Menopause and Climacteric
Definition. Menopause refers to final cessation of menstruation while climacteric means the period at which the woman gradually changes from the reproductive life into one of senescence. Meno¬pause is also referred by the laity as ‘the change of life’. However both the terms are often synonymously used, menopause being the popular term used. These are physiological processes due to cessa¬tion of ovarian follicular function.
Aetiology. Menopause occurs as result of exhaustion of eggs from ovarian follicles and Consequent oestrogen deprivation.
Physiological Changes in Climacteric or Menopause and Post menopausal age.
Genital. Progressive atrophy of genital organs occurs with more and more deposition of fibrous tissue in them.
Ovary. They go small (5 gm. each), fibrotic with furrowed surface, Follicles get exhausted. Ovarian Vessels become sclerosed. Cortical stromal hyperplasia is a frequent finding due to high LH level in women aged 40¬46 years. Ovarian stroma becomes a source of small amount of androgens.
Fallopian tubes shrink with diminished mortility.
Uterus becomes small and fibrotic due to atrophy of muscle. Endometrium becomes thin and atrophic (senile). In some women, endometrial. hyperplasia may occur after menopause as a result of constant oestrone stimulation. Cervix atrophies and flushes with the vaginal vault. Cervical secretion becomes scant, thick and later 4isappears. The vaginal epithelium atrophies with loss of rugosity. Vaginal smear shows atrophic changes. Vagina contracts with shallowness of the fornices. Vulva gradually atrophies with narrowing of the introitus : pelvic cellular tissue becomes gradually lax.
Secondary sex characteristics. Breasts show gradual atrophy of the glandular tissue resulting in flabbynes. These become pendulous due to deposition of fat around. Pubic and axillary hair becomes sparse.
Physical. Body weight decreases after 65 years. There is decrease in cell mass of organs. Skin wrinkles, becomes less elastic with hair appearing on face. Subcutaneous fat deposition. occurs on the hip and thighs. Height diminishes postraenopausally after 65 years. Kyphosis may develop due to spinal osteoporosis.
Metabolic. Osteoporosis occurs as a result of oestrogen deprivation. Reduction in trabecular bone (collagen matrix) (Osteoblasts) and Calcium leads to oestrogen deprived Osteoporosis. Premenopausally woman is protected against ischaernic heart disease due to high HDL and low LDL cholesterol. The latter rises postmenopause, thus incidence of ischaernic heart disease also rises. Premature menopause natural or by oophorectomy suffers from increased risk of cardiovascular diseases (cardiac and cerebral stroke) and osteoporosis.
Digestive. Hypochlorhydria develops. Motor activity of entire alimentary tract diminishes resulting in dyspepsia and constipation in postmenopausal women. Bladder and urethral epithelia atrophy.
Psychosexual. Emotional upsets are common. At menopause sex urge may increase. After 60 years, sex urge wanes as an aging process.
Endocrinal. There is gonadal failure at menopause. Plasma Oestradiol level falls, oestrone remains normal, ovarian stroma however, produces andostenedione. Extraglandular conversion of androstenedione to oestrone occurs in fatty tissue. Postmenopausally, adrenal cortex becomes the source of oestrone derived from androstenedione. Oestrone becomes the predominating oestrogen after menopause. Postmenopausal daily oestrone formation has been estimated as 15 100 gg/day (Mac Donald et al, 1973) and serum level at 30 70 pg/ml. Progesterone secretion ceases from the ovary due to failure of ovulation. Total urinary oestrogen level falls to about 6 Pg1 24 hours at the postmenopausal period. Androstenedione level mostly from adrenal cortex, little . from ovary comes to one half that seen prior to menopause. Testosterone level does not appreciably fall because postmenopause ovary secretes more testosterone.
Pituitary gonadotrophins. FHS and LH are secreted in increasing amount due to the absence of negative feed back control by the ovarian steroids. LH ovulatory surge disappears, the mean basal serum menopausal gonadotrophin levels are in the range of 50 150 rn LU/ml FSH and 50 100 m IU/ml LH. FSH level is 15 times higher than premenopausal level by 3 5 years after menopause while LH level is increased 3 fold. Prolactin level falls.
Timing. The process of climacteric may gradually start 2 3 years before menopause but may continue 2 5 years after it. The age at which menopause occurs varies widely from 40 to 55 years with mean age of about 47 years. Genetic makeup, race and climate influence age of menopause. Women of tropics get earlier menopause than those in colder climate. Some believe that the early the menarche starts, the later would be the menopause while late coming of the menarche is associated with early menopause. Early or delayed menopause is considered when menopause happens before 35 years or after 55 years respectively. Early menopause may be due to ovarian failure, oophorectomy or ovarian irradiation.
Delayed menopause is usually due to some pelvic pathology like uterine fibroid or in association with disease e.g., diabetes mellitus.
