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Menopause

Menopause is a turning point of a woman’s life, it is the absence of menstrual period for 12 consecutive months and marks the permanent end of a menstruation.  It happened to women of age between 45 to 55 years old. It can be categorized into 3 stages, perimenopause, menopause and postmenopause.

Main causes

Aging is the leading cause to menopause. As a woman ages, the function of the ovaries will slowly deteriorate. The eggs will become more resistant to FSH (follicle-stimulating hormone), a reproductive hormone responsible for the growth of ovarian follicles (eggs). This would result in low production of estrogen by the ovaries. This complex series of hormonal changes is one of the causes for menopause to occur. The fluctuating levels of hormones (estrogens and progesterone) would also cause physical, emotional and sexual symptoms related to menopause. Certain Surgeries and medical treatments such as surgical removal of the ovaries (bilateral oophorectomy), chemotherapy, and pelvic radiation therapy could also induce menopause.

In addition, there are other factors which may cause early menopause to women, such as:

·         Smoking

·         Genetic and autoimmune disease

·         Removal of ovaries (oophorectomy, which causes sudden menopause)

·         Living in high altitude

·         Having a vegetarian diet

·         Low body fat

Perimenopause

Perimenopause happens over a period of 12 consecutive months. It is a transition to menopause. The ovaries gradually slow down its function and the periods become unpredictable. The number and quality of the eggs would also decline. However, ovulation still occurs and getting pregnant is still possible at this stage.

Menopause

When estrogen drops past a certain level, the menstrual cycle ends and it is impossible to get pregnant. After 1 year of perimenopause is over, a woman is said to have reached menopause. She will next go into the postmenopause stage.

Postmenopause

Estrogen levels even out at a low level after a year or more into postmenopause. The low levels of estrogens may cause many menopause related symptoms, especially an increased risk of heart disease and osteoporosis. Other symptoms will be discussed later.

Symptoms that affect individuals

Menopause causes a drop in estrogens and progesterone levels which bring about many symptoms to women.

  Hot flashes

It is the most common symptom of menopause. This symptom varies among women. It is a feeling of warmth that spreads over the body making the face and neck flushed, and causes temporary red blotches at the chest, back and the arms. It usually lasts from 30 seconds to a few minutes. Reddened skin, palpitations(irregular heartbeat) and sweating usually accompany hot flashes. Hot flashes increase the skin temperature and pulse and could cause insomnia. This symptom can last from a few years up to as long as 15 years (it varies among women).

  Heart disease

Women having menopause or have premature menopause (because or surgical removal or ovaries at an early age) have a higher risk of getting heart disease due to loss of estrogen.  However, the aging factor also contributes to the higher risk of getting heart disease. Increased in cholesterol level (especially LDL cholesterol) also increases the risk of heart disease.

  Sex problem

Less estrogen leads to vaginal dryness which makes sexual intercourse uncomfortable or painful. Libido (sexual drive) is also affected and it may change for the better or worse. Other factors besides menopause would also affect libido of a woman.

  Osteoporosis

Osteoporosis is a condition whereby bones lose an excessive amount of their protein and mineral content, particularly calcium. Over time, bone mass and bone strength will eventually decrease. As a result, bones become fragile. It is the most common during perimenopause. No pain is associated with bone loss. Osteoporosis causes bone fractures easily, which can be intensely painful and interfere with daily life and this also increases the risk of death.

   Examples of other symptoms:

·         Night sweat during sleep

·         Forgetfulness (in some women)

·         Mood swings

·         Vaginal infections

·         Skin outbreak

·         Headache

·         Weight gain

·         Urinary incontinence

·         Burning sensation upon urination

·         Increased risk for depression

·         Change in shape of breast




Estrogen


During menopause, a woman's ovaries stop making eggs and thus they produce less estrogen and progesterone. Changes in these hormones are what causes menopause symptoms.

There are 3 forms of estrogen, they are; estradiol, estrone and estriol.

Normal ratios are as follows:

Estradiol: 10 - 20%

Estrone: 10 – 20% 

Estriol: 60 – 80%


These ratios is disrupted during menopause and also pre-puberty stage in girls. During this time, estrogen is no longer excreted from the ovaries but the extraglandular sites. Once these estrogen is produced and released into the bloodstream, it then reaches its target tissues and the liver.


Biosynthesis of Estrogen

In women of reproductive age, estrogens is produced by the ovaries which is stimulated by Follicle Stimulating Hormones or FSH.


Synthesis starts in theca internal cells in the ovary, by the synthesis of androstenedione from cholesterol. Androstenedione is a substance of weak androgenic activity which serves predominantly as a precursor for more potent androgens such as testosterone as well as estrogen. This compound crosses the basal membrane into the surrounding granulosa cells, where it is converted either immediately into estrone, or into testosterone and then estradiol in an additional step. The conversion of androstenedione to testosterone is catalyzed by 17β-Hydroxysteroid dehydrogenase, whereas the conversion of androstenedione and testosterone into estrone and estradiol, respectively is catalyzed by aromatase, enzymes which are both expressed in granulosa cells.


