Menopause is an important phase in a woman,s life. Menopause essentially means permanent cessation of menstruation. usually a woman attains menopause around the age of 45-50. given that the average life expectancy of human beings is increasing the world over, a woman may end up spending almost a third of her life span in the post-mnopausal period, if not more. Natural menopause is associated with lack of functioning of ovaries, which are two hormone producing organs situated near the womb or the uterus. Normally, these ovaries produce 3 hormones,viz: oestrogen, progesterone and androgens. When they stop functioning the woman faces many physical and mental changes.
Presenting symptoms of Menopause :
1. Menopause entails decrease in three hormones, viz.; oestrogen,progesterone and androgens. Patients who present to a doctor due to severe menopausal symptoms usually present due to lack of or diminished activity of any of these hormones This may necessitate HRT or hormone replacement therapy, where the deficient hormones are administered to the woman as medications;
Lack of estrogen :
This may lead to hot flash/flush, sleep disturbance, palpitations, dry skin, irritable bladder, and dyspareunia( Painful intercourse).
What are hot flashes?
Sleep disturbances, like inability to get sleep, waking up too early, etc, is common in this age group, but is not always due to hormone disturbances. It could be part of depression. It could be part of hot flushes, as the woman tends to wake up off and on because of severe hot flushes. However, in clinical practise, many women who have sleep disturbances as part of depression expect hormone replacement therapy to cure it. This is quite often because they do not want to be labelled "depressive", while they do not mind being labelled "menopausal".
Following good sleep hygeine may help. This means sleeping at regular times, avoiding heavy evening meals and stimulants, sleeping in a dark, quiet room, restricting the bedroom to sleep, and a relaxing activity or warm milk at bedtime. Physical activity levels are associated with better sleep quality and there is evidence that adopting a regular exercise habit might be beneficial. Both regular walking and stretching appear beneficial but vigorous exercise should be avoided close to retiring.
2. Osteoporosis literally means porous bones. Due to porous bones, the bones may become smaller, even painlessly. These changes are shown on X-ray only after considerable bone is lost from the body. Sophisticated tests like calcaneal ultrasound and Densitometry can detect it much earlier, and remedial measures can be undertaken.
A few frequently asked questions on osteoporosis are given below with answers.
What is osteoporosis?
Osteoporosis is the thinning of bone tissue and loss of bone density over time. Two essential minerals for normal bone formation are calcium and phosphate. After menopause sets in, oestrogen levels fall , and this leads to osteoporosis. Decreased dietary intake of calcium lack of weight bearing exercise, also contribute to the setting in of osteoporosis.
What are the symptoms of osteoporosis?
Osteoporosis is a silent disease. It may not cause any symptoms till there are minute fractures called fragility fractures, which commonly occur in vertebra(Backbone), rib, wrist, and hip. Multiple vertebral fractures lead to a stooped posture, loss of height, and chronic pain with resultant reduction in mobility in the elderly. If there is loss of more than 1.5 inches then it means already there are micro-fractures in the spine. This hump is because of weak extensor muscles of the back along with very small fractures of the upper backbone which go unnoticed most of the time and are not diagnosed in more than one-third cases. This interferes with the quality of women's life by causing chronic backache, decreased chest space resulting in respiratory problems and decreased abdominal space leading to poor digestion.
How can one prevent osteoporosis?
Doing weight bearing exercises for about half an hour per day after theage of 35 is a good way of keeping osteoporosis away. Taking calcium rich food like milk or milk products, green leafy vegetables, and legumes,can aslo prevent osteoporosis. Calcium excretion is enhanced with intake of tea or coffee and one should cut down on their consumption.
How is it possible to know if one’s bones are weak?
Answer: Weakening of bones caused by osteoporosis is a silent disease. One need not wait till one gets physical symptoms to know if the bones are weak. Periodic testing of the bones with special tests like DEXA or ultrasound of the heel bone can detect if the bones are beginning to get holes in them. This will warrant the use of medications, a little more than the ones used for prevention of bone pains.
