MENOPAUSE

INTRODUCTION

Menopause is a term used to describe the permanent cessation of the

primary functions of the human ovaries: the ripening and release of ova and the
release of hormones that cause both the creation of the uterine lining and the
subsequent shedding of the uterine lining (a.k.a. the menses or the period).
Menopause typically (but not always) occurs in women in midlife, during their
late 40s or early 50s, and signals the end of the fertile phase of a woman's life.

The transition from reproductive to non-reproductive is the result of a

major reduction in female hormonal production by the ovaries. This transition is
normally not sudden or abrupt, tends to occur over a period of years, and is a
natural consequence of aging. However, for some women, the accompanying
signs and effects that can occur during the menopause transition years can
significantly disrupt their daily activities and their sense of well-being. In
addition, women who have some sort of functional disorder affecting the
reproductive system (i.e. endometriosis, polycystic ovary syndrome, cancer of
the reproductive organs) can go into menopause at a younger age than the
normal timeframe; the functional disorders often significantly speed up the
menopausal process and create more significant health problems, both physical
and emotional, for the affected woman.

The word "menopause" literally means the "end of monthly cycles" from
the Greek word pausis (cessation) and the root men- (month), because the word
"menopause" was created to describe this change in human females, where the
end of fertility is traditionally indicated by the permanent stopping of
monthly menstruation or menses. However, menopause also exists in some
other animals, many of which do not have monthly menstruation; [1] in this case,
the term is synonymous with "end of fertility".

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 The date of menopause in human females is formally medically defined
as the time of the last menstrual period (or menstrual flow of any amount,
however small), in those women who have not had a hysterectomy. Women
who have their uterus removed but retain their ovaries do not immediately go
into menopause, even though their periods cease. Adult women who have their
ovaries removed however, go immediately into surgical menopause, no matter
how young they are.

Menopause is an unavoidable change that every woman will experience,

assuming she reaches middle age and beyond. It is helpful if women are able to
learn what to expect and what options are available to assist the transition, if
that becomes necessary. Menopause has a wide starting range, but can usually
be expected in the age range of 42–58.[2] An early menopause can be related to
cigarette smoking, higher body mass index, racial and ethnic factors, illnesses,
chemotherapy, radiation and the surgical removal of the uterus and/or both
ovaries.[3]

Menopause can be officially declared (in an adult woman who is

not pregnant, is not lactating, and who has an intact uterus) when there has
been amenorrhea (absence of any menstruation) for one complete year.
However, there are many signs and effects that lead up to this point, many of
which may extend well beyond it too. These include: irregular
menses,vasomotor instability (hot flashes and night sweats), atrophy
of genitourinary tissue, increased stress, breast tenderness, vaginal dryness,
forgetfulness, mood changes, and in certain cases osteoporosis and/or heart
disease.[4] These effects are related to the hormonal changes a woman’s body is
going through, and they affect each woman to a different extent. The only sign
or effect that all women universally have in common is that by the end of the
menopause transition every woman will have a complete cessation of menses.

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DEFINITIONS

Menopause means permanent cessation of menstruation at the end of

reproductive life due to loss of ovarian follicular activity

- Dutta

Menopause is defined as the time when there has been no menstrual

periods for 12 Consecutive months and no other biological or physiological
cause can be identified. It is the end of fertility, the end of the child bearing
years.

Medical dictionary

The word menopause derived from greek word; “Men – month” and
“Pausis – cessation”

And menopause literally means the end of monthly cycles

TERMINOLOGIES

Climacteric :

It is the phase of aging process during which a women passess from the
reproductive to the non reproductive stages. This phase covers 5-10 years on
either side of the menopause

Premenopause :

It is the part of the climacteric before menopause, when the menstruation

cycle is likely to be irregular

Menopausal transition :

The time from the late reproductive stage and entry into post menopause

Post menopause :
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 It is the phase of life that comes after the menopause

Peri menopause :

It is the period around menopause occurs during the years before and one
year after the last menstrual period

Pre mature menopause :

The occurrence of menopause before the age of 40 years

AGE OF MENOPAUSE

 It has been estimated that the onset of menopause usually begins between
the ages of 45-55 years, with a world wide average of about 51 years
 According to the National Family Health Survey conducted in 1998 and
1999, the mean age of onset of menopause in Indian women is about
44.3nyears. with the average life span of an women increasing in the
recent years, women will lead to one third of their life in the post
menopausal stage
 The age of menopause occurs is genetically predetermined and it is not
related to the following factors
a. Number of pregnancy and lactation
b. Use of oral pills
c. Socioeconomic condition and race
d. Height and weight
e. Age at menarche

However cigarette smoking and severe malnutrition may cause early

menopause

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CAUSES OF MENOPAUSE

The causes of menopause can be considered from

complementary proximate (mechanistic) perspectives (how it happens) or from
ultimate (adaptive evolutionary) perspectives (why it happens). The latter group
is hypotheses only.

Proximate perspective

Natural or physiological menopause occurs as a part of a woman's normal

aging process. It is the result of the eventual depletion of almost all of the
oocytes and ovarian folliclesin the ovaries. This causes an increase in
circulating follicle stimulating hormone (FSH) and luteinizing hormone (LH)
levels because there are a decreased number of oocytes and follicles responding
to these hormones and producing estrogen. This decrease in the production of
estrogen leads to the perimenopausal symptoms of hot flashes, insomnia and
mood changes. Long term effects may include osteoporosis and vaginal atrophy.

Evolutionary theories of menopause

In contrast to males, females invest more in their gametes, making them a

highly valuable resource. Selection should therefore in theory favour a quantity
of ova that would be sufficient for the female lifespan. Over-investment is
resourcefully wasteful and under-investment leads to reduced fitness. Human
females, however, spend over one third of their lifespan in a post-reproductive
phase. Possible evolutionary explanations for survival beyond reproductive
maturation range from the non-adaptive to the adaptive.

Non-adaptive hypotheses

The high cost of female investment in offspring may lead to physiological

deteriorations that amplify susceptibility to becoming infertile. This hypothesis
suggests the reproductive lifespan in humans has been optimized, but it has
proven more difficult in females and thus their reproductive span is shorter. If

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this hypothesis were true however, age at menopause should be negatively
correlated with reproductive effort and the available data does not support this.

A recent increase in female longevity due to improvements in the

standard of living and social care has also been suggested. It is difficult for
selection, however, to favour aid from offspring to parents and grandparents
Irrespective of living standards, adaptive responses are limited by physiological
mechanisms. In other words senescence is programmed and regulated by
specific genes.

Adaptive hypotheses
The mother hypothesis

The mother hypothesis suggests that menopause was selected for in

humans because of the extended development period of human offspring and
high costs of reproduction so that mothers gain an advantage in reproductive
fitness by redirecting their effort from new offspring with a low survival chance
to existing children with a higher survival chance.

The grandmother hypothesis

The Grandmother hypothesis suggests that menopause was selected for in

humans because it promotes the survival of grandchildren. According to this
hypothesis, post reproductive women feed and care for children, adult nursing
daughters, and grandchildren whose mothers have weaned them. Human babies
require large and steady supplies of glucose to feed the growing brain. In infants
in the first year of life, the brain consumes 60% of all calories, so both babies
and their mothers require a dependable food supply. Some evidence suggests
that hunters contribute less than half the total food budget of most hunter-
gatherer societies, and often much less than half, so that foraging grandmothers
can contribute substantially to the survival of grandchildren at times when
mothers and fathers are unable to gather enough food for all of their children. In

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general, selection operates most powerfully during times of famine or other
privation. So although grandmothers might not be necessary during good times,
many grandchildren cannot survive without them during times of famine.
Arguably, however, there is no firm consensus on the supposed evolutionary
advantages (or simply neutrality) of menopause to the survival of the species in
the evolutionary past.

