Menopause

It's urban legend that everything that ever goes wrong with women has men in it...and so we come to men-o-pause. This is, of course the time that women pause to consider if they need men in their lives at all! ...well ....thats only part of it....

Menopause occurs in all women and is essentially the cessation of menses. It can only be diagnosed retrospectively when 12 consecutive months have passed without a menstrual period. Perimenopause, on the other hand, is that uncertain time when cycles are skipped and symptoms are sporadic. Age at menopause is also variable. The mean is generally accepted to be 50 years of age with range 45 to 55. In my practice the range of natural menopause is from 40 years to 60 years! (Way to go Ria!) Anything below age 40 would be classified as premature and would be subject to investigation.

Clearly the menopausal transition signifies an end to the ability to reproduce naturally ( I have to add that as those crazy Italians are forever pushing the boundaries with ART ....and I'm not talking Michelangelo here...but Artificial Reproductive Techniques). This fact on its own can often result in distress and a feeling of loss....or a sigh of relief and a burden lifted!It is, however, the physical symptoms, signs and physiological changes that make this phase so important

First a riddle: What do women and killer whales have in common? ...... ( I sense I may be treading on dangerous round with this one! ) ....The answer is: Menopause a significant time prior to a natural demise (Pilot whales too, but that would have ruined the riddle)

Now some philosophical anthropology: Woman potentially undergo menopause at mid life to prevent competition with their offspring ...who are now also reproducing. Careful study of indigent and tribal custom will note that it is the menopausal women that tend the young while the women work in the fields (bedroom/kitchen) and the men hunt or fight (play with the remote/drink beer with other men).

And some physiology: a woman is born with a finite number of oocytes (around 400 000) in the ovaries. Over the years the numbers fall dramatically until there are essentially too few left to ovulate. The pituitary gland of the brain produces a substance called Follicle Stimulating Hormone or FSH which stimulates the oocytes to develop. These oocytes in turn produce estrogen which prepares the lining of the womb for a potential pregnancy and by means of feedback, suppresses FSH release and precipitates a pituitary surge of Luteinising Hormone or LH. This hormone triggers release of the ovum. As oocyte numbers diminish, estrogen levels fail to suppress FSH and the levels remain consistently high (above 30 IU/L). This is then the biochemical marker for menopause.....This is of course important if your gynaecologist has for whatever reason, deprived you of your womb.

Important Downloads

International Guidelines for Mid-life Health

Recommendations for Clinical Care of Midlife Women

Now on to symptoms:

The bodies temperature regulating mechanism is situated in the hypothalamus, intimate next door neighbour to the pituitary. The persistently high FSH plays havoc with the mechanism, resulting, among other things, in the release of stress hormones such as adrenalin and nor-adrenalin which in turn causes sweating, vasodilation and palpitations. Hot flushes / flashes last anything between 30 seconds and 10 minutes and tend to diminish with years from menopause. About 85% of women will be afflicted to varying degrees by this phenomenon. Most women will experience a natural cessation over time. The good news is that 15% of women will never experience a hot flush, the bad news is that 15% of women will have them for good!

Low estrogen levels affect the skin. Estrogen is largely responsible for skin turgor or hydration ...that thing that gives women soft, smooth skin and men that craggy, Marlboro look. So, menopause means more laugh lines and crows feet. It also means thinning of the vaginal skin and dryness. Combine this with a concomitant reduction in testosterone levels and we have very bad news in the bedroom.

Changes in hormones traditionally cause emotional mayhem ( I have a friend who habitually refers to his wife's pre-menstrual phase as 'mad cow disease'...in confidence to me, of course!) so its not hard to imagine the effect of changes as profound and permanent as menopause. There are changes in the levels of neurotransmitters in the brain which can lead to depression, aggression, irritability or plain and simple irrationality!

More disturbingly is an acceleration in bone loss and an increase in the risk of vascular disease including heart attacks. The lipid profile often becomes less favourable and an exacerbation of joint pains and stiffness is not uncommon.

So what to do?

The adage of 'if it doesn't itch, don't scratch it' holds true for menopause too. Menopause is a natural occurrence and not a disease. Our extended life-span is however a new phenomenon and a knowledge of the subject, it's physiology and effects are essential. From a medical point of view, its important to ask the questions ... Are you experiencing 'hot flushes' or sweating unduly at night? Is this affecting your quality of sleep? Have you lost interest in your partner (for no good reason that is) and is sex painful? Do you experience painful joints or have you (or others) noticed a change in mood or patience?

There are good menopausal questionnaires that can help you assess your own status

To treat or not to treat:

That is the question!
Menopausal management with hormones was dealt a significant and largely unfair blow in 2002 with the preliminary results from the Woman's Health Initiative trail and compounded by the Nurses study. These studies showed an increase in breast cancer, heart attacks and strokes in users. To be fair, these studies heightened awareness and lead to vociferous debate and analysis which has benefitted knowledge. The initial findings, however, scared millions of women and thousands of physicians away from a very effective form of therapy and fueled an explosion of sales for the naturopathic and herbal industries alike

Where are we in 2016? :

Hormones taken appropriately in the perimenopause and early post menopause, say up to age 60, reduce the incidence of breast cancer, heart disease, colon cancer, osteoporosis and sexual dysfunction and do not cause an increase in thrombosis or stroke.


Dr Douglas Seton, Obestetrician & Gynaecologist Knysna © 2017

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