All about menopause


  • Health
  • Wednesday, 01 Feb 2006

THE menopause is a natural event that occurs in all women. It is the permanent cessation of periods (menstruation) as a result of the loss of activity of the ovaries and can only be said to have occurred only after 12 months without spontaneous menstruation.  

Physical and other changes occur in the years leading up to the menopause. Most of the changes are normal and are related to the menopause. Others are more related to ageing and may, in some women, be associated with illness, as many conditions that are not related to the menopause e.g. hypertension; diabetes, obesity, etc. are diagnosed about the time of the menopause.  

Each woman’s experience of the menopause is unique. For some, the end of menstruation brings about freedom from concerns about fertility. For others, it is a time of coping with social changes that are inevitable during this time when the children begin to leave home.  

For a few, it is about dealing with illness. For the vast majority, the menopause is a new part of life when they report empowerment, increased confidence and renewed vigour than when they were younger. It is also an opportunity to improve the quality of life with improved health practices. 

Menstrual cycle 

Every woman is born with a finite number of eggs (oocytes). In every menstrual cycle, at least one oocyte is released under the influence of follicular stimulating hormone (FSH) and luteinising hormone (LH) produced by the pituitary gland in the brain.  

The FSH and LH act on the ovary in the first half of the cycle and stimulate an oocyte to develop into a follicle, which produces a large amount of oestrogen. The increase in FSH and LH prepares the uterine lining (endometrium) for pregnancy and causes the release of the follicle at about the middle of the cycle. The ovulated follicle changes into the corpus luteum, which produces progesterone to maintain the endometrium. 

If fertilisation does not take place, the follicle degenerates and the decrease in progesterone causes the endometrium to shed (menstruation). 

With repeated ovulation, the number of oocytes is reduced until there is none left. The oestrogen levels decrease and the body produces more FSH and LH in an attempt to stimulate the ovaries. The menstrual cycle is disrupted and eventually the pattern of low oestrogen and increased FSH and LH is established. 

 

Definitions  

There are several terms about the menopause which need to be defined.  

  • Menopause is the permanent cessation of menstruation. It can only be confirmed when there have been no periods for 12 consecutive months. The average age of menopause is 50 to 51 years, although it may range from 40 to 58 years. There is no correlation between the menopause and the age of the first period (menarche) or the use of the contraceptive pill. 

  • Women who smoke reach menopause a year or two earlier than non-smokers. 

  • The age of menopause is difficult to define in women who started hormone replacement therapy (HRT) in the perimenopause years. 

  • Menopause transition is the period of time leading up to the menopause, during which time the ovaries begin to fail with consequent bodily changes. It ends with the last menstrual period. Symptoms are not uncommon. The duration of the menopause transition is about four years, and is shorter in smokers. 

  • Perimenopause is the period of time during which the ovaries fail until the end of menstruation. It ends 12 months after the last menstrual period.  

  • Postmenopause refers to all the years after the permanent cessation of menstruation. This can only be determined after 12 consecutive months of an absence of periods. It has been estimated that by the age of 54, about 80% of women are postmenopausal.  

  • Premature menopause refers to menopause occurring before 40 years of age, whether induced or natural. This comes about because of genetics, autoimmune conditions, surgical removal of the ovaries, pelvic irradiation or chemotherapy. There is an increased risk of osteoporosis and possibly heart disease for the rest of the woman’s life. The psychological impact of a premature menopause affects many women who lament their loss of fertility and with it, their perception of femininity and sexual desirability.  

  • Induced menopause is an immediate menopause that results from ovarian damage, surgical removal of the ovaries, pelvic irradiation or chemotherapy. The abrupt loss of ovarian hormones may result in more intense symptoms and possible increased risk of osteoporosis and possibly heart disease.  

  • The emotional impact may be more than that of a menopause that occurs naturally. The need to cope with the condition that resulted in the medical intervention and the side effects of the treatment is an additional burden e.g. hair loss, tiredness, nausea and other symptoms during chemotherapy, and hot flushes and vaginal dryness and irritation following pelvic irradiation. 

  • Induced menopause due to surgical removal of both ovaries, with or without removal of the uterus (hysterectomy), is called surgical menopause. If the ovaries are left in place at the time of hysterectomy, they will continue to produce hormones although periods stop and pregnancy is impossible. However, a hysterectomy can result in the stopping of ovarian hormone production a year or two earlier than expected because of a disruption in the blood supply at the time of operation. Women who have had a hysterectomy will still experience the changes of the perimenopause. 

  • The GnRH analogue medicines used to treat endometriosis; fibroids and premenstrual tension will result in a temporary cessation of periods and perimenopausal symptoms. When the medicines are stopped, the ovaries usually resume their normal production of hormones and the symptoms cease. 

    Confirming menopause 

    The perimenopause can be confirmed by a detailed medical history and an exclusion of other causes for the symptoms. In almost all instances, hormone estimations are not necessary.  

    If there is doubt, an estimation of the blood level of the follicle-stimulating hormone (FSH) will provide a reliable test. When the ovarian production of oestrogen declines, the brain increases the production of FSH in an attempt to stimulate the ovaries to produce more oestrogen. When the FSH is persistently above 30 to 40 mIU per ml, it is accepted that the woman has reached menopause. As the perimenopausal production of oestrogen fluctuates daily, the estimation of FSH more than once is needed to confirm the menopause.  

    Dr Milton Lum is the Chairperson of the Commonwealth Medical Trust. This article provides general information only and is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation that the writer is associated with.

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