A Family Doctor's Tale - MENOPAUSE

DOC MY MENSES HAVE STOPPED COMPLETELY

Menopause is a change of life in most women occurring between 45 to 55 years of age. Every woman will experience menopause. Some will welcome it as it means less worries about having pregnancies or others may feel discomfort, depression and uncomfortable symptoms of menopause such as flushing, irritability and signs of aging as a result of the lower female hormones. Since menopause is inevitable, all women should try to adjust to it either by themselves and their families or with the help of doctors and psychologists.

Menopause is the cessation of menstruation occurring in women between the ages of 45 and 55 years. 
It is important to stress that it is NOT an illness but a natural event. The age that menopause occur may vary with different women.



Natural Menopause

From puberty a woman starts releasing eggs from their ovaries. Both the ovaries and eggs produces female hormones. 
These hormones thickens lining of the womb in preparation for a pregnancy.If the pregnancy does not occur, the lining of the womb is shed off as blood and cells(menses).
As the woman grows older, less eggs are produced resulting in reduced production of the female hormones. This causes the menstrual periods to be less or more than usual. When no more eggs are produced, the amount of the hormones produced are not enough to cause the lining of the womb to thicken.As a result menstruation will stop.


Menopause is said to be established when the woman does not have any menstruation for one year.


Premature Menopause

Premature menopause occurs when the menses stop in a woman before the age of 40 yrs. 
Causes of premature menopause are surgery to remove the womb or ovaries in the case of cancer, chemotherapy and radiotherapy. 
Without the protective effect of estrogen,  these women will have a higher chance of having osteoporosis and heart disease later in life .

Women who smokes usually have menopause 2 years earlier than non-smokers.


Most women do not have any symptoms except for the loss of their monthly periods.


In the others, the change in female hormones may cause the following symptoms:
1.Irregular menstrual patterns - usually the menses can become lighter or further apart. One or two periods may be missed.


2.Hot flushes -sudden feeling of heat starting from the chest to the face. There may be associated sweating, fast heart beats, fainting and insomnia.
The exact cause is not known and may be due to vasomotor disturbances related to the fluctuating hormone levels. 
It usually improve after 1-2 years.


3.Vaginal tract changes - With menopause, the walls of the vagina become thinner, dryer because of less secretions, and more prone to infection. Because of these changes, sexual intercourse may be uncomfortable or painful.


3.Incontinence - With age and onset of menopause, the muscles around the bladder opening may  weaken, leading to leakage of urine with straining or coughing  (incontinence).
Muscles of pelvic floor loses tone with possible prolapse of uterus.


4.Breasts tissues may  become atrophied with decrease in size of the nipples. The breast may become more pendulous.


5.Skin may be less smooth and wrinkles may appear. 
Hair may also become thinner and drier.


6.Mood and memory: irritability, anxiety, depression, insomnia (difficulty in sleeping), poor concentration and poor memory may be due to the lowered female hormones or psychological due to change in the body, skin and appearance.


7.Osteoporosis:
The bones may become brittle, fragile and fracture easily after menopause because estrogen is important in maintaining bone mass.  Hormone replacement may be able to reduce the bone loss and prevent osteoporosis.


8.Cancer:
Menopause itself does not cause an increased risk of women cancer. It is rather the age group that they are in which may increase the risk of cancer.


9.Heart disease and stroke
After menopause, women are more likely to get hypertension or high blood cholesterol which increases the risk of a heart attack and stroke.


10.Metabolic disease
Again after menopause some women tend to burn less energy and gain weight.
Decrease metabolism leads to accumulation of sugars which can increase the risk of Diabetes


In most cases of menopause, no treatment is necessary as it is a normal physiological event.
It is important that there is reassurance and psychological support from family and friends.
Menopause may mean the end of fertility but it also means the freedom from all the discomfort and inconvenience of monthly menstruation and fear of pregnancy.


Hormone replacement therapy used to be the best solution for all the symptoms and problems of menopause at one time. They help to prevent heart disease and osteoporosis as well as to reduce the symptoms of menopause such as hot flushes, skin , breast and vaginal changes.
Estrogen and progesterone are the two types of female hormones prescribed for and after menopause. A combination of the two hormones is taken, as progesterone helps to protect the uterus from endometrial cancer. If the woman have had removal of the womb, she will normally be given only estrogen.


HRT comes in the form of pills, patches, implants or vaginal creams to replace the level of sex hormones in your body. There are both benefits and risks to the use of HRT:


Benefits Risks
Relieves hot flashes and vaginal dryness.
Prevents osteoporosis and protects against fractures of the wrist, spine and hip.
Indirectly improves some emotional symptoms by relieving the physical discomfort of menopause.
 Safe for short term use. May increase risk for breast cancer for long term users (more than 5 years).
May cause PMS (Pre-Menstrual Syndrome) symptoms such as bloating or irritability.
May have side effects such as vaginal bleeding, nausea, hair loss and headaches.


Hormone replacement therapy has however recently fell out of favor due to new study which indicate higher incidence of breast and womb cancer.


For premature menopause where symptoms of menopause are more obvious due to their age, hormone replacement therapy is still given at intervals of 6 to 12 months.


The current treatment for the symptoms of menopause in the older women are:
1. A healthy life style.
Exercise
Regular exercise strengthen the muscles and bone.
Exercise also burns up calories to reduce obesity and hence prevent diabetes, hypertension and heart disease.
Walking is one of the best weight-bearing exercises to prevent osteoporosis. Swimming and dancing are also good exercises.


