ust like the adage "once a man, twice a child", every female, if she lives long enough will have to go through what is known as menopause which is also known as the 'change of life'. But it's not a one-size-fits-all change; menopause affects women differently, with hot flashes and night sweats being the most commonly discussed symptoms. However, there many other symptoms that can impact a woman's quality of life, and there are a variety of methods women can try to manage the often frustrating and life-altering symptoms.
Natural menopause is defined as the permanent cessation of menstrual periods, determined retrospectively after a woman has experienced 12 months of amenorrhea (the absence of menstruation) without any other obvious pathological or physiological cause. Menopause before age 40 is considered abnormal and is referred to as primary ovarian insufficiency (premature ovarian failure).
The menopausal transition or perimenopause begins on average, four years before a woman's final menstrual period and includes a number of physiologic changes -- irregular menstrual cycles, marked hormonal fluctuations, hot flashes, sleep disturbances, mood symptoms, vaginal dryness, changes in libido, bone demineralization and changes in lipid profile.
According to Dr. Lorne Charles, obstetrician and gynecologist, while menopause is a frustrating transition period for women, there are many things that they can do safely to mitigate the effects of menopause. He noted that menopause is generally viewed as a taboo topic as there is a lot of apprehension concerning the subject matter, and sometimes even distress when the word 'menopause' is mentioned.
Speaking at a recent Doctors Hospital Distinguished Lecture Series, Dr. Charles tried to place menopause into a more positive context. He said the only reason it is talked about today in the first instance is due to human life expectancy increasing over the years.
"If you wind the clock back 200 years, many women would not have made it to menopause, so with increased life expectancy in the modern era comes transitions that we would have never seen before and it's all part of life, and it's all about inquiring the knowledge about these transitions and managing them consciously so that you have the most healthy and most disease-free life possible," said the physician.
According to the doctor, who practices out of all major medical facilities on the island, the science of menopause is not clearly understood, but the most common belief is the minute a fetus is conceived and the sex is determined, the female fetus has a fixed number of eggs (follicles) that may ultimately unite with sperm to produce a new human being at the appropriate time. He said a female starts out with approximately two million eggs and by the time she is born, the number of eggs has already reduced to one million. By the time girls reach puberty, their eggs number at 500,000; with every subsequent menstrual cycle, one egg is released and the number reduces. Throughout a female's life, the doctor said, said there is a progressive depletion of follicles, which are ultimately depleted to the point of a conspicuous hormonal transition, which is what menopause is as a concept.
"Natural menopause is defined as the permanent cessation of menstrual periods, determined retrospectively after a woman has experienced 12 months of amenorrhea without any other obvious pathological or physiological cause. Menopause before the age of 40 is considered to be abnormal."
Average age
According to Dr. Charles, the average age a woman should expect to go through menopause is 51, although the age range can vary between 45 and 55 years old.
"If you are 45 years or older and you have not had a menstrual period in 12 months, there is a good chance that you are menopausal. Most women in this group do not need any lab testing to confirm menopause, especially if they are having symptoms such as hot flashes or vaginal dryness.
Prior to menopause, women will go through a pre-menopausal period that includes the late reproductive years in the 40s when menopause has not yet arrived but women may start to have changes that are indicative of its coming. Women then transition into the menopausal stage (peri-menopause), which Dr. Charles believes is very noticeable in many women, and which is divided into two segments -- early transition and late transition -- before menopause eventually takes place.
During the early transition, women typically first notice a lengthening in the intermenstrual interval (in contrast to the shortening that occurs in the late reproductive years. Normal intermenstrual interval during the reproductive years is 25 to 35 days; during the menopausal transition this may increase to 40 to 55 days.
During late transition, after the initial lengthening of intermenstrual interval, women develop more dramatic menstrual cycle changes with skipped cycles, episodes of amenorrhea and an increasing frequency of anovulatory cycles. According to the doctor, this stage lasts anywhere from one to three years before the final menstrual period.
Menopause timing
Although the median age at natural menopause is 51.4 years, according to Dr. Charles, there is considerable variability around the onset of menopause, which affects five percent of women after age 55, five percent between ages 40 and 55 and 90 percent between age 45 and 55. Timing is affected by a number of factors -- genetics, ethnicity, smoking and whether the woman has had a hysterectomy.
"Usually in families [mothers and daughters], the females have similar lengths. It varies among races as well. Smoking can bring about menopause two years earlier, and hysterectomy - once you remove the ovaries, menopause is instantaneous. But studies have shown, even if you leave the ovaries in with the uterus absent, by someone unknown mechanism, it also brings on menopause."
