Menopause: when the bleeding stops, delight or despair?
Menopause: when the bleeding stops, delight or despair? |
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Key words: menopause, culture, hot flushes, mood changes, oestrogens, progestogens
Menopause: Global and UK demographics
What is menopause? This is the last menstrual period and the word is derived
from the Greek word "menos"- month and "pauses" an ending.
It may be more appropriate therefore to consider the term climacteric which
encompasses the years of progressive ovarian failure. While the age of menopause
has not changed, for over 150 years female life expectancy on the other hand
has been increasing. In 1850, a woman could expect to live about 40 years of
life, in fact most women did not survive to the menopause. Women now will spend
one third to one half of their lives – about 30 years – postmenopausal
1,2 (Fig 1).
More than 19% of the women world-wide are at least 50 years old whilst in the
United Kingdom, the figure is more than 35%. The current worldwide mean life
expectancy for both sexes is 63 years, sixty-one years for men and sixty-five
years for women.. Life expectancies in the United Kingdom are: 77.7 years for
both sexes, 75 years for men, and 80.5 years for women respectively1.
The number of women in all age groups will keep growing, so that by year 2021,
it is projected that the number of women between 45 and 59 years old will increase
by about 32% over the 1987 figure. The most impressive increase is estimated
to be a 50% growth in the number of women aged 85 and older (Fig 2) 2
An important factor in determining the psychological response to the menopause
and the climacteric is the social and cultural background. The women cease to
be bearers of children and drawers of water to become ‘elders’ in
African tribes. In India, the women end purdah and stop wearing a veil. In the
Arab societies where the women are no longer "contaminated" by menstrual
blood, the menopause may indeed be welcome or even perceived as a delight.
In Western society, however, with its current youth oriented culture, emphasis
is on early achievement and success, physical attractiveness, and sexual prowess.
The menopause may be regarded by many if not by most women as something to be
feared rather than a symbol of achievement and maturity i.e. despair. There
are many features of the menopause.
Clinical features of the menopause
Vasomotor symptoms
By far the most common symptom for which menopausal women seek treatment is
the hot flush. It is estimated that these episodes of flushing and perspiration
will occur in more than 80 per cent of menopausal women, and will persist for
a least one year. Hot flushes are most often described as heat starting in the
face, neck, or chest – sometimes accompanied by reddening and sweating
– and spreading. Night sweats, which sometimes necessitate a woman getting
up during the night (to shower, change clothes, etc) can be a major cause of
sleep deprivation.
Oestrogen is known to regulate circadian rhythms. In addition to night sweats,
the disruption of this rhythm caused by decreased oestrogen levels can contribute
to the insomnia that can start in perimenopause and last well after the menopause.
Urogenital symptoms
The female genital and lower urinary tracts are anatomically closely related
and have a common embryological origin. Both are sensitive to the effects of
oestrogen. Epidemiological data suggest that there is a causal relationship
between oestrogen deprivation, urogenital atrophy and the onset of urogenital
dysfunction. Despite the fact that 10% to 40% of all postmenopausal women experience
urogenital symptoms of oestrogen deficiency, only about 25% seek medical help
for these symptoms.
Symptoms include vaginal dryness, dyspareunia (painful sexual intercourse),
and a susceptibility to bacterial infection. Some women experience recurrent
episodes of urinary frequency and urgency (“urethral syndrome”).
2,3 Symptoms due to loss of tone of urogenital tissues are reported by two thirds
of women by age 75 years. These symptoms include frequency, urgency, nocturia
and incontinence. In addition to frequency and urgency, studies indicate that
many women report the onset of incontinence shortly after their last menstrual
period. Prevalence of incontinence increases as postmenopausal time passes3.
Central nervous system
There are also neuroendocrine symptoms which may be acute and last for months
including mood changes, anxiety, irritability, loss of libido, memory loss,
poor concentration and low esteem. Perimenopausal women often experience depression,
anxiety, and loss of libido; these feelings, in combination with the fatigue
and irritability caused by loss of sleep and the decrease in self-esteem that
can result from some social views of menopause, can be extremely distressing.
This, in turn, can impair concentration and oestrogen deficiency has been implicated
in memory impairment 4
Skin
As oestrogen decreases, there is a loss of collagen and a resulting thinning
of the skin. The loss of collagen from ligaments and other soft tissue may be
responsible for the musculo-skeletal joint aches and pains that many women experience.
Oestrogen deficiency causes a decrease of tone in the tissues of the pelvic
floor that can lead to uterine prolapse. Dry mouth and dry eyes are also possible
sequelae of a loss of oestrogen.
Osteoporosis
The major long-term problems associated with oestrogen deficiency are osteoporosis
– a reduction in bone density that renders the bones vulnerable to fracture
– and arterial disease. In the age group generally comprising premenopausal
women, many more men than women die of cardiovascular disease; this disparity
decreases, however, in the age group comprising postmenopausal women. It is
hypothesized that women lose their protection against arterial disease after
menopause.
Data from National osteoporosis society suggested osteoporosis affects more
than 2 million women in the UK and, 1 in 4 women would have had osteoporosis
related fracture by their 60s. One in two women have had an osteoporosis related
fracture by their 70s. Other problems include development of kyphosis (Dowagers
hump), loss of height, the neck becomes weak and head falls forward.
In an average 10,000 patient practice, 700 postmenopausal women are likely to
be affected and at risk: 70 women in their 50s, 125 women in their 60s, 250
women in their 70s and 250 in their 80s. Each year there are 60,000 hip, 50,000
wrist and 40,000 vertebrae fractures in the UK (National Osteoporosis Society)
Hip fractures alone cost the National Health Service (NHS) in the UK more than
£160 million per annum. Osteoporosis and its sequel cost the NHS an estimated
£0.5 billion per annum.
Management of the menopause
Hormone replacement therapy was originally an oestrogen-only preparation, used
orally as Bishop (1938) 5 first advocated for surgical menopause. There was
a boom of hormone replacement therapy (HRT) in the USA in the 1960's, when it
was fashionable to prescribe oestrogen in order to maintain continued youth
in older women, e.g. the concept of feminine forever6. This changed dramatically
in the 1970's when the complications of unopposed oestrogen replacement gradually
became apparent. Subsequent investigation showed that the addition of progestogens
in adequate dosage, and for long enough, reduced these unwanted consequences
in-patients with uterus. HRT is available in many formulations and can be administered
in a number of routes (Table 1). The HRT market in the United Kingdom is currently
valued around £146 m. The number of women in the United Kingdom choosing
to use HRT is increasing with less than 15% of women aged 45-54 in 1995 and
17% of women aged 40-65 in 1997. Like any medication, HRT use has advantages
and disadvantages. Each potential user needs proper counselling.
TABLE 1 Hormone replacement therapy and routes of administration
Figure 1: rise in female life expectancy in the last 150 years
Figure 2: UK female population over 45 years of age and projected changes
Conclusion
In conclusion, the number of postmenopausal women globally and in the United
Kingdom is growing. Initial use of and compliance with – HRT is low with
average duration of HRT use being about 18 months. The overall objective in
the management of the menopause is to improve the quality of life of our ageing
population (men and women) to enjoy a third phase of their lives.
References
©2001 Sexual Health Matters. Published Quarterly by Express Print Works, Middlesbrough,
UK
ISSN 1469-7556
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