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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). 

Hot flushes:

What are hot flashes?
Hot flushes are sudden or mild waves of heat on the upper part of the body that last from 30 seconds to a few minutes, caused by a decreased estrogen production during menopause. Hot flushes are typically experienced as a feeling of intense heat with sweating and rapid heartbeat, and may last from two to ten minutes for each occurrence. The sensation of heat usually begins in the face or face and chest, although it may appear elsewhere such as the back of the neck, and it can spread throughout the whole body. In addition to being an internal sensation, the surface of the skin, especially on the face, becomes hot to the touch. The sensation of heat is often accompanied by visible reddening of the face.
The hot flush event may be repeated a few times each week or constantly throughout the day, with the frequency reducing over time. Some women undergoing menopause never have hot flushes. Others have mild or infrequent flushes. The worst sufferers experience dozens of hot flushes each day. In addition, hot flushes are often more frequent and more intense during hot weather or in an overheated room. Hot flashes may be accompanied by perspiration and shivering, increased heart rate and/or feelings of irritation, anxiety, or panic.
Will all women going through menopause get hot flashes/flushes?
Not all women going through menopause get hot flashes. Various studies quote various figures for the percentage of women suffering from hot flashes at the time of menopause. The quoted figures vary from 56% (2) to 79% .

What are night sweats?
Night sweats, medically termed "sleep hyperhidrosis," are episodes of nighttime sweating, which can range from mild to profuse. They usually accompany hot flashes, and thus the usual accompaniments of hot flashes,viz: nausea, chills, headache, etc may accompany episodes of night sweats.
Will women who suffer from hot flashes and night sweats begin to suffer immediately after menopause?
Hot flashes can begin during the late premenopausal or early perimenopausal years, but they become more frequent and severe during the late perimenopausal and early postmenopausal years. Hot flashes can last from a few seconds to more than an hour and persist for 1 year in 95%
of affected women and up to 5 years in 65% of affected women.4–6 Hot flashes are not confined to the menopause transition associated with natural age-related decline of estrogen and progesterone.
Hysterectomy, by itself can, with or without oophorectomy, cause hot flashes in 95%–100% of women.

What are the factors that trigger hot flashes or night sweats?
Spicy foods and hot drinks can trigger hot flashes. Stress cannot trigger hot flashes, but,it is possible that stress of of midlife transitions (aging parents, empty nest, retirement) or other stressful events may increase the frequency and/or intensityof hot flashes. (4).
What is the treatment for hot flashes?
In mild cases, physical measures like avoiding synthetic clothes, spicy food, too much caffeine or alcohol, keeping a cool environment, avoiding layered clothing, etc, may help. Meditations, deep breathing exercises, and measures to reduce stress can all help.
However, in severe cases, medications called oestrogens, will be required. Treatment with oestrogen, is called hormone replacement therapy. Non-hormonal treatment like isoflavone tablets may suffice for milder symptoms. There are many other medications also available for treatment of hot flashes, for women who are not fit candidates for oestrogen treatment.
How long will a woman suffering from hot flashes have to take hormone drugs, if at all they are prescribed?
Usually hot flashes last only for 3-5 years, and drugs will be needed only for that period. However, each individual is a different person, and the duration of therapy has to be tailored as per the requirements of that person, by the doctors prescribing the medication.
Is oestrogen available in food?
Ostrogens made by plants, called phytooestrogens are available inlarge amounts in food products like soy products, and sesame seeds(til). Smaller amounts are available in chickpeas(Bengal gram, channa), garlic, Mung bean sprouts, dried apricots, dried dates, sunflowerseeds, almonds, green bean and peanuts.
They are not as potent as the oestrogens made by the human body, but they have much less side effects compared to human oestrogen. Japanese and other Asian communities


Sleep disturbance:

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.

Vaginal dryness and increased frequency of urination

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.

Email: shobhanamohandas@yahoo.co.in.

Mental disturbances




.   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.

Email: shobhanamohandas@yahoo.co.in.













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