Indeed, analysis of historical data found that the length of a female’s

post-reproductive lifespan was reflected in the reproductive success of her
offspring and the survival of her grandchildren.Interestingly, another study
found comparative effects but only in the maternal grandmother – paternal
grandmothers had a detrimental effect on infant mortality (probably due to
paternity uncertainty). Differing assistance strategies for maternal and paternal
grandmothers have also been demonstrated. Maternal grandmothers concentrate
on offspring survival, whereas paternal grandmothers increase birth rates.

A problem concerning the grandmother hypothesis is that it requires a

history of female philopatry and yet present day evidence shows that the
majority of hunter-gatherer societies arepatriarchal. In addition, all variations on
the mother, or grandmother effect fail to explain longevity with continued
spermatogenesis in males (oldest verified paternity is 94 years, 35 years beyond
the oldest documented birth attributed to females). It also fails to explain the
detrimental effects of losing ovarian follicular activity, such
as osteoporosis, osteoarthritis,Alzheimer’s disease and coronary artery disease.

ENDOCRINE CHANGES

1. Hypothalamo – pituitory gonadal axis

During few years prior to menopause, the effective folliculogenesis is

impaired with diminished Estradiol production. As a defence mechanism,

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hypothalamo pituitory axis increases the follicular stimulating hormine and
leutinizing hormone.

However due to depletion of the ovarian follicles and increased resisitence of

follicles to the gonadotrophins, follicular stimulating hormone fails to stimulate
sufficient estradiol secretion and estradiol levels steadily declines eventually
resulting in the failure of endmetrial development and absence of uterine
bleeding.

2. Estrogens

Ther is a significant fall in the level of serum estradiol from 50-300pg/ml

before menopause to 10-20 pg/ml after menopause. With times the sources fail
to supply the precursors of estrogen and about 5-10 years after menopause sharp
fall in estrogen then the women said to be on state of true menopause

3. Androgens

After menopause the stomal cells of the ovary continues to produce

androgens because of increase in leutinizing hormone. They are produced partly
by the adrenal and partly by the ovary. Thus cumulative effect is a decrease in
estrogen and androgen ratio. This results in increased hair growth and changes
in the voice

4. Progesterone

A trace amount of progesterone detected is propably adrenal origin

5. Gonadotrophins

The secretions of both follicular stimulating hormone and leutinizing

hormone are increased are due to absent negative feed back effec of estradiol
due to enhanced responsiveness of pituitory GnRH. Follicular stimulating
hormone rises about 10-20 fold where as LH rises about 3 fold. Ultimately due

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to physiological aging GnRH and bothe follicular stimulating hormone and
leutinizing hormone decline along with decline of estrogens.

ORGAN CHANGES

 Ovaries shrink in size, become wrinkled and white. Thinning of cortex

with increasing medullary components. Stromal cells have got secretory
activity
 Fallopian tubes shows feature of atrophy. The muscle coat become
thinner and the cilia dissappear
 The uterus becomes smaller the endometrium becomes thin and atrophic
the cervical secretion becomes scanty
 Vagina becomes narrower due to gradual loss of elasticity, flatten rugae,
absence of doderline’s bacilli and the vaginal Ph becomes alkaline
 The vulva shows features of atrophy , the labia becomes flattened, pubic
hair becomes scantier and narrow introitus
 The breast fat is reabsorbed and the glands become atrophic. The nipples
decrease in size ultimately breasts become flat and pendulous
 Bladder and urethra epithelium becomes thin and more prone to infection
and damage
 Loss of muscle tone leads to pelvic cellular tissue and ligaments
supporting the uterus and vagina lose their tone
 Bones losses its mass by about 3-5% per year due to deficiency of
estrogen leads to osteoporosis

PRE MENOPAUSE

Any of the following patterns are observed

a. Sudden cessation of menstuation

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 b. Gradual hypomenorrhoea ( scanty mens) or infrequent cycles
( oligomenorrhoea)
c. Irregular with or without excessive bleeding

SIGNS AND SYMPTOMS OF MENOPAUSE

Symptoms are divided into physiological, psychological and social

I Physiological aspect

1. Vasomotor symptoms
 The characteristic symptom of menopause is ‘hot flush’. Hot flush is
characterized by sudden feeling of heat followed by profuse sweating. It
affects the chest area and spreads upwards to the facial skin and generally
lasts less than one minute
 Palpitation, weakness , fatigue
 Perspiration, cutaneous vasodilation
 Pulse rate rises 20 beats per minute
 These vasomotor changes is due to instability of hypothalamus where
thermoregulatory centre situated
2. Cental Nervous System Symptoms
 Estrogen known to regulate the synthesis and the rate of release of many
neurotransmitters
 A deficiency of estrogen reduces seratonin synthesis in the brain and
which leads to the development of insomnia during menopause
 Along with normal aging, estrogen plays a role in the decline of the
cognitive functions in the women. Dementia and mainly Alzheimer’s
disease are more common
3. Reproductive tract symptoms
 Vaginal dryness: Vaginal symptoms occur as a result of the lining tissues
of the vagina becoming thinner, drier, and less elastic as estrogen levels

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 fall. Symptoms may include vaginal dryness, itching, or irritation and/or
pain with sexual intercourse (dyspareunia). The vaginal changes also lead
to an increased risk of vaginal infections.
 Dyspareunia
 Uterine descensus
 Cystocele , rectocele and or enterocele
 Fibroids
 Loss of Libido

Sex therapists say tha low libido becomes a problem that should be
addressed only when it is perceived as a problem. "It's usually only in the
framework of a relationship that it becomes an issue" Dr. Zussman says. "It's
when there is a discrepancy in desire between the person and partner, or when
people feel there's something wrong with them because they have a low level of
desire."
Everyone experiences peaks and valleys in sexual desire, an ebb and
flow in libido that could be caused by any of a variety of factors. Occasionally,
a hormonal imbalance or prescription drug will sap sex drive. And, of course,
there's a difference between sexual drive and sexual function. Problems related
to orgasm

 Endometriosis
 Infections
 Breast Pain :Pain, soreness, or tenderness in one or both breasts often
precedes or accompanies menstrual periods but can also occur during
pregnancy, breast-feeding, and menopause. It can be resumed in a
generalized discomfort and pain associated with touching or application
of pressure to breast. Consult your doctor if the pain is severe or persists
for two months or more, also if the breast pain that is accompanied by a

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 breast lump or nipple discharge. Click here for more information
about Breast Pain. Also it is important to read about Breast Tenderness.
4. Urinary symptoms
 Urgency and frequency of urination
 Dysuria
 Urinary tact infection
 Stress incontinence that is Incontinence, especially upon Sneezing,
Laughing, UrgeIncontinence : Incontinence falls into three main
categories, although people can leak through because of a combination of
causes. First, there's stress incontinence, in which you urinate
accidentally when you laugh, cough, sneeze or exert yourself. This
happens either when the bladder neck shifts position out of reach of the
internal muscles that put pressure on it or when those muscles themselves
fail to work effectively, because of age, surgery or childbirth. The second
one is urge incontinence, in which the bladder develops a "mind of its
own," contracting and emptying whenever full despite an individual's
conscious efforts to resist. And last, overflow incontinence, in which you
completely lose the sensation that you have to go. You should see your
doctor if you urinate when you shouldn't, because you have no sensation
that your bladder is full.
 Urethral syndrome
 Itching
 Dryness