Q: I am 42 years old. I get low back ache when I try to work for long periods of time. How can I get rid of this problem?
Low back in the 40 plus woman could be due to lumbar strain. A lumbar strain is a stretch injury to the ligaments, tendons, and/or muscles of the low back. The stretching incident results in microscopic tears of varying degrees in these tissues. The condition is characterized by localized discomfort in the low back area with onset after an event that mechanically stressed the lumbar tissues. The treatment of lumbar strain consists of resting the back (to avoid reinjury), medications to relieve pain and muscle spasm, local heat applications, massage, and eventual (after the acute episode resolves) reconditioning exercises to strengthen the low back and abdominal muscles. Resting the back should not go on for too long, as this can also be bad for your back.
Other causes of back ache could be bony projections hitting the spinal nerves or degenerative conditions of the bones or joints of the back. Correct diagnosis can be evolved with investigations.
Conditions affecting the uterus or ovaries can also rarely cause backache, and this should be ruled out. However, in majority of cases, back ache is caused by abnormalities caused in the back itself. If the source of the pain lies in the reproductive organs, other problems often occur as well, including a sensation of pressure on the bladder, urinary urgency, and pain during urination, defecation or sexual intercourse
Q: had undergone hysterectomy for fibroid uterus . The doctor did not remove my ovaries. However, now I get severe pain in my knees . Is it related to hysterectomy or menopause?
Answer: Hysterectomy or menopause cannot cause pain in the knees. Pain in the knees could be caused due to inflammation in the kneejoint, injury to muscles or ligaments around the knees, or even degeneration of the bones near the knee joints, called osteoarthritis. None of these conditions are caused by menopause. It is a misconception to think that hysterectomy can lead to many aches and pains.
It is commonly known that after menopause, bones become weak. This is because, the hormone oestrogen is not there to hold the mineral calcium in the bones, and this leads to the bones becoming porous. However, this phenomenon is most commonly seen in the hips, back and wrists.
.Q: I have undergone hysterectomy with removal of both ovaries. I am 40 years old. Should I take any suppliments to prevent backache? I have heard that menopause leads to weakening of bones.
Answer: Your ovaries still had a few ova in them which would have protected your bones for some more time, besides many other functions. Since your disease needed removal of this protection, it would be good for you to take hormone replacement therapy till you are 45- 50 years of age. This will also prevent weakening of bones. Life style changes should be made , as written in the answer to the previous question.
Q2. I have undergone hysterectomy and my ovaries are intact. Should I take treatments like calcium suppliments or some other drugs ?
If the ovaries have not been removed, they will continue to produce hormones if you are at an age when they still function. They will stop functioning after some time when the number of ova in the ovaries get depleted with age. Till such a time, there is no need to take supplements, just because one has undergone hysterectomy. You must remember to find time to walk for at least 20 minutes a day , avoid easily digestible sugars, take adequate amount of vegetables and fruits, and make sure you take at least a glass of milk or curd or buttermilk, so you have some amount of dietary calcium. After the age of 50, oestrogen will stop protecting the bone, so it will be good if you can take calcium tablets regulary, as the body’s need for calcium increases, ( 1200-1500mg/day is the requirement after 50 years)and this much calcium cannot be provided by the average Indian diet, which gives only about 600-800 mg of calcium per day.
Q3. I have undergone hysterectomy with removal of both ovaries. I am 40 years old. Should I take any suppliments to prevent backache? I have heard that menopause leads to weakening of bones.
Ans: Your ovaries still had a few ova in them which would have protected your bones for some more time, besides many other functions. Since your disease needed removal of this protection, it would be good for you to take hormone replacement therapy till you are 45- 50 years of age. This will also prevent weakening of bones. Life style changes should be made , as written in the answer to the previous question.
Some commonly asked questions are discussed below
Q1. I have a severe burning sensation when I pass urine. My husband says there is a reddish portion near my vagina. My previous doctor has prescribed antibiotics, but I am not getting any relief. I am 65 years old.
