Menopause is a natural phase in every woman’s life, but what exactly happens during menopause, and how can we manage menopausal symptoms? Let’s dive deep into this topic.
What is Menopause?
Menopause is defined as the time in a woman’s life when there is a permanent cessation of ovarian function. It’s confirmed when a woman hasn’t had a menstrual period for one year. The average age of menopause is 51.1 years.
Another condition to be aware of is ‘Premature Ovarian Insufficiency’ (POI). This is when menopause occurs before the age of 40. This condition affects about 1% of women. Another form of menopause, termed “surgical or induced menopause,” occurs due to the removal or damage to both ovaries or because of treatments like chemotherapy or radiation.
The Journey of Oocytes: From Birth to Menopause
Our reproductive journey starts long before we’re born. Here’s a brief overview:
- 1,000-2,000 germ cells migrate to the gonadal sites and multiply.
- Five months gestation: There are about 6-7 million oocytes.
- Birth: We’re born with approximately 1-2 million oocytes.
- Puberty: This number dwindles down to around 500,000 oocytes.
- Menopause: Fewer than 1,000 oocytes remain.
Before you reach menopause, you’ll undergo a phase called “perimenopause.” This is when menstrual cycles start to become irregular, shifting from a predictable pattern to increasingly anovulatory cycles, and finally, the cessation of menses.
Reproductive Aging and its Stages
The process of reproductive aging is complex and is categorized into various stages. One of the well-recognized frameworks for understanding reproductive aging is the Stages of Reproductive Aging Workshop (STRAW). This classification helps in understanding the transition from reproductive years to menopause.
Early-Stage Menopause
In the early stages of the menopausal transition, signs include increased variability in menstrual cyclicity (more than seven days apart), elevated FSH levels, decreased AMH, and a reduced antral follicle count (AFC).
Late-Stage Menopause
As a woman moves into the late menopausal transition, which typically spans 1 to 3 years, vasomotor symptoms such as hot flashes become prevalent. Other indicators in this stage are an interval of amenorrhea lasting 60 days or more, culminating with 12 consecutive months of amenorrhea.
Postmenopausal Phase
Following this, the early postmenopausal phase encompasses the first six years after the final menstrual period (FMP). The late postmenopausal stage spans from 6 years after FMP until death.
These insights, presented at the North American Menopause Society (NAMS) Meeting in 2011, offer a comprehensive understanding of the stages women undergo during this significant life transition.
Understanding Common Menopause-Related Symptoms
As women transition into the menopausal phase, they often experience a range of symptoms that can impact their daily lives. Here are some of the most frequently reported challenges:
- Hot Flashes: Sudden feelings of warmth, often accompanied by sweating and followed by chills.
- Night Sweats: Intense hot flashes during the night that can disrupt sleep.
- Vaginal Dryness: Reduced moisture in the vaginal area, leading to discomfort or pain, especially during intercourse.
- Mood Changes: Fluctuations in mood, including irritability, anxiety, and even depression.
- Sleep Disturbances: Difficulties in falling asleep, staying asleep, or experiencing restful sleep.
- Weight Gain: Changes in metabolism can lead to weight gain, especially around the midsection.
- Joint Pain: Aching or soreness in the joints, often described as a stiffness.
- Reduced Libido: A decrease in sexual desire or interest in sexual activity.
It’s essential for women to recognize these symptoms and understand they are not alone. Many treatments and therapies are available to relieve and improve the quality of life during this significant transition.
Tackling Vasomotor Symptoms of Menopause
Vasomotor symptoms, particularly hot flashes, are a prevalent concern for many women transitioning into menopause. In fact, between 60-80% of women report experiencing such symptoms. While most women may only endure these symptoms for a year, up to 25% continue to experience them five years after their final menses. These hot flashes, which can occur as frequently as every hour, often come accompanied by sweating, palpitations, anxiety, sleep disturbances, and a diminished quality of life.
To alleviate these symptoms, several treatments are available:
- Lifestyle Adjustments:
- Stay cool and use moisture-wicking sheets.
- Engage in regular exercise and maintain a healthy weight.
- Quit smoking and avoid known triggers like alcohol.
- Complementary and Alternative Medicine (CAM):
- Cognitive behavioral therapy and mindfulness training have shown promise.
- While some women turn to phytoestrogens, herbal therapies, black cohosh, Chinese herbs, and paced respiration, the evidence of their efficacy is inconsistent. Notably, acupuncture, evening primrose, flaxseed, and certain other herbs (like ginseng and dong quai) have been found ineffective.
- Non-Hormonal Options: Although not as effective as Hormone Replacement Therapy (HRT), drugs like Paroxetine serve as a first-line non-hormonal option for those who cannot receive HRT.
- Hormonal Options: For severe vasomotor symptoms, estrogen, either alone or combined with progestins (if uterus present), has proven to be the most effective, reducing frequency and severity in a significant majority of women.
However, caution is advised when considering systemic hormone therapy, especially for those with contraindications such as unexplained vaginal bleeding, estrogen-dependent cancers, severe liver disease, and several others.
Lastly, while there’s a buzz around bioidentical hormones, the evidence does not support their use over conventional menopausal hormone therapy. They come with important concerns, including variable purity, potency, and possible risks associated with variable bioavailability.
Hormone Replacement Therapy (HRT) and Menopause: A Deep Dive
Hormone Replacement Therapy (HRT) plays a pivotal role in alleviating the challenges associated with menopause. According to the North American Menopause Society’s position statement, for women under 60 years of age or those within ten years from their Last Menstrual Period (LMP), the benefits of HRT generally outweigh the risks. However, for older women or those more than a decade from their LMP, the balance shifts with greater absolute risks of Coronary Artery Disease (CAD), stroke, and Venous Thromboembolism (VTE).