5. Cardio Vascular System symptoms

 Oxidation of low density lipoprotein and foam cell formaion cause

vascular endothelial injury and smooth muscle proliferation. All these
lead to vascular atherosclerosis changes, vasoconstriction and thrombus
for motion

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  Risk of ischemic heart disease, coronary artery disease and stroke are
increased

6. Skeletal system symptoms

 Bone mass loss and deterioration of bone tissue

 Bone loss: Rapid bone loss is common during the perimenopausal years.
Most women reach their peak bone density when aged 25-30 years. After
that, bone loss averages 0.13% per year. During perimenopause, bone
loss accelerates to about a 3% loss per year. Later, it drops off to about a
2% loss per year. No pain is usually associated with bone loss. However,
bone loss can cause osteoporosis, a condition that increases the risk of
bone fractures. These fractures can be intensely painful and can interfere
with daily life. They also can increase the risk of death.
 Bone mass increases to 5% per years during menopause
 Back pain, joint pain
 Loss of height and kyphosis
 Aching, Sore Joints, Muscles and Tendons : Aching Joints and muscle
problems is one of the most common symptoms of menopause. It is
thought that more than half of all postmenopausal women experience
varying degrees of joint pain. Joint pain is basically an unexplained
soreness in muscles and joints, which are unrelated to trauma or exercise,
but may be related to immune system effects mostly caused by
fluctuating hormone levels. It is not wise to ignore these aches and pains.
Early treatment can often bring about a cure and prevent further
development of arthritis. Getting plenty of rest, using herbal aids, eating
nutritious foods, preferably organic food, fruits and vegetables-and
avoiding known toxins and stimulants, are healthy strategies for fighting
joint pains.
 Fracture may involve the vertibral body, femoral neck or distal forearm

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6. Changes in Fingernails-Softer, Crack or Break Easier : A black or blue
nail tells the world that you and your hammer had a problem. Reddish
yellow nails demonstrate that you change your nail polish often. Nails
that split and break can be a sign that you're spending too much time with
your hands in the sink. Nails that take on a convex, spoon like appearance
may mean respiratory deficiency or simply that you're not getting enough
iron. Nibbled nails and hangnails can betray your anxiety level.
Fingernail and toenail problems are usually caused by inflammation of
the skin around the nail or by an infection. A persistently painful and
inflammed fingernail or toenail requires your doctor's attention.
7. Skin, Hair and Soft tissue
Hair Loss or Thinning, Head, Pubic, or Whole Body;
Increase in Facial Hair : Connected to estrogen deficiency, since the hair
follicles need estrogen; some women notice this before any other sign
because it is obvious. Hair loss can be sudden or gradual loss or thinning
of hair on your head or on other parts of your body. You'll notice hair in
your brush, your hair may also get drier and more brittle or notice a
thinning or loss of pubic hair. A gradual loss or thinning of hair without
any accompanying symptoms is common. However, hair loss that is
accompanied by general ill health requires your doctor's attention. The
thickness of skin decreases 1-2% per year
 ‘Purse string’ wrinkling around mouth and ‘crow feet’ around eyes are
the characteristics
 Loss of pubic and axillary hair and slight balding
 Breast atophy
 Breast tenderness
 Itching, Crawly Skin : When your estrogen levels drop, your collagen
production usually slows down as well. Collagen is responsible for
keeping our skin toned, fresh-looking, resilient. So when you start
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 running low on collagen, it shows in your skin. It gets thinner, drier,
flakier, less youthful-looking.
This is another of those symptoms of menopause that
makes you feel older before your time and, in this case, it's clear why.
You may look a little older than you used to. Worst, this sign often shows
up early in menopause. Collagen loss is most rapid at the beginning of
menopause. It is possible that premature menopause also leads to more
rapid collagen loss.
 tingling of skin
 Dryness

8. Digestive Problems, Gastrointestinal Distress,

Indigestion, Flatulence, Gas Pain, Nausea
Changes in gastrointestinal function with excessive gas production,
gastrointestinal cramping and nausea.A certain amount of flatulence is perfectly
natural, but people who switch to a healthy diet sometimes worry unnecessarily
that they're producing too much. So if you're eating lots of whole grains, fruits
and vegetables, which means a healthy diet, it's likely that your digestive system
is churning out a healthy amount of gas. If you have gas and stomach or
abdominal pain for more than three days, or if the pain is more severe than
before, you should see your doctor immediately.

 Burning Tongue, Burning Roof of Mouth, Bad Taste in Mouth: Change

in Breath Odor :Burning mouth syndrome is a complex, vexing condition
in which a burning pain occurs on your tongue or lips, or over widespread
areas involving your whole mouth without visible signs of irritation.
The disorder has long been associated with a variety of other
conditions, including menopause. It affects up to 5 percent of U.S. adults,
women seven times more often than men. It generally occurs after age 60.
But it may occur in younger people as well. If you have persistent pain or

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 soreness in your tongue, lips, gums or other areas of your mouth, see your
doctor.
 Weight gain: A three year study of healthy women nearing menopause
found an average gain of five pounds during the three years. Hormonal
changes and aging are both possible factors in this weight gain.
 Gum Problems, Increased Bleeding :The most common gum problem is
bleeding, and it's a sign of inflamed gums, or what dentists call gingivitis.
But gingivitis is just the overture for more serious problems.
Bleeding and sore gums are the same as most health problems:
If you catch them before they get too bad, they're easy to reverse.
"Gingivitis is absolutely reversible in the earlier stages," says Dr.
Allen.To put bleeding gums in reverse, put your hands on floss and a
toothbrush. But make sure to hold that toothbrush the right way. You
have to worry if sores develop under your dentures or if there is swelling,
puffiness, soreness in your bleeding gums. Take advice from your doctor
in these cases. Click here for more information about gum
problems during menopause.

 Sudden Bouts of Bloat :A puffy bloated feeling that seems to come out of
nowhere; usually you'll notice bouts which are periodic increases in fluid
retention and abdominal distension.
Doctors call the gassiness, bloating and discomfort that occur
after eating dairy foods lactose intolerance. It means your stomach is
unable to digest the lactose -or milk sugar- in dairy foods. Unfortunately,
most adults have this problem to some degree, according to Jay A.
Perman, M.D., as people age, they produce less lactase -the enzyme
needed to digest lactose. Without lactase, the undigested milk sugar
ferments and gases form. The trapped gas makes your stomach bloat. If

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 you have persistent, unexplained bloating or stomach pain for more than
three days, then you should contact you doctor.

9. Increase in Allergies : Many types of allergy have their basis in hormone

reactions. This is particularly true of ladies who experience increasing
symptoms as they undergo hormone changes, usually in their late
twenties or after the babies are born. Hormone imbalance is a type of
allergic reaction experienced by women from before puberty to old age. It
is a heightened reaction to the normal function of hormones.

II. Psychological aspect

 Anxiety: Anxiety can be a vague or intense feeling caused by physical or

psychological conditions. A feeling of agitation and loss of emotional
control that may be associated with panic attacks and physical symptoms
such as rapid heartbeat, shortness of breath and palpitations. The
frequency of anxiety can range from a one-time event to recurring
episodes. Early diagnosis may aid early recovery, prevent the disorder
from becoming worse and possibly prevent the disorder from developing
into depression. Click here for more information about Anxiety.