Clinical Features of Menopause and climacteric
Menstrual Symptoms. This occurs in forms of (a) progressive scanty menstrual loss followed by cessation of menses, (b) menses at prolonged intervals finally ceasing, (c) sudden cessation of menses. Prior to menopause menstrual cycles become anovulatory. Any excessive menstrual loss or irregular haemorrhage is not menopausal as in commonly believed by lay public but is due to some pelvic pathology.
Other symptoms. Most women remain asymptomatic. They adapt nicely the physiological changes of menopause. Some may have mild symptoms of putting on weight, joint pains, increase of sex desire followed by its gradual decrease.
Signs. The following signs appear gradually in a normal woman in the menopausal period and thereafter.
1. General signs. Increase in weight, deposition of fat on the hip, buttocks, around breasts. Breasts are examined.
2. Genital signs.
Vulva. Progressive atrophy with scanty hair with narrowing of the vaginal introitus.
Vagina. This becomes narrow with ‘tenting’ of vaginal vault,, thinning of mucous membrane and 18ss of rugae.
Cervix. Portio vaginalis atrophies and gets flushed with vaginal vault.
Uterus. Body is felt small and hard.
Adnexae. Ovaries become impalpable.
Diagnosis. This can be made from clinical features aided by atrophic vaginal smear and elevated serum FSH level of 50 mIU/ml and above. Elevated plasma LH level is less helpful. Urinary or serum oestrogen level shows value similar to follicular phase and thus less reliable for diagnosis.
Differential Diagnosis. Stoppage of menses due to menopause may be simulated by that due to pseudocyesis or pregnancy.
Treatment. Psychotherapy. Explanations for the condition and reassurances are to be given to the woman passing through climacteric when seeking advice for cessation of menses. Improvement of health by dietetic adjustment, adequate rest and exercise and regular evacuation of bowel are to be ensured. For sleep disturbance, diazepam (Valium) 5 mg. or Lorazepam 1 or 2 mg. is taken orally at bed time.
Menopausal or Climacteric Syndrome
Menopausal Syndrome refers to group of symptoms that are experienced by some women during climacteric. Hot flushes (vasomotor instability symptom) that last for one year in 80% are characteristic of menopausal syndrome. It diminishes of its own by 3 4 years. The cause of hot flush is unclear but follows oestrogen withdrawal in women with poor vascular control. Rise of hypothalamic endorphin is implicated. It is experienced by, 25% women with psychological background, particularly following oophorectomy or ovarian irradiation at younger age.
Flush depends on rate of oestrogen loss and extragonadal oestrone formation. The body gradually adjusts itself to natural decline of oestrogen and flushes gradually pass off.
Symptoms. These appear as follows: vasomotor and other symptoms usually follow but even precede cessation of menses.
1. Menstrual. Menses stop as already described under menopause. A proportion of premenopausal women come with emotional symptoms, loss of libido and dry vagina during intercourse, Hot flushes and sweats are complained with scanty and delayed menses by some women.
2. Vasomotor. ‘Hot flushes’ (feeling of warmth) due to cutaneous vasodilatation are commonly experienced by these, women on the face and neck spreading all over the body; this feeling of heat may be followed by sweating. They may come once a day but sometimes every hour; they come particularly at night. These are characteristic manifestations of menopausal syndrome.
3. Emotional. This is manifested by headache, irritability, sleeplessness, giddiness, fatigue, depression, palpitation. There may be sensations of ‘pins and needles’ in the sole and palm. Disturbed sleep can be due to hot flushes and sweats.
4. Sexual. These are decreased libido and dyspareunia due to atrophic vaginitis and lack of vaginal lubrication during intercourse.
5. Musculoskeletal. These appear as backache, pain in joints due to laxity of ligaments and muscles.
Signs. These are same as described under menopause.
Diagnosis. This has been already described under menopause.
Differential Diagnosis. Pseudocyesis of spurious pregnancy may be mistaken by the patient for menopausal syndrome. In the former, amenorrhoea, enlargement of breasts and abdomen due to deposition of fat like that in pregnancy occur; there is also the false feeling of foetal movements due to flatulent dyspepsia. The patient should be assured that her symptoms are menopausal. In all these cases, pregnancy may also occur and should be carefully excluded by thorough examination, immunological urinary pregnancy test and pelvic ultrasound.
Definition. Menopause coming on a patient below 35 years is called premature menopause. Cause. Poor stock of ovarian follicles gets exhausted. Clinical Features, Symptoms, Secondary amenorrhoea for more than 6 months. In some hot flushes, mood instability, disturbed sleep, loss of libido, (menopausal syndrome). draying of hair. Signs. Atrophic vaginal epithelism, normal or small sized uterus. Investigations. Raised serum FSH above 50 mIU/ml.; ovarian biopsy showing no ovarian follicles is not done. Treatment Assurance, diazepam for poor sleep. Oestrogen therapy for menopausal syndrome are given. Menstruation can not be brought on hormone therapy.
Male Climacteric. About 10 per cent men experience climacteric symptoms at a later age than women due to androgen deprivation. The rest 90 per cent gradually adapt themselves without symptoms.