Menopausal changes

  • Health
  • Wednesday, 15 Feb 2006

During midlife, women will experience physical changes. Hormonal changes duringperimenopause (pre-menopause) gradually lead up to menopause. But because these changes occur gradually, one may not beaware of them. No two women will experience these changes in the same way. 

Menstrual changes 

During the reproductive years, every woman has a distinctive menstrual pattern. At perimenopause, some women just simply have one last period and none after that. However, most women experience changes or irregularity in their periods over a period of time during perimenopause. This is due to the decreased frequency of the release of eggs (ovulation) with consequent irregular secretion of the ovarian hormones.  

The initial changes may not be noticeable. The menstrual cycle usually shortens with periods occurring more frequently than monthly. The bleeding may last more or less than previously and the flow may be lighter, heavier or just spotty. 

Later, as menopause approaches, it is not uncommon for women to skip periods. Some women may have no periods for several months and then menstruate regularly again.  

Although irregular periods are common during menopause, it cannot be assumed that all changes are due to the body's hormonal changes.  

Other conditions may cause abnormal uterine bleeding. A doctor should be consulted if any of the following occur: 

  • periods that last more than seven days or two or more days than usual 

  • the interval between the start of one period and the start of the next period is less than 21 days 

  • heavy periods or if there are clots  

  • bleeding between periods, whether it is spotting or occurs as a heavier flow 

  • bleeding after sexual intercourse. 

    Abnormal uterine bleeding could be due to hormonal imbalance; pregnancy; reaction to contraceptive pills, depot contraceptives or intra-uterine contraceptive devices; fibroids; non-cancerous (benign) uterine polyps; cancers of the cervix, uterus or vagina; and conditions that interfere with blood clotting. 

    The doctor may perform one or more of the following procedures to establish the cause of any abnormal uterine bleeding: 

  • ultrasound, which uses sound waves to create a picture of the pelvic organs.  

  • endometrial biopsy, a common procedure that can be done at the doctor's clinic without anaesthesia. A small sample of the uterine cavity is removed and examined by a pathologist. The procedure is often used to rule out cancer of the uterus. It can also determine non-cancerous causes like polyps. 

  • dilation and curettage is a procedure in which the cervix is dilated and the uterine lining gently scraped and the tissue examined. Because anaesthesia is necessary for the procedure to be carried out, it has been performed less often since endometrial biopsy was introduced about a decade ago. The procedure is usually done as a day case.  

  • hysteroscopy is a procedure in which a thin telescope-like instrument is inserted through the vagina and cervix to enable the doctor to see the inside of the uterine cavity. If there are any abnormalities observed, a biopsy can be carried out. The procedure can be done, as a day case, under sedation, or local or general anaesthetic. 

    The treatment of abnormal uterine bleeding depends on the cause. They include: 

  • operative hysteroscopy to remove polyps or fibroids in the uterine cavity by an electrical loop or laser. 

  • endometrial ablation, in which the lining of the uterine cavity is destroyed by heat or freezing. It cannot be used to treat fibroids unless the fibroids are also removed at the same time. 

  • laparoscopy, in which a slender telescope-like instrument is inserted into the abdominal cavity through a small incision in the lower abdomen to enable the doctor to see the pelvic and other abdominal organs. Sometimes, ovarian cysts and fibroids can be removed. 

  • myomectomy, in which fibroids are removed through an abdominal incision. General or regional anaesthesia and hospitalisation are required. 

  • hysterectomy, a procedure in which the uterus is removed. The ovaries may or may not be removed during the procedure. If both ovaries are removed, immediate surgical menopause occurs. General or regional anaesthesia and hospitalisation are required.  

    Post-menopausal bleeding 

    It is advisable to consult the doctor immediately should any bleeding occur 12 months after the last menstrual period.  

    Some women who are taking hormone replacement therapy (HRT) may have bleeding. Unless the bleeding is the typical pattern caused by hormone treatment, all post-menopausal bleeding requires investigation to rule out cancer. 

    Reduced fertility 

    A woman's fertility declines from the late 30s. This is due to the ageing of the eggs in the ovaries. The risk of spontaneous miscarriage is increased so much so that by the age of 45 , the rate is about 50%. At the same time, the risk of congenital abnormality in the foetus increases from the age of 37 so much so that by the age of 45 , the risk is about one in 40.  

    Although assisted reproduction technologies are available for perimenopausal women, they are expensive, have some risks and have low success rates. 

    There is also an increased risk of pregnancy complications like hypertension and diabetes in the mother, the need for Caesarean section and stillbirth. 

    Despite reduced fertility, a woman is not free from an unplanned pregnancy until a year after the last menstrual period. Even if there are other signs like hot flushes, it does not mean that one cannot get pregnant. About 75% of pregnancies in women over the age of 40 years are not planned.  

    If pregnancy is not desired, an effective contraceptive method is necessary.  

    It is usual practice for doctors to advise using a contraceptive for another year when the menopause occurs at age 50 or more, and for another two years when the menopause occurs before 50 years of age.  

    It is advisable to stop the combined oral contraceptive pill at about 50 and change to an alternative contraceptive method until the menopause status can be determined.  

    Fertility awareness techniques may the only method available for couples because of religious or cultural reasons. However, it can be difficult for women with erratic cycles. The alternative methods can be used until the age of 55 when the loss of natural fertility can be assumed.  

    HRT cannot be relied upon as a contraceptive as ovulation may still occur. It is also difficult to assess the timing of the natural menopause in women on HRT. 

    Vasomotor changes 

    Some perimenopausal women experience hot flushes (also known as hot flashes). It is more common in Caucasian than Asian women and is due to sudden changes in the body's temperature regulation.  

    The brain, which mistakenly senses that one is too warm, initiates events to cool down. Blood vessels near the surface of the skin increase in diameter. The increased blood produces the red, blushed appearance of the face and upper body. One may also start to sweat. A hot flush occurs suddenly and may last a few seconds to several minutes or more. A few women may experience a cold chill after the flush. 

    Hot flushes may occur with increased sweating during sleep. The night sweats and hot flushes may interfere with sleep, although it may not wake the affected individual.  

    Hot flushes usually have a consistent pattern and can occur several times in a day or a few times a month. Some women will get hot flushes for a few months, some for a few years and others do not get them at all. There is no way of knowing when they will stop. However, hot flushes are not harmful. 

    Most women can identify certain factors that start their hot flushes e.g. hot drinks, hot or spicy food, caffeine, alcohol, stress, emotions, and external heat. Certain medicines like tamoxifen used for chemotherapy and raloxifene for prevention and treatment of osteoporosis can trigger hot flushes. 

    If one has hot flushes, one can take steps to improve one's comfort, to the extent that the hot flushes can sometimes be eliminated altogether: 

  • identify the factor(s) that trigger the hot flush and avoid it if possible. 

  • dress in layers. Remove pieces of clothing at the first sign of a hot flush to feel cooler. 

  • keep the office or home cool by using a fan or air conditioner. Sleep in a cool room. 

  • exercise regularly to reduce stress and promote better sleep. Some research indicates that women who exercise have fewer and less intense hot flushes. 

  • reduce stress with a leisurely bath, meditation, massage or yoga. 

  • slow and deep, abdominal breathing at the start of a hot flush may be helpful. 

  • consult your doctor. There may be benefit from HRT. Other alternatives like oral contraceptives, progestogens, antihypertensives like methyldopa and clonidine, and antidepressants may be helpful. 

    Dr Milton Lum is 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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