The primary indications for HRT include:
- Treatment of bothersome Vasomotor Symptoms (VMS) like hot flashes.
- Prevention of bone loss in postmenopausal women at elevated risk of osteoporosis or fractures.
- Management of hypoestrogenism due to various causes like hypogonadism, premature surgical menopause, or Premature Ovarian Insufficiency (POI).
- Treatment of genitourinary symptoms.
Various HRT regimens are available, including continuous and cyclic methods, using combinations of estrogens and progestins. The Women’s Health Initiative (WHI) study, which enrolled over 27,000 postmenopausal women, has provided some insights into the risks and benefits of HRT.
The study revealed that younger women who initiate HRT closer to the age of menopause showed no increase in coronary heart disease (CHD) or stroke and even displayed trends towards cardiac protection, especially with estrogen therapy. The risk of CHD, stroke, and VTE increases the further out from the onset of menopause one is when starting HRT.
It is important to discuss the benefits and risks of initiating HRT with your provider so that a personalized treatment plan can be made based on your risk factors.
Adding testosterone to the mix, it’s noteworthy that the hormone’s levels decrease after menopause primarily due to the reduced peripheral conversion of androstenedione. Though testosterone can improve sexual function, it’s not FDA-approved for use in women and is used off-label. Its benefits need to be weighed against potential side effects like hirsutism, acne, and others.
ACOG’s guidelines further clarify that systemic HRT is the most effective therapy for vasomotor symptoms. They recommend individualized treatment, using the lowest effective dose, and local therapy for vaginal symptoms only. It’s important to note that HRT should not be used for primary or secondary prevention of coronary heart disease currently. The general recommendation is to discontinue systemic estrogen by the age of 65.
Sexual Dysfunction during Menopause
Menopause can sometimes throw a wrench in one’s sexual well-being. Common challenges include:
- Loss of Libido: About 23% of menopausal women report a decrease in sexual desire.
- Dyspareunia: Pain during intercourse due to vaginal dryness and atrophy.
- Other Factors: Depression, chronic illnesses, medication side effects, and more can contribute to sexual dysfunction.
But there’s hope. Treatments range from lubricants and hormone therapy to relationship counseling and health optimization.
The Silent Threat: Osteoporosis
One of the significant health concerns for post-menopausal women is osteoporosis, a condition where bones become weak and brittle. This increases the risk of fractures, especially in the hip, which can lead to decreased mobility and independence.
It’s crucial for postmenopausal women, especially those aged 65 or older, to get screened for osteoporosis. Younger women with increased risk factors should also consider screening.
Fertility Options for Early Menopause
Premature Ovarian Insufficiency (POI) is a condition where a woman’s ovaries cease to function before the age of 40. Infertility can bring about feelings of loss and grief, especially for those who hope to conceive. However, reproductive medicine offers hope and a suite of options.
Fertility Treatments for Early Menopause
While natural conception might be challenging with early menopause, several fertility treatments can pave the way for potential parenthood:
- In Vitro Fertilization (IVF) with Donor Eggs: Given the diminished egg quality and quantity in women with early menopause, donor eggs can significantly increase the chances of a successful pregnancy. These eggs, typically from younger donors, are fertilized in the lab with the partner’s (or donor’s) sperm. The resulting embryo is then implanted in the uterus of the intended parent.
- Embryo Adoption: This is an option for those open to adopting an embryo. Embryos created via IVF by other couples but not used are available for adoption. Once adopted, these embryos can be transferred to the recipient’s uterus, offering another pathway to pregnancy.
- Hormone Replacement Therapy (HRT): While HRT doesn’t directly aid in fertility, it plays a vital role in preparing the uterus for pregnancy, especially when using treatments like IVF with donor eggs.
Emotional Considerations
The journey through early menopause and the pursuit of fertility treatments is as emotional as it is medical. Many women grapple with feelings of inadequacy, loss, or guilt. It’s crucial to seek psychological counseling or support groups familiar with these unique challenges. This emotional support can be invaluable throughout a woman’s fertility journey.
Conclusion
Menopause, whether natural, premature, or induced, represents a significant transition in a woman’s life, bringing with it various physiological and emotional changes. Understanding its intricacies and seeking timely interventions can lead to a better quality of life despite the challenges. From managing bothersome symptoms to navigating the complexities of fertility post-menopause, modern medicine and supportive therapies offer a beacon of hope. Knowledge, support, and self-compassion are key in any health journey. By arming oneself with information and seeking the proper medical and emotional guidance, women can confidently traverse the menopausal landscape, embracing each phase with strength and resilience.
Sources
- “Assessment and Quantification of Ovarian Reserve on the Basis of Machine Learning Models.” Frontiers in Endocrinology, 2023.
- Speroff’s Clinical Gynecology and Infertility,8th edition, 2011
- Greenspan’s Basic & Clinical Endocrinology, 10th edition, 2017
- Hansen et al, Hum Reprod 2008
- Speroff’s Clinical Gynecology and Infertility,9th edition, 2019
- North American Menopause Society (NAMS) Meeting, 2011
- Harlow et al., Menopause 2012
- Freeman et al., Obstet Gynecol 2011
- MacLennan et al., Cochrane Review, 2004
- ACOG Practice Bulletin 141, Management of Menopausal Symptoms, Reaffirmed 2018
- North American Menopause Society 2017. Hormone therapy position statement
- ACOG Committee Opinion 532, Compounded Bioidentical Menopausal Hormone Therapy, Reaffirmed 2020
- Somboonporn et al., Cochrane Rev, 2005
- ACOG Committee Opinion 565, Hormone Therapy and Heart Disease, Reaffirmed 2018
