Tuesday, October 25, 2016

Menopause

The period that marks the permanent cessation of menstrual activity, normally occurring in the U.S. between the ages of 40 and 58. Menopause is said to have occurred once the woman has experienced 12 full months without any menstrual bleeding. The mean age of menopause in the U.S. is 51. The menses may stop suddenly, but this phenomenon is relatively rare. For most women there is first a menopausal transition often lasting a few years, during which ovulation becomes infrequent, menstrual cycles become irregular, brief periods of amenorrhea, polymenorrhea, or hypermenorrhea occur, and follicle-stimulating hormone levels rise. Natural menopause will occur in 25% of women by age 47, 50% by age 50, 75% by age 52, and 95% by age 55. Pathologic or premature menopause due to surgical removal of the ovaries, chemotherapy, radiation therapy, or to disorders such as malnutrition, debilitation, or extreme emotional stress can occur at any age. Women with short menstrual cycles, lower body weight, a history of smoking, nulliparity, and lower socioeconomic status may reach menopause earlier than the rest of the population. Obesity and overweight may contribute to a delayed onset of menopause.

SYMPTOMS
The symptoms associated with menopause begin soon after the functional decline of the ovaries results in decreased estrogen levels, or after medical, radiation, or surgical treatments destroy the reproductive glands. Symptoms, which may last from a few months to years, vary from hardly noticeable to severe. Included are vasomotor instability (hot flashes and night sweats), insomnia, atrophy of vulvo-vaginal tissues, vaginal dryness, and dyspareunia. Vaginal pH becomes more alkaline, increasing the chance for infections. Atrophic cystitis due to the effects of decreased estrogen levels on bladder mucosa and associated structures can occur. Breast size may decrease, skin turgor and elasticity decrease, and pubic and axillary hair may be reduced. A panel of the National Institutes of Health in 2005 found limited, if any, evidence that anxiety, fatigue, apathy, depression, poor concentration, lapses in memory, palpitations, headache, numbness, tingling, myalgia, or urinary disturbances (e.g., frequency and incontinence) had any provable relation to menopause. The long-term effects of lower estrogen levels include incremental bone loss (osteopenia or osteoporosis).



TREATMENT
Menopausal hormone replacement therapy (HRT) may be used cautiously for relief of symptoms. This therapy consists of estrogen alone (in women who have had a hysterectomy) and estrogen combined with progesterone (in patients with an intact uterus). HRT is contraindicated in women who smoke or in women with a history of an estrogen-dependent breast cancer, endometrial cancer, thromboembolic disease, acute liver disease, and vaginal bleeding of unknown cause. Many women with a strong family history of breast cancer should also avoid hormone therapy. Decisions regarding use of hormone therapy are based on the relative benefits and risks of treatment for the individual woman. Important benefits may include reducing the risk of bone loss and decreasing symptomatic hot flashes. Significant adverse effects may include increased potential for developing estrogen-related malignancies, heart attacks, strokes, blood clots, and postmenopausal bleeding. The Women’s Health Initiative has led to a revision in recommendations for HRT because health risks appear to outweigh benefits. The advantages and disadvantages of hormonal therapies should be openly discussed with patients so that they may make informed choices about treatment. Because of the known risks, HRT should be used at the lowest effective dose for the shortest amount of time until treatment goals are met. Some antidepressants (e.g., fluoxetine, paroxetine, or venlafaxine) and some anticonvulsant medications, such as gabapentin, may be prescribed for hot flashes and other menopausal symptoms. Although researchers have not proved the effectiveness of herbal compounds and soy products, some women take them for relief of menopausal symptoms. Relaxation techniques, yoga, tai chi, or meditation also help.

PATIENT CARE
Because women may experience a variety of symptoms during this period of their lives, their nature, severity, and personal impact need to be sensitively addressed by health care professionals. Menopause is a normal phase in the reproductive cycle. The postmenopausal woman should be encouraged to maintain a diet high in calcium, vitamins, and minerals to maintain strong bones. Any vaginal bleeding or spotting that occurs after menopause should be promptly reported and investigated. If a woman is in a sexual relationship, remaining sexually active will help to preserve vaginal elasticity, and lubricants can be used before intercourse to reduce dryness. Performing Kegel exercises strengthens vaginal and pelvic musculature.

Vaginal canal, normal vs. menopause

Artificial menopause
Menopause following oophorectomy (surgical removal of the ovaries), radiation therapy, or chemotherapy.

Induced menopause
Menopause that occurs after treatments that are toxic to the ovaries (such as cancer chemotherapy) or after surgical removal of the ovaries.

Male menopause
SEE: climacteric

Premature menopause
Natural or artificial menopause occurring before age 35.

Surgical menopause
Menopause that results from oophorectomy (surgical removal of the ovaries).

Temporary menopause
A brief cessation of menstrual periods followed by resumption of menses. It can be induced by medication, over-zealous exercising or dieting, illness, or other stressors.