The most common symptom during the menopausal transition are hot flashes which he said occur in up to 80 percent of women in some cultures. A hot flash typically begins as a sudden sensation of heat centered on the upper chest and face that rapidly becomes generalized. The sensation of heat lasts from two to four minutes, is often associated with profuse perspiration and occasionally palpitations, and is sometimes followed by chills and shivering and a feeling of anxiety. Hot flashes usually occur several times per day, although the range may be from only one or two each day to as many as one per hour during the day and night. Hot flashes are particularly common at night. When hot flashes occur at night, they are typically described as night sweats.
According to the physician, only 20 to 30 percent of women seek medical attention for treatment of hot flashes, even though more than 80 percent of them will have them for more than one year. Untreated, hot flashes stop spontaneously within four to five years of onset in most women. He said that some women have hot flashes that persist for many years, with nine percent reporting persistent symptoms after age 70.
"The hot flashes in themselves aren't harmful, but they're distressing," he said.
A distressing feature of hot flashes is their tendency to disrupt sleep due to them occurring more frequently at night. Women may experience sleep disturbances even in the absence of hot flashes. During the transition to menopause, some women begin to have trouble falling asleep or staying asleep, even if night sweats are not a problem. The estimated prevalence of difficulty sleeping based on two longitudinal
cohort studies was 32 to 40 percent in the early menopausal transition, increasing to 38 to 46 percent in the late transition.
Sleep disturbances
"Many of the phenomenon that women experience overlap. If you wake up in the night with hot flashes, that will result in a sleep deficit. You're going to feel tired the next day, maybe a bit cranky, not motivated to work. True sleep disturbances exist in menopause, but often times it's a mixed issue, resulting from the other symptoms, the hot flashes etcetera. That is also a common phenomenon that, in turn, leads to fatigue, in some instances depression,
menstrual migraines. And all of this is related to the changes in hormones. How the body works is that if there is a change in hormonal levels that creates a symptom. Once a level remains consistent, the symptoms tend to subside, so all of this tumultuous experience is really for the transition. After a woman becomes established in menopause it tends to go away in the majority of cases.
Let's talk about sex
Apart from the hot flashes, Dr. Charles said the less discussed symptom, which is nonetheless significant is urogenital atrophy - the modern term for what was called atrophic vaginitis.
Menopause leads to a 95 percent reduction in estrogen production, a key hormone in females. The drop in estrogen concentration, exacerbated by the normal aging process, is responsible for the adverse changes seen with urogenital atrophy.
"The vagina goes through changes -- there is dryness, less secretion during sexual arousal, less blood flow, less glycogen, which provides a nutrient for a particular bacteria which gives a vagina its acid pH and that acid environment fends off some infections. But with the withdrawal of that, the vagina becomes more prone to infection. It becomes less capable of handling friction, sexual activity. There's loss of elasticity. The vagina is no longer able to stretch as it would have," said the doctor.
"[Estrogen] is a dominant hormone throughout a female's reproductive life, and that is the hormone that is withdrawn at menopause, so that is why there are so many symptoms for a female, because it is an essential part of her life prior to that point," he said.
According to the doctor, estrogen loss at menopause is constant and is there to stay; the loss of vaginal function and atrophy will be continuous and progressive.
"Ultimately there will be shortening and narrowing of the vaginal canal, thinning of the wall and it's going to be more susceptible to thinning and bruising, and all of this leads to a potentially vicious cycle if the woman is not cautious, because that leads to less sexual activity which makes the issue worse. The remedy for it involves frequent sexual activity. So, if there is a vicious cycle where the woman is apprehensive because of the changes and it's causing pain and she's not going to have sex she's going to make it worse and really complicate the issue."
The gynecologist/obstetrician said a lot has been done to find remedies to treat hot flashes -- with estrogen being the drug of choice and a "fad" for a while. Remembering his time at medical school, Dr. Charles believes hormone replacement therapy (HRT) became the new fountain of youth before a study showed that it put women at increased risk for breast cancer and endometrial cancer.
"Although exceptions can be made for estrogen therapy based on some extreme cases with women having hot flashes, I personally don't practice it," he said. "My reasoning for that is that separate from breast cancer, there are other issues that estrogen can cause in a female while trying to relieve those symptoms, and it's too difficult to assess who is at risk versus who is not."
Dr. Charles said many women do not discuss menopause as an issue with their healthcare provider. According to him, in The Bahamas, gynecologists generally do not highlight menopause as an issue because patients do not complain about it; most people believe it's a normal part of the aging process and don't complain. But he said it does not have to be that way.