 Irritability :A significant change in mood for an extended period of time

associated with loss of interest in usual activities, sleep and eating
disorders, and withdrawal from family and friends. "Occasional
irritability is a normal part of being human," says Paul Horton, M.D., a
psychiatrist in Meriden, Connecticut. "But irritability also can go hand in
hand with almost any illness. Very often, people who are falling ill will
become irritable but don't know why."
If your irritability persists more than a week and is adversely
affecting your job performance and relationships with your family,

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 friends and co-workers, better see your doctor. Click here for more
information about irritability during menopause.
 Depression ; Feelings of sadness can be normal, appropriate and even
necessary during life's setbacks or losses. Or you may feel blue or
unhappy for short periods of time without reason or warning, which also
is normal and ordinary. But if such feelings persist or impair your daily
life, you may have a depressive disorder. Severity, duration and the
presence of other symptoms are the factors that distinguish ordinary
sadness from a depressive disorder. This is called: Depression, or
irritability, which is a significant change in mood for an extended period
of time associated with loss of interest in usual activities, sleep and eating
disorders, and withdrawal from family and friends.
Depression can happen to anyone of any age. It afflicts almost
19 million Americans each year, and up to one in five American women
will suffer from clinical depression at some point in her life. Women are
two to three times more likely than men to suffer from depression. Many
women first experience symptoms of depression during their 20s and 30s.
 irritability due to altered hormonal levels or disturbed sleep cycles or
vasomotor changes
 Headache : Though headaches can be caused by a variety of factors such
as muscle tension, drinking too much alcohol or can occur with common
illnesses such as the flu.
During the early stages of menopause, you may find that
you're getting more and worse headaches. This is often caused by your
dropping estrogen levels. Many women with regular menstrual cycles get
headaches just before their periods or at ovulation. These headaches,
sometimes called "menstrual migraines" occur when estrogen levels
plunge during the menstrual cycle. So, when your body begins slowing
down its production of estrogen due to premature menopause, you may

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 wind up getting one of these hormonally-induced headaches. Severe
headaches that are accompanied by confusion or high fever can indicate a
serious health condition and require your doctor's immediate attention.
 Menopause Sleep Disorders (With or Without Night
Sweats): If you're waking up a lot at night, tossing and turning, and
generally suffering with insomnia, it might be connected with
menopause. When you begin going through menopause, you may find
that your sleep is less and less restful, when you sleep at all.
In the past, doctors believed that interrupted sleep was a
consequence of night sweats, but recent studies indicate that you can also
have problems with sleep that aren't connected to hot flashes. Typically,
the frequency of insomnia doubles from the amount you may have had
before you entered premature menopause. And research also indicates
that women begin to experience restless sleep as many as five to seven
years before entering menopause. Again, though, the problem is
recognizing that the insomnia you're suffering from has its roots in
changes in your hormone levels.
 Mood Swings, Sudden Tears : A person with a mood problem is like a
human roller coaster. One minute he's up, the next minute he's down. He
never seems to be able to get off the ride. His mood swings are intense,
sudden and out of control. Chronic and severe mood swings are a
psychological disorder, a health problem every bit as real as a physical
ailment. In fact, sometimes they're the result of a physical problem, like a
premenstrual syndrome. And just like a physical problem, they can be
treated. You should contact your doctor to get more advice.
 dysphagia
 Memory loss :Memory loss affects most people in one way or another.
More often than not, it is a momentary memory lapse; nothing to worry
about - it happens to the best of us. However, when memory lapses begin

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 to become a regular occurrence, it is wise to dig a little deeper and seek
medical advice.
Women approaching menopause often complain of memory loss
and an inability to concentrate. Misplaced car keys, skipped
appointments, and forgotten birthdays, but these memory lapses are a
normal symptom of menopause. It is mostly associated with low levels of
estrogen and with high stress levels.
Difficulty Concentrating, Disorientation, and Mental Confusion:
During early menopause, many women are troubled to find they have
difficulty remembering things, experience mental blocks or have trouble
concentrating. Not getting enough sleep or having sleep disrupted can
contribute to memory and concentration problems.
If your doctor determines that your disorientation isn't caused
by a serious medical condition, then you might consider these
possibilities: -Investigate your drugs. -Disorientation is a side effect of
some drugs. -Learn to relax. -Practice stress-reduction techniques, such as
deep breathing exercises, yoga and meditation and try to be physically
active on a regular basis.
 Fatigue : "Fatigue is second only to pain as the most common symptom
doctors see in patients," says David S. Bell, M.D., a chronic fatigue
researcher at Harvard Medical School and the Cambridge Hospital in
Massachusetts. "One-fourth of all Americans will have long episodes of
lethargy and tiredness." Particularly common in women undergoing the
menopausal transition, chronic fatigue can have a drastic impact on daily
life, putting a strain on relationships, work productivity, and quality of
life.
Fatigue, one of the most common menopause symptoms, is
defined as an ongoing and persistent feeling of weakness, tiredness, and
lowered energy level. This should be distinguished from drowsiness,

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 which implies an actual urge to sleep. Fatigue involves lack of energy
rather than sleepiness. If the fatigue comes on suddenly, it could be a sign
of crashing fatigue. To learn more about Crashing Fatigue, click here.
Other characteristics may include apathy, irritability, and decreased
attention.
 Dementia / forgetfullness
 Tempting to drink alcohol
 Tiredness
 Inability to concentrate
 Dizziness, Light Headedness, Episodes of Loss of Balance :Dizziness is a
transient spinning sensation and/or a feeling of lightheadedness or
unsteadiness; also, the inability to maintain balance upon standing or
walking. Dizziness is a symptom of many medical conditions. There are
things that people can do to cope with their dizziness. But if you
experience an unexplained dizzy spell, see your doctor, because you can't
be sure if it's a trivial problem or a symptom of a serious illness.
 Tingling Extremities : This may feel like the "creepy-crawlies" as if bugs
were walking all over you, a burning sensation like an insect sting, or just
super-sensitivity. In most cases, tingling is harmless. It usually occurs
after you pinch a nerve or press on an artery and reduce blood flow in
your arm or leg causing it to "fall asleep." When you change body
position and relieve the compression, the tingling quickly goes away. But
tingling can also be a symptom of any number of problems, including
anxiety, a herniated spinal disk, poor blood circulation, diabetes, heart
disease, stroke, arthritis, multiple sclerosis, carpal tunnel syndrome or a
tumor. Any unexplained tingling that affects an entire side of your body
or is accompanied by muscle weakness, warrants immediate medical
attention.

21
  Panic Disorder, Feelings of Dread, Apprehension, Doom : A significant
and debilitating emotional state characterized by overwhelming fear and
anxiety. These feelings can be vague or intense caused by physical or
psychological conditions. The frequency can range from a one-time event
to recurring episodes. If your life is totally disrupted by this symptom,
better contact your doctor. Click here for more information about panic
disorderduring menopause.

