Menacing Menopause

The female reproduction system is an amazing yet very complicated one. Though many women have a general idea of how the reproduction system works, they are often unaware of what’s in store for them with the onset of Menopause.   

Medically, a woman is defined as being in menopause when she hasn’t experienced a menstrual period for at least 12 months. Although it’s a natural process which occurs when a woman reaches the end of her child bearing years, the period building towards menopause is not easily understood. Health Capsule spoke to Consultant Gynaecologist and Obstetrician Dr. Kalinga Nanayakkara to disentangle the intricacies surrounding menopause.   

“The ovaries in the female reproductive system produce female egg cells, called the ova. There are approximately 1 million eggs at the time of the birth of a girl child. These ova are transported to the fallopian tube where fertilization by sperm may occur. A fertilised egg moves to the uterus, where the uterine lining thickens in response to the normal hormones of the reproductive cycle. If fertilisation doesn’t take place, the uterine lining starts shedding causing a menstrual flow. To maintain this cycle, the female reproductive system produces female sex hormones,” Dr. Nanayakkara explained.   

The implant is a small pellet. We make an incision in the buttocks of the patient, insert and place it just under the skin and cover it with a plaster. Such an implant can last up to 3 months. There are also patches or stickers which can be pasted on the buttocks, so that the hormones are absorbed through skin

During menopause the female reproductive system gradually stops making the female hormones necessary for the reproductive cycle to work. At this point, menstrual cycles can become irregular and eventually stop. “The tissues, muscles and ligaments of the body are maintained by the oestrogen hormone. As time lapses, the ova become atrophic and begin to die while the secretion of oestrogen hormone too decreases,”he said.   

“A follicle is a small bag like structure in a woman’s ovary in which an egg develops. The follicular phase is the first phase of the cycle, which starts with the woman’s period and ends with ovulation. During this phase, there’s an increase in follicular stimulating hormone called FSH in the body. The FSH and luteinizing hormones (LH) are released from the brain and travel in the blood to the ovaries. Together, they stimulate the growth of about 15-20 eggs in the ovaries, each in its own bag or follicle. These FSH and LH hormones also trigger an increase in the production of the female hormone oestrogen. When oestrogen levels rise, the body turns off the production of FSH. This balance of hormones permits the body to limit the number of follicles that will prepare eggs to be released,” Dr. Nanayakkara elaborated.   

The secretion of oestrogen gradually drops when a woman reaches her late forties or early fifties. The normal age for women in Sri Lanka to experience menopause is above 51 years of age, according to the doctor.   

Signs and Symptoms of Menopause
One of the most common symptoms of Menopause is hot flushes, according to Dr. Nanayakkara. Hot flushes are a sudden feeling of warmth spreading through your body and face. It is often caused by the changing hormone levels that are characteristic of menopause. “This unannounced brief feeling of intense heat lasts for about 90 seconds and it comes periodically. A woman is also likely to experience night sweats which cause difficulty in sleeping. Night sweats can cause great discomfort and drench your clothing and bedding in sweat, even though the area where you sleep is cool, disturbing your sleep. These are the two main physical changes that women with menopause are likely to experience,” said Dr. Nanayakkara.   

Ova gradually diminish after about 45 years and menstruation becomes irregular. This stage just before menopause is called perimenopause. If a woman experiences such irregularities in the mestruation cycle, a doctor need to exclude any threats to their health such as a malignancy, as irregular menopause can be a symptom of other undelying illnesses as well

In addition to these physical changes, some temperamental changes are also experienced by menopausal women. These may include forgetfulness and a tendency to feel agitated or restless often. Dr. Nanayakkara says that in some instances there may be some long term effects on the cardiovascular system and bones.   

