Menopause is a normal stage in every woman’s life that is characterized by a definite stop of menstruation due to the aging of the ovaries. Menopause appears at the age of 51 with a deviation of 3 to 4 years. The ovaries cease to produce ovarian follicles, meaning that women can no longer get pregnant. The climacterium is the time period between normal cycles and menopause, usually lasts 1 or 2 years and is characterized by irregular cycles. At the beginning of the climacterium, menstrual cycles are shorter, then they appear more and more rarely until they finally stop.
Menopause in some women is accompanied with intense symptoms, which may compromise the quality of life. Symptoms may appear with the beginning of menopause or during climacterium.
What symptoms characterize menopause?
The most common symptoms are hot flashes. Hot flashes are the most characteristic symptom in many patients last for many years after menopause. Other symptoms are sleep disturbances, chronic fatigue, anxiety, irritability, crying spells, lack of concentration. Furthermore, psychosomatic symptoms may consist of chronic headaches, muscle and joint pains, pulpitations, shortness of breath and numbness. Menopause is also associated with sexual problems: reduction in sexual drive (libido), vaginal dryness, pain during sexual intercourse and recurrent vaginal or urinary infections. Moreover, weight increase, particularly in the abdomen, is a common problem that a lot of women face and is an index of increasing risk of cardiovascular disease. Finally, another common sign of menopause is the atrophy of skin that leads to an increase in its rinkles.
Which are the long – term outcomes?
The most common menopause-associated diseases are osteoporosis, cardiovascular disease and dementia. Bone loss begins soon after menopause and usually does not produce symptoms until too late in the course of the disease, when bones fracture upon minimal trauma (e.g. by descenting a staircase). The risk of cardiovascular disease (ischemic heart attack and stroke), increases significantly during menopause because of the loss of the protection of estrogens and the simultaneous increase in risk factors like abdominal obesity, cholesterol, triglycerides, hypertension and diabetes mellitus. Dementia may start with functionally non-significant memory disorders which in a minority of women may progress to mental decline.
What is hormone therapy?
It is the replacement of ovarian hormones with hormones that are exogenously administered in the lowest possible dose. Women with an intact uterus receive a combination of estrogen and progestin, while women who have had their uterus removed surgically receive monotherapy with estrogen. Beyond hormone therapy, women during the climacterium may receive low-dose contraceptive pills (because the possibility of a pregnancy still exists in the climacterium) or progestin-only therapy (without estrogen, in order to normalize menstruation ). After the establishment of menopause, hormone therapy is usually prescribed at the lowest possible does to cure symptoms, which is usually 2-4 times lower than the amount of hormones produced normally by the ovaries. The duration of therapy differs from woman to woman according to her medical history and her needs. Therapy can be administered either orally (daily pills) or transdermally (skin patches twice weekly or gel that is applied daily on the skin )
When is hormone therapy indicated?
The main purpose of hormone therapy is the improvement of quality of life. Candidates for hormone therapy are usually women with moderate to severe menopausal symptoms or symptoms and signs of urogenital atrophy. Women with urogenital atrophy who have no other symptoms and their problems are limited to the vagina, may receive local therapy in the form of vaginal estrogen cream or suppositories. Hormone therapy also protects from the menopause-associated high rate of bone loss which is observed during the first years of menopause. Hormone therapy furthermore prevents weight increase and delays the appearance of skin and muscles atrophies due to estrogen loss.
When is hormone therapy not indicated?
Hormone therapy (HT) is not indicated in women free of symptoms. Furthermore HT is not indicated in women with a history of breast cancer , endometrial cancer or ovarian cancer, active liver disease or thromboembolic disease. Women who receive long term HT may have a slight increase of risk of breast cancer. This risk translates clinically into 2- 4 extra cases every 1000 women. By using estrogens in the lowest effective dose, as well as natural progesterone, we practically minimize the risk. Concerning deep vein thrombosis, the risk from hormone therapy is mainly associated with the use of pills and is mainly restricted to older obese women who smoke. We can avoid the risk of thromboembolism by using transdermal therapy (skin patches), which according to recent clinical studies do not increase the risk of deep vein thrombosis.
Is there alternative therapy?
Phytoestrogens are used as an alternative therapy of climacteric syndrome. These are natural estrogens derived from plants like soya, which in the gut are metabolized in active estrogenic compounds. They have a mild effect on hot flashes, while their effectiveness in preventing osteoporosis is not yet demonstrated. They are mainly effective in recently menopaused women with natural menopause and mild symptoms. They are not effective in women with premature ovarian failure or premature menopause, in women who have had their uterus removed, or in women with severe symptoms. They should be used on long-term because of the lack of safety data.
Which are the causes of early menopause and why is hormone replacement therapy necessary?
Many women experience menopause earlier than the age of 45, which is estimated as the lowest normal age. This situation is called early menopause. In some women menopause appears before the age of 40. This is defined as primary ovarian failure (POF) or primary ovarian insufficiency. Women with family history of early menopause , women who have undergone gynecological operations involving the ovaries and those who have received radiotherapy or chemotherapy are at risk for POF. Further risk factors include genetic abnormalities (e.g. Turner Syndrome mosaicism) and ovarian inflammation caused by autoantibodies (antibodies that their organism produces against their own cells).
POF is considered a disease, as it is associated with 3 – 6 times increased risk for osteoporosis and cardiovascular disease. As a result, every patient with primary ovarian insufficiency should be treated by hormone replacement therapy, independently of the presence of climacteric symptoms. Hormone replacement therapy should continue until the average age of natural menopause ( 50 -52 years old).
What is included in annual check – up in menopause?
1. Blood pressure assessment: hypertension usually presents soon after menopause
2. Papanicolaou cervical smear cytology test (Pap smear). Women should start screening after their first intercourse and repeat the test once a year.
3. Gynecological examination – transvaginal ultrasound
4. Mammography (after the age of 40 )
5. Bone Mineral Density assessment by DEXA. The first examination is usually performed around the time of menopause. For women under the age of 60, lumbar spine measurement is preferred as it is more sensitive to estrogen depletion. After the age of 60, the preferred measurement site is the hip, as it is more reproducible. (degenerative arthritis of the lumbar spine or calcium deposits in the aorta compromise the reliability of the method in this site).
6. Blood tests: glucose, lipids and thyroid function should be tested after the establishment of menopause, since diabetes, hypelipidemia and hypothyroidism are common diseases frequently presenting after menopause. Frequency of assessment depends on the results