III. Social aspects

 Lonliness
 Social isolation
 Lack of interest in family, friends and the society

DIAGNOSTIC EVALUATION

 History collection – presence of typical symptoms along with

amenorrhoea for more than 12 months
 Physical examination – appearance of menopausal symptoms ‘hot
flushes’ , night sweats
 Serum FSH levels – excess of 30 IU confirms the diagnosis
 Serum estradiol - < 20 pg/ml
 Vaginal cytology – features of low estrogen
 Pelvic examination – indicate the changes in the vaginal lining
 Pap smear – to detect precancerous lesions and hidden tumours
 Bone density studies - to detect osteoporosis
 Lipid profile
 Thyroid profile – because thyroid disease can mimic the symptoms of
menopause

22
TREATMENT

The treatment includes

1. Non hormonal treatment

2. Hormonal replacement therapy

1. NON HORMONAL TREATMENT

Nutritious diet : balanced with calcium and protein is helpful

Supplementary calcium : daily intake of 800-1000 mg can reduce osteoporosis

and fracture

Exercise : walking, jogging

Vitamin D : supplementation of vitamin D3 (400IU/ day) along with calcium

can reduces osteoporosis and fractures. Exposure to sunlight enhances the
synthesis of cholesterol (vitamin D3) in the skin

Biophosphanates : prevent osteoclastic bone resorption Alendronate,

pamidronate, risedronate are the drug of choice

Fluoride : prevents osteoporosis and increases bone matrix. It is given at a dose

of 1mg / kg for short term

Calcitonin : inhibits bone resorption. 50-100IU daily given by subcutaneous

injection

Selective estrogen receptor modulators (SERMs) : are tissue specific in action.

Raloxifene has shown to increase bone mineral density, reduces serum LDL and
rises HDL2 level. And also inhibits the estrogen receptors at the breast and
endometrial tissues thus it prevents breast and endometrial cancer.

23
Hypnotics , Tranquilizers and Sedatives : usually prescribed. These can allay
the psychologic symptoms but cannot relieve true symptoms

Clonidine : an alpha adrenergic agonist may be used to reduce hot flushes

Thiazides : reduce urinary calcium excretion

1. HORMONE REPLACEMENT THERAPY ( HRT )

The hormonal replacement therapy is indicated in menopausal women to

overcome the short term and long term consequences of estrogen deficiency

The OBJECTIVE of HRT is to ensure the potential benefits and minimize

the risks.

Indications of HRT

 Hormone replacement therapy is generally adviced for women who are

symptomatic and are at high risk of developing cardiovascular disorders,
osteoporosis, alzhemier’s disorders or colonic cancer
 Premature ovarian failure
 Gonadal dysgenesis
 Surgical radiation menopause

Contraindications of HRT

 Undiagnosed genital tract bleeding

 Estrogen dependent cancer
 History of venous thromboembolism
 Active liver disease
 Gall bladder disease

Benefits of HRT

 Improvement of vascular symptoms (70%-80%)

24
  Improvement of urogenital atrophy
 Increase in bone mineral density ( 2%-5%)
 Decreased risk in vertebral and hip fractures (25%-50%)
 Reduction in colorectal cancer ( 20%)
 Possibly cardio protection

Various forms of HRT

a. Oral estrogen regime

Commonly used estrogens are conjugated equine estrogen 0.625 mg or 1.25

mg is given daily for women who had hysterectomy. Oral estrogen therapy
causes risk in plasma estrone levels

b. Estrogen and cyclic progestin

For a women with intact uterus estrogen is given continuously for 25 days
and progestin is added for last 12- 14 days. Because women with intact uterus
only estrogen therapy leads to endometrial hyperplasia and endometrial
carcinoma.

c. Subdermal implants

Implants are inserted subcutaneously over the anterior abdominal wall using
local anesthesia. 17 beta estradiol implants 25mg – 50mg or 100mg are
available and can be kept for 6 months. This method suitable mostly for patients
after hysterectomy

d. Percutaneous estrogen gel

1gm applicator of gel , delivering 1mg of estradiol daily, is to be applied on

to the skin over the anterior abdominal wallor thighs. It maintains blood level
of estradiol 90-120pg/ml

25
 e. Trans dermal pouch

It contains 3.2mg of beta estradiol , releasing about 50 microgram of estrdiol

in 24 hours. It should be applied below the waist line and changed twice a week.
Skin reaction, irritation and itching have been noted with their use

f. Vaginal cream

Conjugated vaginal estrogen cream 1.25mg daily is very effective specially

when associated with vaginal atrophy

Tibolone is a steroid, a dose of 2.5mg given having weakly estrogenic ,

progesterone and androgenic properties

Monitoring prior to and during HRT

A base level parameter of the following and their subsequent checkup

annually are mandatory

 Blood pressure recording

 Breast examination
 Pelvic examination
 Cervical cytology
 Pelvic ultrasonography to measure endometrial thickness
 Mammography
 Serum level of estradiol

Risks of hormone replacement therapy (HRT)

 Endometrial cancer
 Breast cancer
 Venous thromboembolic disease
 Coronary heart disease
 Lipid metabolism

26
  Dementia
 Alzheimer’s disease

ALTERNATIVES TO HARMONAL THERAPY

There are some medications available to help with mood swings, hot flashes,
and other symptoms. These include low doses of antidepressants such
as paroxetine (Paxil), venlafaxine (Effexor), bupropion (Wellbutrin),
and fluoxetine (Prozac), or clonidine, which is normally used to control high
blood pressure. Gabapentin is also effective for reducing hot flashes.

Other therapies

 Lack of lubrication is a common problem during and after perimenopause.

Vaginal moisturizers can help women with overall dryness, and lubricants
can help with lubrication difficulties that may be present during intercourse.
It is worth pointing out those moisturizers and lubricants are different
products for different issues: some women feel unpleasantly dry all of the
time apart from during sex, and they may do better with moisturizers all of
the time. Those who need only lubricants are fine just using the lubrication
products during intercourse.

 Low-dose prescription vaginal oestrogen products such as oestrogen creams

are generally a safe way to use oestrogen topically, in order to help vaginal
thinning and dryness problems (see vaginal atrophy) while only minimally
increasing the levels of oestrogen in the bloodstream.

 In terms of managing hot flashes, lifestyle measures, such as drinking cold

liquids, staying in cool rooms, using fans, removing excess clothing layers
when a hot flash strikes, and avoiding hot flash triggers such as hot drinks,

27
 spicy foods, etc., may partially supplement (or even obviate) the use of
medications for some women.

 Individual counselling or support groups can sometimes be helpful to handle

sad, depressed, anxious or confused feelings women may be having as they
pass through what can be for some a very challenging transition time.

 The bisphosphate drug alendronate can help prevent loss of bone mass,
reducing the risk of fractures, according to a Cochrane review of studies.
This applies both to women that have suffered bone loss but have not yet
suffered fractures, and women that have suffered both bone loss and
fractures.

LIFESTYLE CHANGES

Lifestyle advice at menopause. Many women only see health care practitioners
for advice about their health when they are approaching or are at the
menopause. They have concerns about living well for the rest of their lives.
Some say that they do not want to grow old the way their mother or
grandmother did. When women present with these concerns, it is a good
opportunity to review their lifestyle with them. Women want sensitive, unbiased
and up-to-date information and an explanation of normal menopausal changes.
General health advice is the same throughout a woman’s life, but there is a
particular emphasis on certain factors for menopausal woman: mainly the
effects that the menopause has on cardiovascular and bone health as well as the
day-to-day symptoms.

The key areas to cover are:

✦smoking status

28
✦diet and nutrition

✦exercise

✦alcohol consumption

✦weight control

✦psychological aspects of the menopause

✦breast and cervical screening

✦reducing the impact of symptoms.

Stopping smoking

Smoking has many negative effects:

✦cigarette smoking can increase the risk of having a heart attack by two or

three times. Coronary heart disease (CHD) is the most common cause of death
in women

✦smokers are 1.5 times more likely to have a stroke

✦smoking tends to increase blood cholesterol levels

Diet and nutrition

29
Nutrition is important for all women around the time of the menopause, and a
healthy, balanced diet should below in fat, low in salt and rich in calcium.

