Menopause is a pivotal event in the life of every woman, as it brings to an official end the years of menstruation, and by the same token, signals the almost complete cessation of the reproductive capability of the individual. It is identified by the absence of menstrual periods for 12 or more successive months without the presence of lactation or other physiological causes.
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Medical Complications of Menopause
Menopause is often dreaded by women, not only because of the implications of approaching old age that it carries, but because of the many symptoms it brings with it such as anxiety and depression; loss of libido and vaginal dryness; hot flashes and night sweats; and disturbances of sleep and concentration. These may begin years before menopause, and continue to show themselves for up to seven years afterward.
However, other complications are potentially more serious than these. Post-menopausal women may experience cardiovascular problems, decreased bone strength, weight gain, bladder incontinence, and increased fat mass. Altogether, menopausal symptoms are a real problem for many women, affecting the quality of life enough to cause loss of productivity and health.
Changes in the pattern of the menstrual cycle occur for several years before periods finally cease. Some women have delayed cycles, others have frequent periods. Some have light bleeding, others heavy. Still, others simply continue to have shorter and lighter cycles until they finally cease.
Although menopause is a physiological event, it is accompanied by a higher risk of some diseases, namely, osteoporosis and fractures, as well as heart disease.
Cardiovascular Disease
Within menopausal women, cardiovascular risk increases, ascribed to the combined effects of vasoconstriction and unfavorable changes in the lipid profile. Both stroke and coronary artery disease are increased to 2-3 times higher than in pre-menopausal women. HRT to prevent cardiovascular risk is best started within 10 years of the last period, below the age of 60 years, and in women without a history of smoking and with a favorable lipid profile.
Osteoporosis
Bone strength is significantly reduced after menopause due to estrogen deficiency, beginning at around the age of 40. At this time, 0.3% to 0.5% of bone is lost each year, escalating ten times over the 5-7 years following this. However, the risks of HRT mean that despite this danger, women should try other safer measures to improve bone health. This includes exercise, the cessation of smoking, and supplementary calcium.
Urinary Incontinence
Women nearing menopause may find they have poor bladder control, especially during sneezing, coughing, laughing, or lifting somewhat heavy objects, with a higher incidence of urinary infections.
Urovaginal dryness may also make sexual intercourse painful, leading to a secondary loss of libido aggravating the reduced sexual desire due to hormonal changes themselves. The resulting relationship changes may push this into a vicious cycle.
Effects at the Workplace
Menopausal symptoms that could affect workplace performance include hot flushes, heavy periods, urinary urgency and incontinence, poor sleep, headaches and migraines, low mood, irritability, anxiety or panic attacks, with loss of concentration and memory, among others. Failure to understand the reasons for a deterioration in performance or the need for breaks or days off during this period could lead to discriminatory action against women.
Dangers in Overlooking Medical Conditions
One danger is that in assuming that all these changes are due to menopause or its approach, the presence of organic illness may be overlooked. For instance, amenorrhea could be due to pregnancy, diseases of the endometrium such as Asherman’s syndrome due to scarring following curettage, tuberculosis, or endometrial cancer.
Changes in the bleeding pattern may be a sign of reproductive tract cancers or tumors, anemia, thyroid conditions, or other endocrine conditions.
Dysfunction of the endocrine axis that regulates the functioning of the endometrium could also be overlooked, with some possible reasons being obesity, malignancy, or anorexia nervosa, as well as abnormally high prolactin levels, all operating at the level of the brain. Ovarian dysfunction could also be present, including polycystic ovarian disease and premature ovarian failure, or ovarian tumors.
An orderly workup should help distinguish these causes from one another. The levels of follicle-stimulating hormone (FSH) are helpful in this especially when menopausal vasomotor symptoms are present. FSH levels above 25 IU/L typically indicate that menopause is imminent or has set in, confirmed by levels above 40 IU/L for a year or more following the cessation of periods.
After 3-6 years of amenorrhea, the FSH levels plateau, with the ovaries showing very few antral follicles, and signs of urogenital atrophy setting in. Vasomotor symptoms eventually fade on an average of 7 years.
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Dangers in the Treatment of Menopause
Many women have heard about menopausal hormone replacement therapy (HRT). This form of treatment is based on the hypothesis that menopausal symptoms are due to estrogen deficiency. HRT aims to minimize the disturbances due to menopausal symptoms and avert the long-term complications listed above.
Both estrogen and progesterone may be used, or estrogen alone. Either way, it may be given as oral tablets, creams, or patches for skin use. Again, a single dosage may be used throughout, or the dose may vary to better reflect earlier cyclic changes in hormone levels.
Estrogen alone; estrogen and progesterone; progestin alone; combined oral contraceptives; all may be used to treat vasomotor symptoms and vaginal atrophy and prevent bone loss while keeping the lipoprotein profile healthy. However, it must be noted that the use of hormone therapy is associated with an increased risk of several serious and life-threatening conditions.