“Oestrogen prevents women from being susceptible to heart attacks. When the secretion of oestrogen drops, the likelihood of women experiencing heart attacks is equal to the vulnerability of men,” he explained. Oestrogen also protects bones in a woman’s body as they tend to have smaller and thinner bones. “A sharp decrease of oestrogen when women reach menopause can develop the risk of osteoporosis; a bone disease that occurs when the body loses too much bone, makes too little bone, or both. The thickness of the bones and the potential for new bone formation decreases. They are easily vulnerable to fractures,” he cautioned.   

Treatment and management
“When patients complain of hot flushes and night sweats, we usually prescribe a synthetic oestrogen in the form of a tablet. However it must be noted that these are not the same as the contraceptive pills which also contain hormones,” he cautioned.   

Conjugated oestrogen of the lowest strength is a form of medicine that contains a mixture of oestrogen hormones. It is used to treat moderate to severe hot flushes and other symptoms of menopause. “This treatment is called the Hormone Replacement Therapy. Usually doctors place their patients on this therapy until about 60 years of age. We don’t advise hormone replacement therapy, for women beyond 60,” he said. “We have experienced that after 4 - 5 years of menopause and after 60 years of age, patients hardly ever complain of hot flushes.”   

Dr. Nanayakkara says that factors affecting the age of the onset of menopause can vary from person to person. Hereditary factors can cause the early onset of menopause for some women. “For women who live an active life, they may achieve menopause later. For instance for women who are engaged in continuous work and lead active lives, hormone secretion goes on for a longer time,” he said.   

Complications
Ova gradually diminish after about 45 years and menstruation becomes irregular. This stage just before menopause is called perimenopause. If a woman experiences such irregularities in the menstruation cycle, a doctor needs to exclude any threats to their health such as a malignancy, as irregular menopause can be a symptom of other underlying illnesses as well. “However there is no cause to worry as the odds of an irregularity becoming a malignancy is 300 to 1. It is always advisable to seek medical advice if you are experiencing irregularities for about 6 months or more. A gynaecologist must be consulted in such matters,” Dr. Nanayakkara said.   

A sharp discrease of oestrogen when women reach menopause can develop the risk of osteoporosis; a bone disease that occurs when the body loses too much bone, makes too little bone, or both. 

Asked about scepticism surrounding hormone replacement therapy, Dr. Nanayakkara said scientific trials have been conducted to prove that this form of therapy is safe. “Some women were fearful of the hormone replacement therapy, as a trial which surfaced several years ago found that conjugatory oestrogen increases the incidence of uterine cancer. 

However recent trials have shown that hormone replacement therapy is safe. Most pills prescribed for menopause has both oestrogen which cause the uterine cells to grow and progrestone which causes the cells to mature. These are at a very low dose and therefore are completely safe and prevents any malignancy,” he said.   

Treatment
Dr. Nanayakkkaara notes that the type of treatment depends entirely on the patient. “Some patients are able to bear changes of menopause without medication. For such patients we delay this treatment as much as possible. For instance women who are staying at home can manage the changes. A woman engaged in a stressful job may find it difficult to cope with the symptom.”   

Although there are several types of treatment available for treatment of menopause, hormonal implants and patches or stickers are not freely available in Sri Lanka. “The implant is a small pellet. We make an incision in the buttocks of the patient, insert and place it just under the skin and cover it with a plaster. Such an implant can last up to 3 months. There are also patches or stickers which can be pasted on the buttocks, so that the hormones are absorbed through skin,” he described. It wears off after 3 or 4 days after which a new patch must be used. We prescribe this to patients who are reluctant to take the oral treatment.”  

The most prescribed medication is in the oral form. “This is not the contraceptive pill, but a lower dose of conjugated oestrogen available under several brand names. It is important that women experiencing menopause symptoms seek professional medical help rather than self treat their conditions. 

To assess a patient’s condition and deliberate on the treatment, the doctor needs a baseline. He or she needs to evaluate a patient’s blood sugar, cholesterol and blood pressure levels. 

Therefore seeking the medical advice of a professional is essential to determine the type of treatment,” he said.