease in collagen production. Collagen production is reduced by the falling levels of estrogen, which in turn, causes skin to lose its elasticity and become dry and thinner. It becomes more prone to bruising, and the development of wrinkles may be accelerated. Estrogen deficiency is also believed to be a contributing factor in hair dryness and thinning/loss.
Women show a particularly marked rise in osteoporosis risk after their estrogen production falls at menopause. Aging and falling estrogen levels increase loss of bone mineral density, which ultimately leads to bone thinning and fragility (osteoporosis). Bone loss affects both sexes as they age however; the rate of bone loss is significantly greater in women. In the first five years after menopause, some women may lose as much as 15% of their bone mass. Hence, osteoporosis is far more common in women than men.
Osteoporosis is defined as a systemic skeletal disease characterised by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture.
Worldwide, the lifetime risk for osteoporotic fractures in women may be as high as 40%; in men it is 13%. It is estimated that osteoporosis affects one in three post-menopausal women.
Bone loss alone does not cause any symptoms, (but can cause the sufferer severe pain) however the increase fragility means a simple fall could end in fracture. Fractures commonly occur in the wrist, spine and hip. Such fractures can significantly alter quality of life.
The major osteoporotic complications are fractures of the hip and of the spine. The mortality rate for those suffering hip fractures varies from 15% to 30% owing to secondary complications such as pneumonia. Hip fractures are associated with considerable morbidity, lengthy hospital admissions and a correspondingly large economic burden.
Worldwide, the number of hip fractures could rise from 1.7 million in 1990 to 6.3 million by 2050, with the most dramatic rise expected to be in Asia over the next few decades as the population there both grows and ages.
(Bulletin of the World Health Organisation 1999)
Hormone Replacement Therapy (HRT)
HRT is prescribed as a first line treatment for the relief of menopausal symptoms. It eliminates or relieves symptoms such as hot flushes, night sweats, insomnia, mood swings, migraine and a number of vaginal problems.
HRT is also licensed as secondary treatment of the potentially life threatening disease osteoporosis.
HRT is a well established and well researched form of medication. It has been available for over 50 years. It’s effectiveness in the treatment of menopausal symptoms as well as its bone protecting properties have been proven in numerous studies.
The vast majority of women taking HRT are very satisfied with the results. HRT can completely alter a woman’s life.
Hormone Replacement Therapy works by restoring the body’s premenopausal level of estrogens. This results in menopausal symptoms being relieved.
Most common of the HRT types currently available is what is known as “sequential combined” HRT. This means a progestogen is added during the second half of a 28 day treatment.
Women who still have an intact uterus are advised to take HRT with an added progestogen. Also popular is “continuous combined” HRT, as the name suggests the progestogen is taken continuously throughout the 28 day treatment.
Unopposed estrogen (with no added progestogen) stimulates the thickening of the uterine lining, which is at risk of becoming cancerous. The progestogen protects the uterus from such unwanted effects. Some progestogens have even been found to enhance estrogen’s beneficial effects on symptomatic relief and bone mineral density.
For those women without an intact uterus, “mono-therapy” is suitable (unopposed estrogen).
There are several different forms (e.g. tablet, cream, patch) of hormone replacement therapy available today. Oral (tablet) HRT is, by far, the most commonly prescribed of these. It is also best tolerated among patients.
There are two forms of estrogens used in preparations today; conjugated equine estrogens and those estrogens derived from plants.
Conjugated equine estrogens are obtained from the urine of pregnant mares. This type does not conform to the natural estrogens produced by the body but do have an estrogen-like effect.
17-beta estradiol is synthetically manufactured using natural plant sources such as yam and soy. It is identical to the estrogen produced in the human female body.
This type of estrogen is widely preferred due to its natural properties. A recent survey of physicians found over 75% favoured 17-beta estradiol over other types of estrogens. (HRT marketing understanding 2002) .
Resource Medical UK Ltd offers BEDOL.
All progestogens used are synthetically manufactured. They are different to the progestogen produced in the human body but this is not a bad thing. They can be tailored to promote additional positive effects. Most progestogens are made from plant sources.
Progestogens are either progesterone (e.g. medroxyprogesterone acetate) or testosterone derivatives (e.g. norethisterone). Progesterone derivatives more closely resemble natural hormones.
The key role of the progestogen is uterine protection. Some progestogens have been found to have positive effects on osteoporosis. Progesterone is often referred to as “the feel good hormone” this is due to its antidepressant and mood enhancing effects.
Resource Medical UK Ltd offers CLIMANOR.
Continuous combined hormone replacement therapy
Continuous combined HRT is taken over a treatment period of 28 days. A tablet containing both estrogen and progestogen is taken daily.
Continuous combined HRT causes menstrual bleeding to stop all together after a few months of treatment. Women who suffer from menopausal symptoms or those who do not wish to continue having periods will be suited to this form of treatment.
Sequential combined hormone replacement therapy
Sequential combined hormone replacement is suitable for women suffering from menopausal symptoms but with irregular cycles.
The progestogen is taken for the second half of the treatment cycle only. This mimics the activity of a woman’s natural cycle.
With sequential combined therapy the patient will still experience a monthly menstrual bleed – although without the menopausal complaints.
This form of therapy is suited to women who want to maintain their period.
Resource Medical UK Ltd offers CLINORETTE and CLIMANOR.
Estrogen and estrogen/progestogen combinations are available in weekly and twice weekly patches. These are a good alternative for women who prefer not to take oral medication, although can prove awkward and inconvenient for women leading an active life.
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