IN previous centuries, women were not expected to live beyond
menopause.
With gradual increase in life expectancy over the last century,
women now spend one third to one half of their life after
menopause. In Malaysia, the life expectancy of a female is
approaching 74 years.
Clinically, menopause is defined as the cessation of menstrual
cycles and results from either follicular depletion (natural
menopause) or surgical removal of the ovaries (induced or surgical
menopause).
The secretion of the ovarian hormones, oestrogen and
progesterone ends with menopause. However, menstrual cycles seldom
cease abruptly.
There is an interval termed the ``perimenopause'' or
``menopausal transition'', during which there are considerable
hormonal fluctuations.
Natural menopause occurs at a median age of 51.4 years, ranging
from 40 to 58-years-old.
Hot flushes are early symptoms of menopause. It can occur in the
climacteric (the time from the decline in reproductive capacity
onwards) before the cessation of menses.
Its intensity is maximum for the first two years although it can
persist as long as 15 years. It tends to be more severe in
surgically-induced menopause.
It can lead to a lack of sleep, irritability and depression.
Mood changes and decline in cognitive function can also occur. All
these symptoms can easily be treated with oestrogen therapy with
excellent results.
Dry vagina is another early symptom that starts about six months
after cessation of periods. This can lead to dyspareuria itching,
postcoital bleeding as well as vaginitis.
Skin changes also occur during menopause. Loss of collagen is
rapid in the first five years while wrinkling and dry skin can
occur earlier. In the urogenital system, loss of collagen can lead
to uterovaginal prolapse as well as urinary incontinence.
Besides dryness of the eyes, full thickness mascular
degeneration is more severe after menopause. But cataract formation
is less with women on hormonal replacement therapy (HRT).
The cardiovascular system is a major system involved in the
menopause.
Oestrogen protects against coronary artery disease to a large
extent before the menopause.
The skeletal system is also a major site for the effects of
oestrogen deficiency. Osteoporosis leading to fractures is a known
complication after menopause. The dreaded fracture in the hip is a
leading cause of morbidity and mortality.
How do women perceive menopause? A study found that
well-educated, middle-aged women defined menopause as a normal
developmental process as: cessation of menstrual cycles end of
reproductive ability a time of hormonal changes a change of life a
changing body a time of changing emotions an ageing process These
women did not consider menopause primarily as a time of symptoms
and increased disease risk, or a time for medical care.
What preventive medicine should be provided for postmenopausal
women to increase mortality rates? Smoking cessation to prevent
lung cancer should be the emphatic message of all health providers.
Postmenopausal women should be carefully screened for breast cancer
risk factors. Risk could be assessed on the basis of family
history, fertility, and age at menopause and first pregnancy.
Preventive measures necessitate frequent self-examination, and
annual mammography in women older than 40 years should be
encouraged. For cardiovascular diseases (CVD), it is important to
assess family history and such risk factors as blood pressure,
cholesterol level, diabetes, smoking poor diet and lack of
exercise.
Such lifestyle factors as diet, exercise and weight control are
important in determining a woman's risk for CVD, osteoporosis,
diabetes, breast cancer and depression. Menopause is a high-risk
time for weight gain. Although the average weight gain during the
menopausal transition is one to two kilogrammes, it can be much
greater.
In addition, the hormonal driven shift in fat distribution from
peripheral to abdominal, which may begin even before menopause, may
increase health risk. Together, diet and exercise are crucial
components of preventive medicine for women pre-, peri-and
postmenopause.
A diet rich in fruits, vegetables, whole grains, nuts and
low-fat dairy products; low in saturated fat, cholesterol, sugar
and refined carbohydrates, and emphasising chicken and fish rather
than red meat can reduce body-mass index (BMI), increase the good
cholesterols and lower the bad cholesterols, and hence reduce blood
pressure and blood glucose.