Reddish marks in the vagina at this age are usually caused due to atrophy of the vaginal skin, which breaks off, causing the spots. At this age, it is caused due to lack of the hormone oestrogen. Local oestrogen creams or tablets could help in this condition.
Q2. I get no lubrication during intercourse. I stopped getting periods 4 years back.
Menopause could bring about lack of lubrication during intercourse. Local lubricant creams or oestrogen creams could help
Q3. I have itching near my private parts. I tried betnovate C, but the itching is increasing.
Commonest cause for itching in the vulva is fungal infection. Lack of oestrogen in menopause could aggravate it. Antifungal creams along with local oestrogen therapy could help. Other infections should be looked for and treated.
Q4. I get recurrent bouts of itching. It goes off for some time when I wash with hot water, but it returns after that.
Commonest cause of itching is fungal infection. Antifungal creams could help. If it is assossiated with fungal vaginitis, antifungal vaginal pessaries and creams could help. In a menopausal woman, local estrogen preparations may be needed along with it.
Q5. I get severe pain near my private parts. My doctor prescribed Evalon cream, but I cannot tolerate it. I get severe burning when I apply it. What can I do?
There is a condition called vulvodynia, which is difficult to treat. Local application of anaesthetic gel into the vagina, local injections with lignocaine, etcare some of the treatment modalities.
Questions and Answers compiled by:
Dr.Shobhana Mohandas. MD.DGO.FICOG.
Consultant Gynaecologist, Sun Medical centre, unit of Trichur heart hospital,l, Thrissur, Kerala.
Women in their menopausal period may suddenly
develop depressive symptoms, like easy crying, easy irritability, or
sleeplessness. These symptoms are actually due to some changes
in their brain which were there even before menopause.
However, they manifest themselves at the time of menopause.
Thus it is called unmasking of depression, meaning, the depression
was already there, but gets unmasked at the time of
menopause. Usually at this time, the woman
also faces an "Empty nest syndrome". This means, till
about 40 years, her house was filled with echoes of her children
asking her for something or screaming
for something not done. But
suddenly they leave her and fly away to be on their own. She
suddenly feels unwanted and this adds to her symptoms of
depression. If it is severe, along with medicines to replace
deficient hormones, she may need antidepressant
Women in their menopausal period may suddenly develop depressive symptoms, like easy crying, easy irritability, or sleeplessness. These symptoms are actually due to some changes in their brain which were there even before menopause. However, they manifest themselves at the time of menopause. Thus it is called unmasking of depression, meaning, the depression was already there, but gets unmasked at the time of menopause. Usually at this time, the woman also faces an "Empty nest syndrome". This means, till about 40 years, her house was filled with echoes of her children asking her for something or screaming for something not done. But suddenly they leave her and fly away to be on their own. She suddenly feels unwanted and this adds to her symptoms of depression. If it is severe, along with medicines to replace deficient hormones, she may need antidepressant medications.
Some commonly faced problems are answered below'
Q1. My wife is menopausal and is very irritable. I have read that it could be due to menopause. Can you prescribe some hormones to cure it?
Irritability in the menopausal woman cannot be fully cured with hormones. If it is caused by hot flashes, and night sweats, hormone replacement will help. Otherwise, counseling and anti depressant medications may be needed.
Q2. My wife does not get sleep at night and feel like crying very often. Many doctors have asked her to take pills for sleeping . They say it is a psychological problem, but we have not given her any stress at home.
Crying spells and inability to sleep in the early waking hours of night are hallmarks of mental depression, caused due to reduced serotonin levels in the brain. It is not necessarily caused by stress in the house. It can be cured with medications. It may be aggravated in the menopausal woman due to fluctuations in the hormone level.
Q3. Why do women get irritable at the time of menopause.
Irritability at the time of menopause could be caused, either due to depression or due to hot flushes, which is an accompaniment of menopause.
Questions and Answers compiled by:
Dr.Shobhana Mohandas. MD.DGO.FICOG.
Consultant Gynaecologist, Sun Medical centre, Unit of Trichur Heart hospital, Thrissur, Kerala.