Facts about nutritional health – calcium and salt:

✦high salt intake is linked with the development of high blood pressure

✦hypertensives excrete higher amounts of calcium in their urine than people

with low blood pressure

✦It is thought that calcium lost in the urine is replaced through calcium stripped

from the bone, and that salt plays an important role in speeding calcium loss

✦You should be able to get all the calcium you need from a healthy diet. Adults

need 700 mg a day, although those with osteoporosis may need more

(DH, 1998)

✦vitamin D is necessary for the effective absorption of calcium from the gut,

most being obtained from direct sunlight; a smaller amount is obtained from the
diet. Supplements of 10 mcg vitamin D may be necessary for elderly and
housebound people, those on a restricted diet, and where there is little exposure
to sunlight

The following table lists foods that are valuable sources of calcium.

Food Quantity mg of calcium

30
  Milk (skimmed) 100 mls 122
 Milk (semi 100 mls 120
skimmed)
100 mls 118
 Milk (whole)
 Milk(soya) 100 mls 89

 Cheese (cheddar) 100 g 739

 Yoghurt (fruit
100 g 140
low fat)
 Ice cream (dairy) 100 g 100

 Sardines in oil 100 g 500

 Whitebait (fried)
100 g 860
 Tahini (sesame
100 g 680
paste)
 White bread 1 slice 33
 Figs (dried)
100 g 250
 Cheese omelette
100 g
 Green/french 287
beans 100 g
56

Facts about nutritional health – general:

✦diet should be high in fruit and vegetables, containing at least five portions

daily

✦ fruit and vegetables contain antioxidant vitamins and minerals which are

crucial in preventing the damaging effects of free radicals

✦smokers use antioxidants faster

31
✦you should aim for at least two portions of fish a week, one of which should

be oily fish

✦maintaining a healthy weight is important. Obesity is a major risk factor for

CHD and is associated with high blood pressure, heart attacks, heart failure and
diabetes. Women should aim for a health body mass index (BMI) of 20 – 25.

Exercise

Regular exercise is necessary to remain active, healthy and independent.

✦Physical activity reduces the both the risk of developing CHD and of having a

stroke by lowering blood pressure.

✦Exercise increases energy levels, muscle strength and bone density.

✦Exercise can reduce stress, anxiety and likelihood of depression.

✦Exercise helps weight loss and improves sleep.

✦Weight-bearing exercise such as brisk walking, dancing, skipping, aerobics,

tennis and running stimulate bone to strengthen itself.

✦Cycling and swimming are both good cardiovascular exercises.

✦Exercise should be varied and should be taken for at least 30 minutes on five

or more days of the week for maximum benefit.

Weight control

32
  It is not inevitable that women will put on weight at the menopause, but
many do.
 This is in part due to a decline in muscle mass and a subsequent slow-
down in the basal metabolic rate, without reducing the amount of food
and alcohol and while taking little or no exercise.
 Women should be advised to:

✦eat a healthy diet

✦exercise regularly; start slowly and gradually increase

✦lose extra weight slowly and steadily.

Psychological aspects

Depression, anxiety, tiredness, loss of concentration and memory problems are

all common experiences during or after the menopause. To help these aspects,
note that:

✦regular mental stimulation seems to maintain cognitive ability

✦regular exercise can make sleeping easier

✦ a balanced diet will ensure an adequate intake of essential minerals and

vitamins

✦social activity improves mental function

✦concentration can be improved with crosswords, puzzles, quizzes etc.

33
✦learning new skills or languages improves mental function

✦moderating alcohol intake is important for good memory function.

Health screening

It is important to encourage women to attend breast and cervical screening as

per NHS guidelines. Women should also be encouraged to be aware of any
changes intheir breasts, seeking help promptly if they occur.

Education

Many women arrive at their menopause transition years without knowing

anything about what they might expect, or when or how the process might
happen, and how long it might take. Very often a woman has not been informed
in any way about this stage of life; it may often be the case that she has received
no information from her physician, or from her older female family members, or
from her social group. There appears to be a lingering taboo which hangs over
this subject. As a result, a woman who happens to undergo a strong
perimenopause with a large number of different effects may become confused
and anxious, fearing that something abnormal is happening to her. There is a
strong need for more information and more education on this subject.

Treatment of osteoporosis

The goal of osteoporosis treatment is the prevention of bone fractures by

slowing bone loss and increasing bone density and strength. Although early
detection and timely treatment of osteoporosis can substantially decrease the
risk of future fracture, none of the available treatments for osteoporosis are
complete cures for the condition. Therefore, the prevention of osteoporosis is as
important as treatment.

34
Osteoporosis treatment and prevention measures are:

 Lifestyle changes including cessation of cigarette smoking, curtailing alcohol

intake, exercising regularly, and consuming a balanced diet with
adequate calcium and vitamin D.

 Calcium and vitamin D supplements may be recommended for women who

do not consume sufficient quantities of these nutrients.

 Medications that stop bone loss and increase bone strength

includealendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva),z
oledronicacid (Reclast), raloxifene (Evista),and calcitonin (Calcimar).Teripar
atide (Forteo) is a medication that increases bone formation.

Complementary therapies

A wide range of complementary therapies can be used to reduce or stop the

short term symptoms of the menopause, but not to prevent or treat
osteoporosis.

1. Acupuncture and acupressure Acupuncture uses needles put into

the skin at specific points on the body, whereas acupressure uses
pressure on these points.
2. Hypnotherapy : Hypnotherapy aims to improve health of a patient
through inducing a trance-like state, with therapist and patient
working together to reduce anxiety and stress.
3. Aromatherapy : Aromatherapy treats illness with concentrated
plant oils ( ginger, jasmine, lavender oils ) most commonly applied

35
 through massage. The oils can also be administered as an
inhalation or in a bath to reduce insomnia, anxiety, depression,
headache, muscle pain etc.

ABNORMAL MENOPAUSE

There are two types of abnormal menopause

1. Premature menopause

If the menopause occursat or below age of 40, it is said to be premature.

Often there is familial diathesis. Treatment by substitution therapy is of value

2. Delayed menopause
 If the menopause fails to occur even beyond 55 years it is called delayed
 The common causes are constitutional, uterine fibriods, diabetes mellitus
and estrogenic tumour of the ovary
 The cases should not be neglected. In the absence of pelvic pathology,
diagnostic curettage should be done and an early decision of
hysterectomy should be taken to prevent incidence of endometrial cancer.

ARTIFICIAL MENOPAUSE

Artificial menopause is of two types

1. RADIATION MENOPAUSE

The ovarian function may be suppressed external gama radiation in women

below the age of 40. The menopausal symptoms are not so intense as found in
surgical menopause. The menstuation may resume after 2 years and even
conception is possible

2. SURGICAL MENOPAUSE

36
 While most women go through natural menopause about 50 years of age,
there are some who undergo menopause in their 40s and even as early as 30s
and 20s. Approximately 600,000 women in the US have a hysterectomy which
is the second most common major surgery among women. About 55% of
women who have had hysterectomies also undergo bilateral oopherectomy. This
means they experience surgical menopause as well.

What is surgical menopause?

The ovaries produce oestrogen, progesterone and androgens which are

essential to the regulation of the menstrual cycle. When a hysterectomy done,
these hormones get suddenly interrupted and their levels fall resulting in
symptoms of menopause. This is termed surgical menopause.