Vaginal atrophy
When atrophy really sets in, it can create discomfort even in the absence of sex. The vagina can feel irritated, like a chapped lip with dryness and pain which Dr. Charles said can be distressing.
The first line of treatment for vaginal atrophy or dryness is moisturizers and lubricants. According to Dr. Charles, through regular use of vaginal moisturizing agents, symptoms of vaginal dryness can be managed, however, while the agents may improve coital comfort and increase vaginal moisture, they do not reverse most atrophic vaginal changes. As such, those products are useful mostly for women with mild symptoms.
Women who are sexually active with a partner have fewer symptoms related to vaginal atrophy.
"Since vaginal atrophy results in a loss of tissue elasticity, in addition to lubrication, this benefit likely derives from mechanical stretching of the vulvovaginal tissue or increased vaginal blood flow."
The obstetrician/gynecologist said low dose vaginal estrogen therapy is the most effective treatment for moderate to severe symptoms of vaginal atrophy. The therapy restores the lining of the vagina and recreates lubrication, treating the problem of dryness effectively; the benefits to the urinary tract are realized with estrogen creams in the vagina. That use of estrogen therapy is appropriate for women with symptoms of vaginal atrophy in the setting of low estrogen levels, provided that there are no contraindications to the therapy -- women with estrogen-dependent tumors. Dr. Charles said vaginal estrogen therapy leads to restoration of the normal vaginal pH and microflora, increased vaginal secretions and decreased vaginal dryness.
Prior to initiating vaginal estrogen, there are some conditions that should be excluded. Women with postmenopausal bleeding should be evaluated for endometrial hyperplasia or cancer; women with urinary tract symptoms should be evaluated for urinary tract infection or other conditions such as interstitial cystitis, or urinary tract malignancy.
"Low dose vaginal estrogen therapy may be used indefinitely, based on the low risk of adverse effects, although clinical trials to date have not followed women beyond one year," he said.
Cognitive changes and osteoporosis
According to the doctor, women often describe problems with memory loss and difficulty concentrating during the menopausal transition and menopause.
"There can be some cognitive changes in menopause. It's not known necessarily that it's due to menopause itself, or if it's just the aging process, but there could be memory loss, difficulty concentrating after menopause, and it's thought to be related mostly to the transition which is the peri-menopausal period. It could be a complex combination of factors," he said.
The other big concern with menopause is osteoporosis, which is characterized by low bone mass, micro-architectural disruption and skeletal fragility, resulting in decreased bone strength and an increased risk of fracture. Dr. Charles believes that the majority of postmenopausal women with osteoporosis have bone loss related to estrogen deficiency and age. He said osteoporosis has no clinical manifestation until there is a fracture, of which vertebral fracture is the most common clinical manifestation of osteoporosis. Most of the fractures are asymptomatic and diagnosed as an incidental finding on chest or abdominal x-ray. Other fractures, like hip fractures, are relatively common in osteoporosis; hip fractures affect up to 15 percent of women and five percent of men by 80 years of age. Distal radius fractures (Colles fractures) may occur and are more common in women shortly after menopause.
Medics believe that all postmenopausal women with osteoporosis should receive adequate calcium (500 to 1,000 milligrams per day) and vitamin D (a total of 800 international units daily). Dr. Charles recommends that the first measure is lifestyle changes, which should include regular exercise, smoking cessation, counseling on fall prevention and avoidance of heavy alcohol use. In addition, affected patients should avoid, if possible, drugs that increase bone loss such as glucocorticoids.
Bisphosphanates are also recommended in the treatment of postmenopausal women older than 50 with a history of hip or vertebral fracture or with osteoporosis.
Dr. Charles said bisphosphanates are very effective, but hard to take and are extremely hard on the stomach orally. They should not be given to patients with upper gastrointestinal disease, and should be discontinued in patients who develop any symptoms of esophagitis. The alternative to the oral medication is an intravenous dose.
There are many things that can be done safely to mitigate the effects of menopause for women. Dr. Charles believes that the stage should also be seen as an opportunity, separate and apart from addressing those symptoms, for a woman to do a general medical assessment.
"Once that transition comes along, at least consciously, mammograms every year, pap smears every year, colonoscopy at age 50 and above which is associated with endometrial cancer and just generally a complete visit to the gynecologist to counsel and advise what to expect, because separate and apart from the symptoms of menopause itself and the impact it has on the body at that age and beyond, cancers are a more pertinent issue and a woman should be well educated on screening, avoidance and prevention at that age," he said.

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