These include breast cancer, ovarian cancer, thromboembolic events, stroke, and cardiovascular disease. The breast cancer risk goes up primarily due to the increase in breast tissue mass over the first year after commencing therapy and is increased after 3-5 years of combined therapy, but 7 years after using estrogen alone.
Other health risks associated with the use of HRT include vaginal bleeding, urinary incontinence, dementia over the age of 65 years, cardiovascular events including stroke, blood clots, and heart attacks until the cessation of therapy, as well as the reduced effectiveness of mammograms for the early detection of breast cancers. It is important to balance this with the knowledge that overall mortality does not increase with the use of HRT.
“It is currently believed that, overall, the risks of long-term (more than five years) use of HRT outweigh the benefits.”
For these reasons, “hormone therapy should only be used for the shortest duration of time and at its lowest effective dose.” Moreover, HRT is advised against in women who have had breast or endometrial cancer in the past, thromboembolism of the deep veins, pulmonary embolism, liver disease, and cardiovascular disease. The risk is lower with the use of vaginal pessaries, but thromboembolism is still seen in a few uncommon cases.
Menopausal symptoms by themselves may well compromise the quality of life, which is further worsened by the above conditions. Nonetheless, in view of the small but definite risks of HRT, it should be reserved for those who are unable to cope with these changes. Other treatments should also be used only when truly indicated.
Raloxifene, Bazedoxifene, and Ospemifene are three relatively safer selective estrogen receptor modulators (SERMs) that copy the action of estrogen. These are often used to prevent osteoporosis and maintain a healthy cholesterol level. Non-hormonal agents like gabapentin, pregabalin, paroxetine, fluoxetine, and clonidine have all been shown to cause a reduction in these symptoms.
For otherwise healthy and active women, with the threat of osteoporosis, bisphosphonates, or calcium/vitamin D will offer protection against osteoporosis. The former may cause adynamic bone if taken at high doses and for a long period, which mandates the stopping of this drug from time to time. Gratifyingly, the increase in bone density persists for a few years.
Many complementary and alternative therapies, and drugs used in modern medicine, are being prescribed nowadays as treatments for menopause, though there is little evidence as to their efficacy. Complementary and alternative medicine offers herbal preparations as well as supplements. These include phytoestrogens, vitamin E, and omega-3 fatty acids. Though rigorous proof of efficacy is unavailable in most cases, they are relatively safe – but that does not justify their irrational use.
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The Problems of Ignoring Menopause
It is probably better to focus on lifestyle changes for the woman who finds it difficult to cope with the changes occurring at this time, along with mental health support. A diet rich in vitamins and calcium, regular exercise, adequate sleep and rest, maintaining a healthy weight, and a network of friends who can provide healthy mental and physical companionship and stimulation, could go a long way in supporting the health of women during this period, which may last for years.
Urinary incontinence may be managed in mild cases by Kegel’s exercises of the pelvic muscles, as well as the judicious use of estrogen vaginal creams, rings, or tablets to restore the fulness of the vaginal tissues. This could go a long way in restoring social self-confidence. The same therapy is also useful for restoring sexual desire, along with the use of water-based lubricants.
Simultaneously, support at the workplace for those women who find their functioning severely impaired, whether in terms of physical symptoms, the loss of emotional equilibrium, or a general impairment of cognitive skills, should be mandatory. About one in 3 women will be or has recently passed through menopause, and 80% would have symptoms. In almost half the cases these symptoms would be difficult to deal with.
Along with menopausal symptoms, women at this age may be also facing increased home-related caregiving burdens and responsibilities, as well as age-related medical conditions, all of which may act together to significantly impair their performance at work. Some experts point out, “Many women find that adapting problematic symptoms around inflexible work expectations is just too difficult. Others may find that managing symptoms mean they miss out on promotions and training, reduce their hours, lose confidence in the workplace and see their pay levels drop, all contributing to a widening gender pay gap.”
These days, when elderly women in the workforce are becoming much more common, ignorance about menopause could not only cause difficulties in pursuing full-time vocations but could pose medical harm. The complications of menopause must be recognized, as well as a potential injury due to medications. Finally, mental ill-health must be recognized and treated as with any other psychological condition.
The chief obstacle to a rational understanding and management of menopause is the perception that it is a “woman thing”, mainly a matter of taking charge of one’s feelings and getting over it without making a fuss. While women must be encouraged to cope with their symptoms and health risks, this does not mean dismissing their real discomfort and, in some cases, misery.
One government document comments, “The evidence paints a consistent picture of women in transition feeling those around them at work are unsympathetic or treat them badly, because of gendered ageism.” This may be even more difficult for non-White women who are more likely to be casual workers.
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Further Reading
Primary care settings failing to address women's hot flashes