DR SACHIN VIJAY NAIKNAWARE. GYNAEC LAPAROSCOPIC SURGEON.
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starting from birth there are many biological,physiological and psychological changes in womens life from puberty to menopause.starting from menstrual cycle during puberty there is usually a monthly menstrual cycle to its permanent cessation which is called as menopause. when the menstrual cycle stops for a period of 12 months is known as menopause which occurs due to cessation of ovarian function.
the process of menopause is not a abrupt change but it is a gradual change. the age at which menopause occurs ranges between 45-55 years. the average being 50yrs. but there is no reliable test to predict when a women will experience a menopause, tus it is a retrospective diagnosis.. the menopausal transition starts with varying menstrual cycle length and end with the final menstrual periods. peri-menopause is a term sometimes used to describe “the time around menopause” in the same way post-menopausal is the period after menopause. due to increased life expectancy about 1/3rd of womens life will be spent in postmenopausal period.
HORMONAL CHANGES DURING PREGNANCY:- some years prior to menopause there is depletion of ovarian follicles and follicles become resistant to pituitary gonadotrophins, which leads to decreased estradiol production -this decrease the negative feedback effect on hypothalamus-pituitary axis resulting in increased FSH which subsequently causes increased LH. then as the follicle count deceases oestrogen production drops down to optimum level of 20pg/ml which is necessary for endometrial growth leading to absence of menstrual cycle.
as ovarian oestrogen production decreases ovarian stroll cells continue to secrete Androgen because of increased LH, resulting in decreased oestrogen:androgen ratio causing facial hairs to grow and changes in voice after menopause. obese patient convert more androgen to oestrogen and so less likely to develop symptoms of oestrogen deficiency and osteoporosis, but they are more prone for endometrial hyperplasia and endometrial carcinoma.
along with changes in oestrogen and progesterone production and androgen, there is increased secretion of LH & FSH due to absent feedback effect of estradiol or due to enhanced responsiveness of of pituitary to GNRH. along with hormonal changes, there are changes in other body organs also.
1.ovarian shrinkage with coracle thickening and increased medullary component.
2. uterus becomes smaller with body of uterus to cervix ratio 1:1.
3.vagina loss its elasticity and become narrower.PH become alkaline.
4. breasts becomes flat and pendulous due to fat absorption and gland atrophy.
5. bladder and urethral epithelium undergo atrophic changes with recurrent UTI.
6. muscle tone decreases which may lead to pelvic organ descent or prolapse.
Menopause not only is associated with absence of menstruation but it causes many genitourinary,vasomotor and psychological symptoms and few health hazards due to hormonal deficiency, most prominent of which is “HOT FLUSHES” a flash is feeling of warmth spreading over body and pronounced in chess and neck and may sometimes associated with facia fishing and intense perspiration, lasting usually for 30 seconds to few minutes. Approximately 40% of women in menopausal period may feel the flashes sometimes or other, presently there is no diagnostic test or method which will predict when hot flashes will occur and how long will they lasts,sometimes they are associated with night sweats which may cause awakening or there s difficulty in falling asleep and associated daytime tiredness.
Few women in menopausal period may develop thinking and emotional symptoms which include but not limited to irritability, fatigue,sudden mood changes, mood swings and memory problems.
Genitourinary symptoms also predominates in this period including atrophic vaginitis,endometritis,urinary urgency or frequency,dysuria, stress urinary incontinence and recurrent urinary tract infection.
Significant health hazards related to menopausal periods are directly due to hormonal deficiency are osteoporosis,and cardiovascular diseases. following menopause there is decline in collagen organic matrix affecting vertebral bodies, femoral neck and distal end of radius with greater liability for fractures.also there is increased osteoclastic activity leading to greater bone resorption.
Prior to menopause women have a decreased risk of heart disease and stroke as compared to men but around menopause risk for cardiovascular disease increases may be due to rise in lipid levels of both triglyceride and cholesterol and LDL increase more as compared to HDL.
Presently for diagnosing menopause no single reliable hormonal or any other test is available but few tests can be done as an indicator with retrospective absence of menses for a period for 12 months as a diagnostic tools. some indicators are
- cessation of menses for a continuous period of 12 months.
- serum estradiol level less than 20 pg/ml.
- serum LH & FSH level more than 100 min/ml.
- vaginal cytology smear showing features of low oestrogen maturation index.
CONCLUSION:- Menopause is a normal pert of life and not a disease that require treatment. however treatment of associated symptoms is necessary if they are severe and causing lifestyle disturbances. starting with non hormonal treatment which includes healthy nutritious diet, regular exercise,supplementary calcium and in some cases SSRI shown to be effective in reducing hot flushes in around 60% of symptomatic women and not the least Clonidine -an alpha adrenergic agonist may be used to reduce the severity and duration of hot flushes.
Hormone replacement therapy is indicated to overcome the short term and long term consequences of oestrogen deficiency and to ensure potential benefit and to minimise the risks and to prevent osteoporosis,atherosclerosis,cardiovascular diseases, urogenital atrophy and degenerative skin changes.