The menopause which is derived by the two Greek words 'men' (month) and 'pauses' (termination) is moment of cessation of menstruation permanently following to the loss of ovarian activity. pre-menopausal years covering the period from Normal ovulatory (accompanied by ovulation) cycles until cessation of menses (menstruation) are named as ‘perimopozal years of transition' and characterized with irregularities in the menstrual cycle. Again, 'climacteric' derived from the greek Word ‘ladder’ indicates the stage that a woman reaches to postmenopausal years by passing from productivity ages through the perimenopausal transition stage and menopause .
Whereas some women don’t react at al lor present unrecognized mild reactions during the menopausal years , some experience very severe and varied symptoms. The differences of menopausal reaction between different cultures have not been very well documented. Individual cases have been such conditioned by socio-cultural factors that it is difficult to predict what is biological and what is due to cultural diversity. For example, Japanese, Chinese or Mayan language has no words to describe hot flashes. Nevertheless, menopausal symptoms are experienced by most of the women there is sufficient evidence to believe that variability between the cultures is determined not by the physiology but behaviors, communities and individual perceptions.
The symptoms associated with the decreased ovarian follicular activity (decreased activity in the ovaries) and loss of estrogen related to this, are presented below:
1. irregularities in the menstrual cycle (menstrual irregularities)
2. vasomotor symptoms (hot flashes),
3. Urogenital atrophy (weakness and volume loss of urinary tract, vagina and surrounding tissues).
4. health problems related to Long-term estrogen deficiency: The results of osteoporosis and cardiovascular diseases
Menopause age in Turkey has been detected to be between 45 – 63. Considering that the average life expectancy of Turkish women is 67,3 3 according to Turkey demographic and health survey data, it can be said that 24% of a woman's life belongs to late postmenopausal period. In this regard , we are experiencing a new problem which is one of the greatest achievements of the 20th century. We are waiting for getting older! Improving the quality of life of almost every individual in a society is one of the most popular topics of scientists . Two of the most important factors affecting the quality of life are maintaining the intellectual and sexual function even at the advanced ages. Postmenopausal hormone therapy which was initially improved to address the specific symptoms of lack of estrogen at menopause , are recently used for the potential benefits of these two functions the long term.
There may be wrong thoughts and beliefs related to menopause . Thoughts like the woman who is in menopausal period is now old, sexual life ends and nothing will be the same again as in the past … Even postmenopausal women can be wrapped in their own thoughts and feelings and have trouble. But the situation is not like that at all. Yes, nothing will be the same, yes facial wrinkles that are the marker s of several life experiences will be added, pregnancy won’t occur but this is only the good news of sexual life which can be continued for years without need of protection.
Menopause can be a sweet break both to the hustle and bustle of everyday life and business life and can also be an opportunity for our close involvement to our mental and physical health. In this period, regular health screenings provide detection of many diseases whose incidence increase with these ages at onset stage and may be even earlier than that, and initiation of the appropriate treatments. In routine follow up examinations of menopause:
- Gynecological examination and ultrasound,
- Obtaining pap smear,
- Annual mammography and breast ultrasound, if necessary,
- Blood tests
- are done.
The problems created by the lack of estrogen
In the period before or after menopause , many women experience mood swings, behavioral changes and decreased libido. It should be discussed that to which extent these symptoms are the direct results of reduced estrogen or whether these symptoms developed secondary to vasomotor symptoms or not ; or whether these symptoms are related to lack of androgen.
Menopausal symptoms which significantly depend on estrogen deficiency are;
Vasomotor symptoms (hot flushes)
These are defined as sudden reddening on the head, neck and chest skin mostly accompanied with intense elevation in body heat and sweating. Varies from a few seconds to 1 hour. More frequent and severe at night and during times of stress. Although seen before menopause, hot flushes are the characteristic of the postmenopausal (after menopause) period and experienced by most women for 1-2 years and even longer than 5 years by some women . The relationship between hot flashes and the reduction in estrogen , has been demonstrated with the effectiveness of estrogen therapy in removing hot flashes. Although it’s a common complaint, it doesn’t create a danger to health, but it’s rather a reliable indicator of physiological changes.
atrophy of the vaginal mucosal surfaces which is the result of Very low estrogen levels, cause vaginitis (inflammation of the vagina), pruritus, dyspareunia (pain and difficulty during sexual intercourse) and stenosis (narrowing). Complaints such as urethritis (inflammation of the urinary outflow tract) and subsequent burning, difficult urination, frequent urination and urinary incontinence are the consequences of mucosal thinning of the urethra (urinary outflow tract) and urinary bladder. urinary incontinence in elderly women is often a complex problem which is an important component of urge incontinence and here a recovery may be achieved with estrogen treatment.
Menopause and Sexuality
Sexuality is a life-long behavior that evolves with change and development. It starts with birth (even earlier than that) and ends with death. Thinking that sexuality ends up with aging is completely illogical. requirement of Proximity to one another, care, compassion and companionship can last a lifetime. Nowadays, elderly people live longer, have better education, leisure and increased awareness against well being and sexuality.