Metabolism of estrogen mainly occurs in the liver and gastrointestinal tissues. The estrogen begins as estradiol and is then broken down into estrone. The two types of estrogen must be later be further broken down so that it can be removed from the body. This happens in the liver. Once the estrogen is broken down it is released in bile or urine. This process of estrogen breakdown is known as hydroxylation.

Treatments

There are a few treatments for menopause and relieving menopausal symptoms. Estrogen influence in the building of bones from calcium, maintains healthy levels of cholesterol in the blood and keeps the vagina healthy. On the other hand, progesterone is always taken with estrogen (only when the woman has uterus). Without progesterone, estrogen increases the risk for womb or uterine cancer. 

Hormone Replacement Therapy (HRT)

HRT is given to women to supplement their bodies with adequate levels of estrogen and progesterone. There are 2 main types of of HRT: Estrogen therapy and Progesterone/Progestin-Estrogen Hormone Therapy.

Estrogen therapy

Only estrogen alone is taken. Low dose of estrogen is often prescribed as a pill or patch to be taken every day. It may also be prescribed as a cream. Lowest dosage of estrogen is highly recommended to relieve the menopause symptoms.

Progesterone/Progestin-Estrogen Hormone Therapy

Also known as the combination therapy, combines doses of both estrogen and progesterone. Estrogen and a lower dose of progesterone may be taken in continuously to prevent the regular, monthly bleeding that can occur when the progesterone makes the endometrium shed each month.  It is recommended to take the lowest dose of hormone therapy for the shortest time possible.

However, currently the HRT is not recommended to prevent the risk of heart disease and stroke and other chronic diseases. On a side note, People with active or history of breast cancer records, recurrent or active endometrial cancer, abnormal vaginal bleeding, recurrent or active blood clots, history of stroke, liver disease and known or suspected pregnancy are not suitable for HRT. HRT can also cause side effects such as monthly bleeding, breast tenderness, blood clots and strokes, fluid retention, headaches, migraine and dizziness. To prevent the risk of estrogen therapy, frequent and regular pelvic exams, Pap smears and physical exams (including breast exams and mammograms) are carried out to detect the problems as early as possible.

Bioidentical Hormone Therapy

It is Also known as natural hormone therapy. Bioidentical hormones act in the body just like the hormones women produce. Bioidentical hormones are hormones that are identical in molecular structure to the hormones synthesized naturally in women bodies. They are not found in nature and are synthesized from a plant chemical extracted from yams and soy. Bioidentical estrogens include 17 beta-estradiol, estrone and estriol. Estradiol is the one which decreases at menopause. Bioidentical progesterone is simply progesterone which is micronized in laboratory for better absorption in human body.

Commercially available bioidentical estradiol comes in several forms such as pill, patch and cream. Micronized progesterone comes in capsule or vaginal gel.

However, women taking bioidentical estrogen must also take in bioidentical progesterone together to prevent endometrial cancer.

Prevention

There is no prevention for menopause as it is a natural phenomenon for women and not a disease. Fortunately there are some steps which can help to reduce the risk factors for other problems and relieve the symptoms of menopause. It is recommended for postmenopausal women to consume plenty amount of calcium and vitamin D from diet. Women who are unable to obtain adequate amount of calcium through diet can consider dietart calcium supplements such as calcium carbonate. Whereas other women who take acid-blocking medications (ranitidine (Zantac) or cimetidine (Tagamet) may better absorb calcium citrate. calcium supplements made from bone meal, dolomite or unrefined oyster shells should be avoided as they may contain lead.

In addition, women should avoid taking excessive doses of calcium as too much of them would increase the risk of kidney stones. Same for Vitamin D, although it is important and part of calcium absorption process, too much of it will lead to drastic consequences. All supplements should be taken in adequate amount.

References:

•   David Zieve and Susan Storck, 2011. Menopause. [online] Place: National Institutes of Health. Available at: <http://www.nlm.nih.gov/medlineplus/ency/article/000894.htm>[Accessed 27 December 2012]

•   Laura J. Martin, MD, 2011. WebMD, Slideshow: All About Menopause and Perimenopause. [online] Last Updated on 2012. Available at:<http://www.webmd.com/menopause/ss/slideshow-menopause-overview>[Accessed 27 December 2012]

•   Melissa Conrad Stöppler and William C. Shiel Jr, 2013. Menopause - prevention. [online] Place: emedicinehealth. Available:<http://www.emedicinehealth.com/menopause/page9_em.htm#prevention>[accessed 30 December 2012]

•   Real Age, 2013. All About women's health - 8 signs and symptoms of menopause. [online] last updated on 2012. Available at:<http://www.realage.com/womens-health-guide/signs-and-symptoms-of-menopause-3> [accessed 28 December 2012)

•   Unknown, 2006. What are bioidentical hormones? [online] Harvard Health Publications, Harvard Medical School. Available at:<http://www.health.harvard.edu/newsweek/What-are-bioidentical-hormones.htm>.[29 December 2012]