Menopause is the cessation of menstruation. It results from a complex syndrome of physiologic changes — the climacteric — caused by declining ovarian function. The climacteric produces various body changes, the most dramatic being menopause.
❑ Physiologic menopause, the normal decline in ovarian function due to aging, begins in most women between ages 45 and 55, on average 51, and results in infrequent ovulation, decreased menstrual function and, eventually, cessation of menstruation.
❑ Pathologic (premature) menopause, the gradual or abrupt cessation of menstruation before age 40, occurs idiopathically in about 5% of women in the United States. However, certain diseases, especially severe infections and reproductive tract tumors, may cause pathologic menopause by seriously impairing ovarian function. Other factors that may precipitate pathologic menopause include malnutrition, debilitation, extreme emotional stress, excessive radiation exposure, and surgical procedures that impair ovarian blood supply.
Many menopausal women are asymptomatic but some have severe symptoms. The decline in ovarian function and consequent decreased estrogen level produce menstrual irregularities: a decrease in the amount and duration of menstrual flow, spotting, and episodes of amenorrhea and polymenorrhea (possibly with hypermenorrhea). Irregularities may last a few months or persist for several years before menstruation ceases permanently.
The following body system changes may occur (usually after the permanent cessation of menstruation):
❑ Reproductive system: Menopause may cause shrinkage of vulval structures and loss of subcutaneous fat, possibly leading to atrophic vulvitis; atrophy of vaginal mucosa and flattening of vaginal rugae, possibly causing bleeding after coitus or douching; vaginal itching and discharge from bacterial invasion; and loss of capillaries in the atrophying vaginal wall, causing the pink, rugal lining to become smooth and white. Menopause may also produce excessive vaginal dryness and dyspareunia due to decreased lubrication from the vaginal walls and decreased secretion from Bartholin’s glands; smaller ovaries and oviducts; and progressive pelvic relaxation as the supporting structures lose their tone due to the absence of estrogen.
❑ Urinary system: Atrophic cystitis due to the effects of decreased estrogen levels on bladder mucosa and related structures may cause pyuria, dysuria, and urinary frequency, urgency, and incontinence. Urethral carbuncles from loss of urethral tone and mucosal thinning may cause dysuria, meatal tenderness, and hematuria.
❑ Mammary system: Breast size decreases.
❑ Integumentary system: The patient may experience loss of skin elasticity and turgor due to estrogen deprivation, loss of pubic and axillary hair and, occasionally, slight alopecia.
❑ Autonomic nervous system: The patient may exhibit hot flashes and night sweats (in 60% of women), vertigo, syncope, tachycardia, dyspnea, tinnitus, emotional disturbances (irritability, nervousness, crying spells, fits of anger), and exacerbation of pre-existing depression, anxiety, and compulsive, manic, or schizoid behavior.
Menopause may also induce atherosclerosis, and a decrease in estrogen level contributes to osteoporosis.
Ovarian activity in younger women is believed to provide a protective effect on the cardiovascular system, and the loss of this function at menopause may partly explain the increased death rate from myocardial infarction in older women. Also, estrogen has been found to increase levels of high-density lipoprotein cholesterol.
Patient history and typical clinical features suggest menopause. A Papanicolaou (Pap) test may show the influence of estrogen deficiency on vaginal mucosa. Radioimmunoassay (RIA) may be performed, but because of the expense involved, it isn’t necessary to confirm a diagnosis of menopause. If done, RIA shows the following blood hormone levels:
❑ estrogen: 0 to 14 ng/dl
❑ plasma estradiol: 15 to 40 pg/ml
❑ estrone: 25 to 50 pg/ml.
RIA also shows the following urine values:
❑ estrogen: 6 to 28 µg/24 hours
❑ pregnanediol (urinary secretion of progesterone): 0.3 to 0.9 mg/24 hours.
Follicle-stimulating hormone production may increase as much as 15 times its normal level; luteinizing hormone production, as much as 5 times.
Pelvic examination, endometrial biopsy, and dilatation and curettage may rule out organic disease in patients with abnormal menstrual bleeding.
Menopause is a natural process that doesn’t require treatment unless menopausal symptoms, such as hot flashes or vaginal dryness, are particularly bothersome. Hormonal agents for patients with a uterus include estrogen with progesterone to prevent endometrial cancer. If the patient doesn’t have a uterus, progesterone isn’t necessary.
The Women’s Health Initiative has led physicians to revise their recommendations regarding hormone replacement therapy (HRT). Health risks (increased incidence of breast cancer, heart attacks, strokes, and blood clots) outweigh the health benefits (decreased osteoporosis) for women taking both estrogen and progesterone. If symptoms are severe, HRT may be considered for short-term use (2 to 4 years) to reduce vaginal dryness, hot flashes, and other symptoms. If this is used, frequent pelvic examinations, Pap smears, physical examinations, breast examinations, and mammograms are indicated to reduce the risks of estrogen replacement therapy while still gaining the treatment’s benefits.
Medications may be prescribed to help with mood swings, hot flashes, and other symptoms. These include low doses of antidepressants, such as paroxetine, venlafaxine, and fluoxetine, or clonidine, which is normally used to control high blood pressure.
❑ Provide the patient with all the facts about HRT, if used. Make sure she realizes the need for regular monitoring.
❑ Before HRT begins, have the patient undergo a baseline physical examination, Pap test, and mammogram.
❑ Advise the patient not to discontinue contraceptive measures until cessation of menstruation has been confirmed.
❑ Tell the patient to immediately report vaginal bleeding or spotting after menstruation has ceased.
❑ Discuss alternatives to HRT, which can help with the discomforting symptoms of menopause:
– Advise the patient to dress lightly and in layers.
– Tell the patient to avoid caffeine, alcohol, and spicy foods. Encourage soy-based foods.
– Instruct the patient to practice slow, deep breathing whenever a hot flash starts to come on, or to try other relaxation techniques, such as yoga, tai chi, or meditation. Tell her that acupuncture may also be helpful.
– If the patient is in a sexually active relationship, tell her to remain sexually active to preserve vaginal elasticity. Water-based lubricants can be used during sexual intercourse to decrease dryness.
– Instruct the patient that Kegel exercises may be performed daily to strengthen the vaginal and pelvic muscles.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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Title: Professional Guide to Diseases (Eighth Edition)
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2005
ISBN: 1-58255-370-X
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