 Although removal of ovaries becomes unavoidable in most hysterectomy

surgeries, even effort is made by the surgeon to leave the ovaries intact in
order to avoid the sudden absence of hormones. Surgical menopause
occurs in women who have not yet had natural menopause
 Most often surgical menopause is caused quite dramatically when there is
surgical interference like hysterectomy, bilateral oophorectomy and total
abdominal hysterectomy with bisalpingo oophorectomy.
 In case of hysterectomy when the uterus is removed and ovaries remain,
menstrual periods stop but significantly the menopausal symptoms occurs
at the same age as would naturally. Surgery is warranted in conditions
such as endometriosis, ovarian cysts, fibroids, ovarian cancer and pelvic
organ prolapse

Planning a surgical menopause

 Surgical menopause is a difficult decision especially at a younger age.

The younger the women, the more problems she will encounter

37
  A complete hormonal check up is essential for every woman who have to
undergo hysterectomy. This way a baseline reading of the hormonal
needs is obtained and one can always try to achieve these normal levels
with the right hormones again
 Post care has to be planned and it is important for a young women
undergoing hysterectomy to be under the care of a hormonal therapy
specialist who can handle the side effects of surgical menopause
 Research is still at an infant stage seeking to determine the long time
effects of surgical menopause on heart diseases, osteoporosis and general
health especially on young women

Symptoms of surgical menopause

 Since there is abrupt disruption of hormones after hysterectomy, the

menopausal symptoms are more severe, more frequent and last longer
when compared to natural menopause. The symptoms are triggered by the
body’s sudden inability to make certain hormones due to removal of
ovaries
 Hot flushes and night sweats are commonest symptoms of surgical
menopause. It is estimated that about 75-90% of women who have had
surgical menopause experience them. This is due to disturbance of the
central thermostat located in the hypothalamus which is kept stable by
normal circulating oestrogen
 Other symptoms of surgical menopause range from sleepless nights,
vaginal dryness , itching, decrease in sexual desire and dyspareunia
(painful intercourse )
 Depression is another common result of low oestrogen level
 Thyroid dysfunction
 Bladder infections
 Incontinence of uterine

38
  Weight gain
 Migraine and irritability

Management of surgical menopause

o Estrogens are immediately given after surgery to try to prevent the

intense changes especially the hot flushes that can occur in women
undergoing hysterectomy. Estrogens replacement therapies like estrogel
have found to relieve many women experiencing surgical menopause
o Various forms of oestrogen replacement therapies like vaginal creams,
sub dermal implants, oestrogen gel , HRT patches are also prescribed

Risks of surgical menopause

 Women with surgical menopause are seven times more prone to

cardiovascular disease risks
 They run the risk of osteoporosis as oestrogen plays a vital role in bone
formation and without oestrogen, calcium is lost from the bones which
when not replaced breaks easily
 It is found that after surgical menopause in particular, bones loose
roughly 3% of their mass per year for the first 5 years and then 1-2% a
year thereafter. Increased bone loss associated with oophorectomy results
in fracture risk as well
 Some studies have found that reduced levels of testosterone in women
are predictive of weight loss which may occur as a result of reduced bone
density
 Gum tissues are affected and regular dental checkups are advised to tide
over this problem
 Women younger than 45 years of age and who have had their ovaries
removed face a mortality risk 170% higher than women who have
retained their ovaries after oophorectomy. Hormone replacement therapy

39
 is commonly advised as it is believed by many doctors to mitigate the
mortality risks.
 There is a definite lowering the sexual desire in women who have
undergone surgical menopause. This reduction is greater than that seen in
women undergoing natural menopause

Surgical menopause is definitely difficult and different when

compared to the natural menopause. But it is important to say positive, one
can also join a local or internet menopause support group, take breaks
throughout the day, relax mentally and keep physically fit by exercising and
eating a healthy diet.

PREVENTION

Menopause is a natural and expected part a women’s development and

does not need to be prevented
But artificial menopause induced by surgery or radiation during
reproductive period can to some extent be preventable
However there are ways to reduce or eliminate some of the symptoms of
menopause. We can also reduce the risk of long term problems like
osteoporosis, heart diseases and breast cancer by taking the following
steps.
Control blood pressure , cholesterol and other risk factors for heart
disease
Encourage for avoidance of smoking , because cigarette use can cause
early menopause
Eat low fat diet
Regular exercise, which strengthens the bones and improves balance
40
 Nutritious diet rich in vitamin D and calcium
Supplementary calcium and vitamin D
Early detection and treatment for bone loss
Avoidance of stress or over exert
Frequent mammogram and breast examination is advisable at least once
in a year.

COUNSELLING AND GUIDANCE:

Women at the menopausal stage need to be supported emotionally;

they may need counseling to be educated about the condition and
explanation about the normal physiologic changes that they are
undergoing

This may also help them to overcome the symptoms of anxiety and
depression.
Certain life style modification is necessary to prevent the occurrence or
minimize the effects of the associated condition.
The life style modification is advised include:
Diet
Smoking cessation
Decreased alcohol intake
Relaxation
Stress reduction.

ROLE OF MIDWIFE:

 Midwives provide health care and counseling through the peri-

menopausal years and beyond, including:
 Preventive measures for conditions that is increasingly common
as a woman ages, particularly those (like heart disease and

41
 osteoporosis) that have an increased risk with the reduced
estrogen levels found in a woman’s body after menopause.#
 The advantages and disadvantages of hormone replace ment
therapy and self- help measures
 The importance of a healthy diet (low in fat, high in calcium)
and exercise aerobic for the cardiovascular system and weight-
bearing for the bones.
 The role of herbal therapies.
 Signs and sympt o ms that might signal a serious health
problem (such as bleeding between periods).
 She gives following advice to reduce menopausal symptoms
4. To reduce hot flushes:
 Not too warm.
 Lower heat.
 Use cotton clothes.
 Use the fan,
 Replace coffee, tea, cola beverages by natural juices.
 No smoking.
 learn to relax, exercise on a regular basis helps to reduce anxiety,
 Take plenty of fluids.
5. To reduce vaginal dryness :
 In sexual relations while devoting more time.
 Loving (necking) as this will increase vaginal lubrication on
naturally.
 Using specific lubricants that are sold in pharmacies, Vaseline or
oil.
6. To control urinary incontinence :
 Exercises to strengthen pelvic muscles:

42
 When the bladder is empty, try to cut the flow of urine for a few
seconds ( the muscles are contracted) and then relax. Perform this
exercise several times a day
7. To prevent osteoporosis :
 Physical exercise moderately and regularly, where all the joints
work and thus hinder the process of decalcification of bone.
 A diet rich in calcium, by increasing the intake of dairy products (
especially for skimmed not gain weight),
 Some calcium rich fish such as sardines, anchovies, anchovy, and
tuna.
 Healthy diet low in fat and rich in fruits and vegetables. Sun to
create enough vitamin D. which is required for proper calcium
absorption.
 Avoid snuff, alcohol and stimulant beverages ( coffee, tea and
cola drinks) and that interfere with calcium metabolism
8. Preventing psychological disorders:
 Keep a positive attitude in life.
 Teach a relaxation technique to reduce stress and anxiety.
 Using their own chores to relax.
 Have more time for the couple.
 Teach him how to overcome the losses (fertility, loss of roles,
leaving the house by children, lost parents, relatives and friends
etc. …
 The promotion of social relationships (friends, women’s groups
and associations), to avoid isolation and loneliness.
 Mental health referral if you look at some pathology such as
anxiety, stress etc.
9. To prevent the Gynecologic Cancer:

43
  Autoexploracines perform breast.
 Annual clinical examination, mammography every two years.
 Exfoliative cervico vaginal cytology
10.Cardiovascular disorders :
 Fat diet rich in olive oil helps regulate cholesterol.
 Healthy diet rich in fruits and vegetables.
 Control of blood pressure to rule out hypertension.
 Exercise.
 Hormone replacement therapy.

