Understanding Menopause

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The menopause is defined as the permanent cessation of menstruation and fertility, naturally occurring at about the age of 45-55 years of age. Menopause is the total cessation of menstruation for 12 months. Should menopause begin before the age of 40, it is referred to as premature menopause or premature ovarian failure, whether induced or due to natural physiological process.

Menopause results due to changes in hormone levels: Initially FSH (Follicle Stimulating Hormone), and then later LH (Luteinising Hormone) concentrations begin to rise, due to the supply of follicles (eggs) diminishing. Oestrogen levels decline and so the reproductive cycle becomes disrupted. Finally, the result of low estradiol levels in addition to grossly elevated LH and FSH levels, defines the menopausal picture.

At the start of menopause when changes begin, the transitory phase is called peri-menopause and can last for between 2 and 6 years- during this time many women can go through this stage without any symptoms.

Most noticeable of peri-menopause and menopause are scanty periods over a variable period of time, albeit in some, sudden amenorrhoea or menorrhagia occurs. Hot flushes, night sweats, vaginal dryness, atrophy of the breast tissue; as well as vague symptoms of low mood, loss of self esteem, irritability, depression, loss of concentration, loss of libido, specific aches and pains, and even possibly weight gain may occur.

Rapid loss of bone density following menopause, and the protection from ischaemic heart disease (pre-menopausal) declines, due to waning oestrogen levels.

Premature menopause typically occurs before the age of 40, and may be associated with missed, irregular or scanty periods, together with other symptoms such as hot flashes, night sweats, difficulty maintaining weight, mastalgia, loss of hair, as well as a range of emotional symptoms such as moodiness and anxiety, similar to those experienced during menopause. Like women who experience menopause, those who experience premature menopause endure the same symptom picture, only for a more extensive period of their lives.

Aetiology of premature menopause varies between women, and may result from a combination of factors:
- In the treatment of cancers of the reproductive system, radiation and or chemotherapy may result in premature menopause.
- The most common and proven risk factor for premature menopause is cigarette smoking
- Stress: although stress alone does not cause premature menopause, it does play a role in the severity and frequency of symptoms.
- Additionally surgery to remove the ovaries may induce menopause. When both ovaries are removed, known as bilateral oophorectomy, a woman goes into menopause immediately. Periods cease, and hormone levels drop dramatically resulting in menopausal symptoms.
- Hysterectomy (surgery to remove the uterus) may end menstrual periods, but does not cause menopause as long as the ovaries are functioning.
- Should blood supply to the ovaries be unintentionally damaged and/ reduced during surgery to the reproductive area, artificial menopause may also result.
- Autoimmune diseases may too contribute to premature menopause. Examples include lupus, hypothyroidism, and Graves disease. When the body produces antibodies that attack the body itself, it may too attack ovarian tissue or even ovarian hormones.
- Viral infections contracted by the mother during an early stage of the pregnancy may affect the ovaries of an unborn child. Additionally it is thought that childhood illnesses such as mumps, may affect the number of eggs a child bears in the ovaries.
- Familial: Should a mother and or sister have experienced premature menopause, the patient too may be at risk.

Diagnosis of menopause is made retrospectively after a woman has missed menses for 12 consecutive months. Extensive medical history and interview, physical examination, as well as special investigations such as blood tests are conducted in order to accurately diagnose, as well as exclude other differential diagnoses. Bloods measuring estradiol, FSH etc. usually indicate where the patient is in the picture of menopause, and assists not only with diagnosis but also adequate treatment.

Patients presenting with symptoms (especially those significantly impacting daily life) should be treated.

Hormone Replacement Therapy (HRT) consists of oestrogen, progesterone and possibly testosterone. Tailored to the patient dosages and/ combinations are prescribed. It is recommended to use the lowest possible dose for the shortest period of time to alleviate symptoms, yet reduce the risks of breast cancer, blood clots, myocardial infarction, and stroke. HRT is contraindicated in women with estrogen-dependent cancers in women with family history of such type of cancers.

Previous widespread treatment with HRT has been doubted by some large prospective studies. The WHI (Women's Health Initiative) was a large randomized clinical trial of more than 16000 healthy women, sponsored by National Health Institute in 2002. It was found that overall risk of estrogen outweighs the benefits thereof. After 5.6 years, follow- up was conducted, and it was found that women had increased risks of breast cancer, heart disease, stroke and blood clots.
Despite there being a universal agreement some benefits and risks according to the Woman's health Initiative may be summarized as follows:

- Risks and benefits depend on each individual, taking into consideration medical history, background risk of disease. At present no evidence of relative risks of different hormone preparations or routes of administration exists. Overall, the WHI study estimated that over 5 years of treatment, an additional 1 in every 100 women would develop an illness that would not have resulted should she not have been taking HRTs. However the decision about taking HRTs is entirely based on an individual basis, taking into consideration severity of symptoms, predisposition, risk factors, and ultimately patient choice.
- HRT is no longer recommended purely for the prevention of postmenopausal osteoporosis in the absence of menopausal symptoms. Where symptomatic treatment is prescribed, use of the lowest effective dose, usually for a shorter period.
Anti-depressants such as SSRIs may considered to ease anxiety and low mood often experienced during menopause.

When managing menopause, it is important to make certain lifestyle changes such as ensuring a nutritious diet, supplementation with Vitamin D, and calcium. As part of an exercise regime, include weight bearing exercises. Together with eliminating use of cigarettes and alcohol, the risk of osteoporosis, bone fractures and cardiovascular disease can well be reduced.

The effect of increased dietary intake of phyto-oestrogens from sources such as soybeans, chickpeas, flaxseed etc. has been shown to assist with alleviating vasomotor symptoms like hot flushes. However due to oestrogen-like effects, concern of increased cancer risk has been raised.

Certain natural medicines or herbal extracts may efficiently alleviate menopausal symptoms but at the risk of containing phyto-oestrogens. As previously mentioned phyto-oestrogens are chemical compounds found in plants, having oestogenic like properties. Because phyto-oestrogens mimic oestrogen concern has been shed as to whether they might pose risk of breast cancer. Animal studies have shown that soy phyto-oestrogens can decrease breast cancer formation in rats, as opposed to animal and human studies that soy phyto-oestrogens can behave like oestrogen and potentially increase risk of breast cancer. Current research is conflicting, and some scientists advise women remain cautious about the intake of phyto-oestrogen containing foods and supplements.

Alternative treatment options may include the high quality extract of Cimicifuga racemosa (black cohosh). According to a paper published by the Journal of the North American Menopause Society by Dog et al in 2003, the review clearly supported the use of Cimicifuga racemosa (being of a specific extract preparation) in women experiencing menopause, and those in which oestrogen therapy is contraindicated.
A specific extract of Cimicifuga racemosa has been shown to not only be devoid of phyto-oestrogens, but show potential protective effect on the breast tissue.

Author - Juanita Ferreira

Published - 2014-06-02