Younger people, especially the doctors tend to underestimate older people’s interest in sex. However, many studies done in this area showed that at least half of women between the ages of 50-82 have ongoing sexual relationship.
The most two important effect of sexual communication in the elderly people are robustness of the relation and physical status of the couple. Therefore, the most important determinant of sexual activity of older women is divorce or inability to find partner related to the fact that women live longer than men. It is shown that sexual activity can be continued throughout life in the same high or low rate if a partner is present.
There are two major changes in aging woman: reduction in amount and t production rate of the fluid that lubricates the vagina and a slight reduction in vaginal elasticity. Dyspareunia associated with postmenopausal urogenital atrophy includes the complaints of;
- feeling of dryness and tightness
- irritation and burning with sexual intercourse
- spotting and pain after sexual intercourse .
All such changes are treated effectively with estrogen therapy. Less vaginal atrophy is seen in sexually active women than the the inactive women and it is thought to be related to the fact that sexual activity maintains the vaginal vascularization and blood circulation.
Although postmenopausal hormone therapy has a a direct effect on the genital anatomy and eliminates vaginal dryness while providing a positive impact on sexual function, it’s considered that loss of estrogen doesn’t explain all of the changes in sexuality during menopause. Woman's physical, emotional, and hormonal status are affected by menopause and any of these listed or all of them can affect sexual arousal and pleasure. Difficulty in sexual intercourse is a cause that makes older women rarely consult to a physician about it because they are reluctant to talk about sexual subjects, whereas gently questioning of these issue, may enable treatment of the atrophy with estrogen and may increase the enjoyment of sex. In addition, the sexual intercourse itself supports the reaction of the blood circulation of vaginal tissues and increases the effects of estrogen. Thus, sexually active women experience atrophy less despite they don’t take estrogen.
General Skin Atrophy
Reduction in collagen and thickening of the skin due to aging may be prevented with hormonal therapy.
Menopause and Osteoporosis
Being the most common problem in the elder people, osteoporosis is the bone mass reduced with the minimal/matrix rate and cause fractions. Decreased bone mass, which is sometimes called as osteopenia, osteoporosis is used for fractures with decreased bone mass. Currently, 20 million people in America are being affected by osteoporosis. Studies indicate that women lose more bone nowadays. Among the factors contributing to this, decrease in calcium supplied by nutrition, performing less exercise and earlier and more bone loss due to smoking may be counted.
Estrogen therapy prevents osteoporosis or at least stops. 80% decrease may be seen in compression fractures in vertebrae with additional calcium.
Menopause and cardiovascular (heart and vascular) diseases
In the years before menopause , women literally 'are protected' from coronary heart disease. Therefore, the incidence of coronary heart disease in women is 10 years behind than men and women have the advantage of 20 years considering infarction and sudden death. An important contribution to this protection is thought to come from the high level of HDL as an estrogen effect. Total cholesterol and LDL levels are lower in premenopausal women than men and increases progressively with aging and increases rapidly during menopause. When atherogenic lipid levels become higher than in men around the age of 60, the risk of coronary disease duplicates in women. These changes can be reduced or even can be reversed with diet and estrogen therapy.
Postmenopausal Hormone Therapy
Since loss of estrogen in menopause is the main problem, it needs to be replaced initially. The patient's risk profile is evaluated first, and the patient is informed about the issue and Hormone Replacement Therapy is recommended. Treatment must be tailored according to the patient's complaints. birth control methods also need to be considered in patients at the age of 40-50s, and in premenopausal patients who are young and have irregular menstruation; low-dose birth control pills are the most appropriate treatment in this period.
Initially, it’s importantly to decide to whom Hormone Replacement Therapy will be given. At this point, the patient's approach is very important. Hormone therapy may not be used in women with very low risks of osteoporosis and heart disease or who have no complaint. Use of the therapy should be well evaluated in terms of profit / loss ratio although hormone therapy is contraindicated in women with a history of premenopausal breast cancer in first-degree relatives. It’S definitely not given for those who have unexplained abnormal vaginal bleeding and pregnancy. Breast, uterine cancer, venous thrombosis, liver disease are contraindications.
Hypertension, smoking, obesity, migraine headaches, endometriosis and fibroids, fibrocystic breast disease are not contraindications for HRT. Treatment can be given in these patients.
Patients for whom HRT have been started are invited for follow up examination in the first 3 months in order to evaluate the continuation of the treatment, if everything is normal the next appointment is planned for the next 6 months and afterwards, annual follow ups are recommended
Today, menopause and treatment is an issue that is quite recent with continuing controversy. Hormone Replacement Therapy increases the duration and quality of life. But today in our country , around 1% of women are receiving HRT, this ratio is around 20% in developed countries. The most important problem in the use of HRT is the misconception about the risk of cancer settled in the community and many physicians. In our country, we hope that, this misconception will change as the level of education improves.