RESEARCH STUDIES

11.Management of Menopause-Related Symptoms

March 2005

Structured Abstract

Objectives: To describe the evidence about symptoms associated with

menopause, factors that influence these symptoms, benefits and adverse effects
of therapies, factors that influence therapies, and future research needs.

Data Sources: Searches of MEDLINE®, PsycINFO, DARE, the Cochrane

database, MANTIS, and AMED; and from recent systematic reviews, reference
lists, reviews, editorials, Web sites, and experts.

Review Methods: The target population includes adult women in the U.S.
undergoing the menopausal transition. All cohort studies reporting menopausal
symptoms in >100 subjects were reviewed and relevant data were extracted,

44
entered into evidence tables, and summarized by descriptive methods. Studies
of nonmenopausal women, of aging, or not published in English were excluded.

Results: Forty-eight studies conducted among 14 cohorts and 22 studies from

other populations provide data about symptoms. Vasomotor symptoms and
vaginal dryness are most consistently associated with menopause; sleep
disturbance, somatic complaints, urinary complaints, sexual dysfunction, mood,
and quality of life are inconsistently associated. No studies provide data on
cognition and uterine bleeding problems, duration and severity of specific
symptoms, or conclusive data on the influence of race/ethnicity, age of onset of
menopause, body mass index, oophorectomy status, depression, or smoking.

Results of 192 randomized, controlled trials of therapies indicate that for

vasomotor symptoms, estrogen is effective; tibolone demonstrates benefit, but
most studies are poor-quality; paroxetine, veralipride, gabapentin, soy
isoflavones, and other phytoestrogens report benefit in some trials. Results for
other symptoms are mixed, adverse effects are inadequately reported, and
placebo effects are large.

No trials describe the influence of bilateral oophorectomy, premature ovarian

failure, use of potentially interacting agents, lifestyle and behavioral factors,
recent discontinuation of hormones, or body mass index.

For women with breast cancer, clonidine, venlafaxine, and megestrol acetate
improve vasomotor symptoms, but results for other symptoms are mixed.

Conclusions: Vasomotor symptoms and vaginal dryness are most consistently

associated with the menopausal transition. Results of treatment trials are
consistent and conclusive only for estrogen. For other agents, the evidence base
is limited by the lack of studies demonstrating effectiveness, poor quality of
existing studies, and incomplete information on adverse effects.

45
 12.Menopause Working Memory Study
This study focuses on the role that estrogen may play in memory in healthy
menopausal women and is funded by the National Institute on Aging. The
purpose of this study is to look at how estrogen affects memory, emotions, and
brain activity in menopausal women. The length of time you'll be on estrogen
or placebo (sugar pill) is approximately 3 months. This is also a brain imaging
study in which you will participate in 4 fMRI scans; 2 before beginning
estrogen or placebo treatment and 2 after starting estrogen or placebo treatment.

PCWBW is looking for menopausal women who meet the following criteria:

 Are between the ages of 48-60 and in good health

 Have irregular periods or have stopped having a period
 Are within 10 years of last menstrual period
 Are a non-smoker
 Are not on any psychiatric medication including antidepressants
 Are NOT taking any hormones including birth control pills

You can help researchers at UP enn to learn more about estrogen's effects on
mood, memory and attention by being a participant. You may earn up to $1250
if you qualify.

SUMMARY

Till now we discussed about definition of menopause, causes, changes,

signs and symptoms, diagnostic evaluation, treatment, life style changes,
complimentary therapies, surgical menopause, prevention, guidance and
counseling for menopausal women and role of midwife in care of menopausal
women.

CONCLUSION

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 Though menopause is normal physiologic process, it will lead to many
complications for women in aging if we are unaware of it. So as a midwife we
should know about what are the changes occurs in the body due to menopause,
measures to treat signs and symptoms and prevention of complications, which
makes the women to lead a healthy life.

BIBLIOGRAPHY
Books :

1. Boback teals (1995) ‘Gynaecological nursing’ ( 4th edition) Philadelphia ,

Mosby publications ; page no 203-261
2. D.C dutta (2006) ‘Text book of Gynecology ’ (6th edition) new Delhi,
new central book agency ; page no. 51-57
3. Myles (1992) ‘Text book of midwives’ (11th edition) Calcutta, Longman
groups pvt ltd ; page no. 215-220
4. Annama Jacob (2002) ‘Text book of comprehensive midwifery’ (2 nd
edition) new Delhi , jaypee brothers pvt ltd ; page no. 115-119
5. Williams (2005) ‘ Text book of gynecology ’ (23rd edition) new Delhi ;
McGraw hill publications; page no. 341-346

Journals
1. Journal of nurse midwifery (2004) jan-feb (44),vol.1 page no. 6
2. Journal of nursing research and midwifery (2006) November, vol 18,
page no. 20-22
3. An international journal of obstetrics and gynecology
4. (2007) vol. 109, march ; page no. 44-56
5. International journal of nursing studies (2008) vol. 54, September ; page
no. 535-538

Web site

1. http:// www.medicinet.com
2. http:// www.medplus.com
3. http:// www.wilkipedia.com

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 OBJECTIVES

GENERAL OBJECTIVE:
At the end of the class group will gain in-depth knowledge regarding
menopause, its signs and symptoms and management.

SPECIFIC OBJECTIVE:-
At the end of the class the student will able to:
 Define menopause
 Explain terminologies regarding menopause
 Recognize age of menopause for women
 Describe endocrine regulation prior to menopause
 Assess signs and symptoms of menopause
 Identify diagnostic tests of menopause
 Explain treatment, life style changes and complimentary therapies for
menopause
 Describe surgical menopause and its management
 List out the preventive measures of menopausal complications

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  Perform counseling and guidance
 Explain the role of midwife in care of menopausal women

Name of the student teacher: Miss. B. Karuna kumari

Course & Class: M.Sc Nursing, 1st year

Subject: Obstetrical & Gynecological

Topic: Menopause

Group: Pear group

Date: 9.8.2011

Time: 2-4pm

Duration: 2hours

Venue: M.Sc Nursing 1st year Class Room

Method of teaching: Lecture cum Discussion

Av Aids: Black board - changes due to menopause

- Hormonal replacement therapy

Power point – life style changes

- signs and symptoms of

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 menopause

Chart - various forms estrogen

therapy

flash cards - indications of HRT

- Contraindications of HRT

Handout - research studies and calcium

rich food for menopausal women

HOD : Mrs. Rafath Razia madam, Professor

Supervised by : Mrs. B. Valli Madam, Assist.Professor,Govt.College of Nursing

SEMINAR
ON
MENOPAUSE

50
 INDEX
Topic Page no.
Introduction 1-2

Definition 3

Terminology 3-4

Causes of menopause 5-7

Endocrine changes 8-9

Organ changes 9

Premenopause 9-10

Signs and symptoms of Menopause 10-22

Diagnostic Evaluation 22

Treatment for Menopause 23-28

Life style changes for menopausal women 28-34

Treatment for Osteoporosis 34

Complimentary Therapies 35

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Abnormal Menopause 35-36

Surgical Menopause 36-39

Prevention of Complications due to menopause 40

Guidance and Counselling for menopausal women 40 -41

Role of Midwife 41-43

Research studies related to menopause 44-46

Summary 46

Conclusion 47

Bibliography 47

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