Eat a balanced diet
A good balanced diet helps to prevent obesity, diabetes, osteoporosis, heart disease and colorectal cancer.
More fruit and vegetables will help reduce calories and prevent colorectal cancer.
Foods rich in calcium and Vitamin D such as fish, low fat high calcium milk can prevent osteoporosis.
Alcohol, coffee, tea, canned drinks should be avoided.
Less sugar, salt and saturated fats will reduce the risk of diabetes,hypertension and heart disease.


Control Stress
Meditation, yoga, deep breathing exercises and sufficient sleep reduces stress and heart disease.
Community service work, hobbies, time with family take the mind off work and stress.


Stay smoke-free
The risk of heart disease, lung and cervical cancer can be reduced by not smoking.


2.hot flushes:
Cool showers and cool temperatures may help to reduce hot flushes.
Hot beverages and spicy foods should be avoided.
Thin cotton clothes is more comfortable.
Drinking a glass of cold water, loosening any tight clothing and using a small fan to cool down can stop the beginning of a hot flush.
Soy products like tofu and soya bean burns up less calories.
Meditation and mild exercise may also help by reducing stress.
hormone replacement therapy (mainly estrogen) for a short period may be used as a last resort.


3.vaginal changes 
Water-soluble vaginal lubricants can reduce dryness.
Estrogen replacement creams may be prescribed to reduce the vaginal discomfort.


4.incontinence:
Doing simple pelvic floor exercises will strengthen the muscles surrounding the sphincter of the bladder opening.
Wearing a pad in the underwear may reduce the discomfort due to leaks.
Injection of collagen sometimes worked to tighten the sphincter of the bladder opening.
Surgery to tighten the muscles of the bladder opening may be used as a last resort.


5.mood changes:
Many women going through menopause may become irritable,anxious or depressed.
Avoid stress and depression by learning how to relax and make time for yourself. 
Exercise can help increase your energy level and improve your mood. It is also good for your health!
Take up a hobby or do some volunteer work that you enjoy.
Build up a good support system by nurturing relationships with your family and friends. Talking to friends or a professional counsellor can help you to manage your emotions. It is good to let your family know what you are going through so that they can understand and provide support. Ask other women how they cope with the changes you are going through.
There is a menopause support group in Singapore that you can contact.


If you are concerned about osteoporosis, you should discuss it with your doctor. To minimize your risk, you should have a diet with adequate calcium and maintain an active lifestyle.


Women who are at higher risk are those who
are fair-skinned (white or Chinese)
are thin and small-built
had early menopause or have ovaries removed
have a family history of osteoporosis
have a diet low in calcium and Vitamin D
drink coffee, tea or alcohol regularly
smoke
are not physically active
are on steroids for long term (E.g. asthmatics)
have certain disease such as an overactive thyroid gland


Breast Cancer
Breast Cancer is the most common cancer among women. It is most common in women in their 50s. Early detection and treatment gives the best chance of a cure. Please do monthly breast self examination. Have a mammography once a year in your 40s and once every two years after age 50. If you suspect you have a lump, consult your doctor.



Cervical Cancer
Cervical cancer is the fourth most common cancer among women in Singapore. It can be prevented through regular Pap smear tests. Pap smears can detect precancer so that simple treatment will prevent the development of full blown cancer.


Regular check-ups
Blood sugar test once every 3 years to detect diabetes early if you are not at risk. Early management can prevent complications such as heart disease and stroke.
Check your blood pressure yearly and blood cholesterol once every 3 years to monitor risk for heart disease and stroke.
Pap smear tests for cervical cancer once every 3 years from age 25 to 65 years if you have had sexual intercourse before. If at age 65, previous smear tests were normal, you can stop your screening for cervical cancer.
Do monthly breast examination. Have a screening mammogram once a year if you are in your 40s, and once every 2 years if you are 50 years and older.



Stay active and be confident about the future. Take care of your health and personal appearance so that you both look and feel good.



Hormone replacement therapy is a treatment that replaces the hormones your ovaries stop making at menopause.



Your decision on HRT need not be permanent - you can always change your mind. Discuss your needs with your doctor to decide what's best for you. Make a decision based on your family medical history and weigh the benefits against the risks.



A New Chapter
Although menopause marks the end of fertility, it is NOT the end of health, attractiveness, or a satisfying and enjoyable life. For many women, menopause means freedom from the inconvenience and discomfort of monthly periods. 
Menopause is a turning point which can lead to the best years of your life.


Every Woman Goes Through Menopause
Every woman's experience with menopause is different. It is important to be informed about menopause so that you know what to expect.


Some women may welcome the cessation of periods, while others may feel a sense of loss that their childbearing ability is gone. By understanding the physical and emotional changes during this period of time, you may be more able to cope with life in the golden years.


The average woman now has a life expectancy of 80 years. This means that the average woman will live more than one-third of her life after menopause!


Because of longer life expectancy, women will also experience age-related health problems.
Heart Disease and Stroke:
Heart disease and strokes are more common in men but when a woman reaches menopause, the incidence of these diseases is similar to that in men. It is important to remember that the fundamental way to a healthy heart is a healthy lifestyle.


Hence it is important to have regular exercise, maintain your weight and have a healthy diet low in fat and sugar.
It is still not clear whether depression or mood swings during menopause are a direct result of the changing hormonal levels. It is possible that other changes in mid-life may contribute to the mood swings or depression. This is usually the time when women retire or have more difficulty finding a job and become financially dependent. For others, their children may leave home because of studies, work or marriage and they may suffer the "empty nest syndrome". They may also have to bear the responsibility of looking after their aged or sick parents. Sometimes the hot flashes can disrupt sleep and cause fatigue and irritability. If you feel depressed, do not hesitate to speak to your doctor. You may benefit from hormone replacement or anti-depressants.


There are other ways to cope with this difficult time.