A trial of dietary study in women with extensive areas of
radiologically dense breast tissue (a risk factor for breast
cancer) has shown that, after two years on a low fat, high
carbohydrate diet, there is a significant reduction in the area of
dense breast tissue, particularly in women going through menopause.
Exercise is a must for postmenopausal women. A study conducted
has shown that brisk walking and vigorous exercise are strongly
associated with a reduced risk for coronary events.
In the study, even sedentary women who became active in midlife
and/or later, had a reduced risk of coronary events compared with
their sedentary counterparts.
So, when and why should a postmenopausal woman be given
oestrogen replacement therapy such as HRT? There are sufficient
studies showing that all-cause mortality is reduced in women who
receive oestrogen replacement therapy, principally because of a
reduction in CVD.
Whether or not HRT should be considered is a very individual
decision, which must take into account symptoms, risk factors and
individual preferences and needs. Alternatives should also be
carefully considered.
If hormonal therapy is chosen, there should be flexibility in
prescribing-there is no ideal for every woman.
Many women express fear regarding HRT, especially because of the
associated risk of breast cancer.
In the US, many women believe that the leading cause of death in
women is breast cancer. Many also believe that only a small
percentage of deaths are attributable to CVD. The actual truth is
just the reverse.
One in three women older than 65-years-old has some evidence of
CVD, and the risk of breast cancer after 65 is one in 36. In terms
of mortality, the case fatality rate of CVD is several times
greater than that of breast cancer.
HRT is indicated for the relief of vasomotor symptoms associated
with menopause, treatment of vaginal atrophy, and prevention and
treatment of osteoporosis. HRT may be prescribed for short-term
relief of symptoms, but clinicians should be prepared to discuss
with their patients the use of HRT for long-term protection-not
only as protection against osteoporosis but also as potential
protection against CVD, cognitive decline and Alzheimer's disease.
These long-term benefits are sustained as long as HRT is
prescribed; the benefits decrease after cessation of HRT.
HRT is not without risks, including endometrial disease, breast
cancer, vaginal bleeding, somatic complaints (for example breast
soreness), and idiosyncratic reactions (for example hypertension
and venous thrombosis).
Endometrial disease occurs with unopposed oestrogen therapy in
women who have a uterus. A woman's risk of developing endometrial
cancer with unopposed oestrogen use is two to eight fold higher
than that for the general population. Although the risk of
developing endometrial cancer is increased significantly in
oestrogen-only users, the risk of death from this type of
endometrial cancer does not increase proportionately.
Endometrial cancers associated with oestrogen use are thought
not to be as aggressive as a spontaneously occuring cancers.
However, it may be that tumours in women taking oestrogen are more
likely to be discovered and treated at an earlier stage, thus
improving survival rates.
Most controversial is the risk of breast cancer with HRT. The
vast literature on the subject is confused, but the consensus would
accept the view that there is a 2.3 per cent increase of breast
cancer for each year of HRT use, which levels off after stopping
use. Women should consider stopping oestrogen therapy after 10
years.
One of the greatest concerns of women taking HRT is the return
of vaginal bleeding. Some women find the bleeding bothersome or
worry that it may be a sign of cancer. Somatic complaints such as
breast tenderness and bloating may also occur but can be alleviated
by alterations in dosage and type of preparation. Recurrent
bleeding during HRT treatment causes many patients to stop
treatment. Bleeding is one of the most common reasons for
discontinuance of HRT.
Menopause is not a disease, but it does have serious clinical
consequences.
The aim of HRT is to provide oestrogen replacement in a fashion
that is as physiologic as possible. This subscribes to the motto of
``My Body, My Life, My Choice'' for every woman.
This article was based on a lecture ``Menopausal Related
Problems in the Elderly'' by Professor Raman Subramaniam and Dr
Ravindran Jegasothy at a seminar conducted recently.
Copyright 2000 NEW STRAITS TIMES-MANAGEMENT TIMES all rights
reserved as distributed by WorldSources, Inc.
