Menopause is an essential phase that every woman is going to pass through. It is defined as 12 consecutive months of amenorrhea due to the lack of ovarian function and it’s associated with the inability to reproduce. It is estimated there will be some 35,000,000 women alone passing through the menopause this year. So we as OB-GYN physicians and other health care professionals, have an obligation to learn all about the menopause, the problems, the solutions, the options that are associated with the menopause so we can better counsel our patient’s. Some hundred years ago, the average life expectancy for women was 52 years. Currently, the average life expectancy is 82 years, and since the average mean of menopause has remained constant at 51, that equates to about 30 years of lifetime in the menopausal phase, or about a third of a woman’s lifetime. That is a lot of time and a lot of potential for problems and a lot of confusion during this time. It’s a complex event, not only characterized by changes, biologic and social and psychologic function, but it is rooted in changes in hormones. These hormones are very complex in that they affect various target organs as well as the brain, in terms of causing a chemical imbalance and changes in stress hormones and various other factors that affect the quality of life.
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It’s not as easy as we used to think that just passage through the menopause was associated with some hot flashes. We now know it affects every organ system within a woman’s body. The main hormones that we are concerned with during the menopause that are the basis for the changes, are primarily changes in the pituitary hormones, FSH and LH, FSH is the main marker that we use during the perimenopause and into the early stages of menopause to actually mark the menopause. During the reproductive years in the early follicular phase of a woman’s cycle, the FSH should be less than 10. As she is approaching the menopause or in the perimenopausal phase, which means that a woman is still having some menstrual cycles, although she may be having some vasomotor symptoms, but she is still having a menstrual cycle occasionally, the FSH will fluctuate, and it’s very important to measure that FSH in the first five days of the menstrual cycle because that is the time that it’s the most accurate. The FSH will fluctuate anywhere from 5 to 30. After the menopause, the FSH no longer is fluctuating, it is well over 50. That is associated with significant drops in other hormones, particularly the bioactive estrogen which is estradiol. During the reproductive phases and the early follicular phase, the estradiol states at low levels of 60 to 80, will rise up to 200 and back down to 60 or 80, where as during the perimenopause, it may start to fluctuate down into the 20 range and by the menopausal years, the active estradiol remains pretty constant between 20 and 40 picograms per ml. Progesterone is no longer being secreted in the menopause, so the levels will be extremely low. The adrenal hormones such as DHEA change very negligibly during this time, but the hormone testosterone which is the primary male hormone made by the ovary will drop to about half of what is normal, which accounts for some change in sexual function.
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As a result of the changes that we see primarily associated with a drop of estradiol, we see some of the early symptoms that are classified as the vasomotor symptoms, such as hot flashes, night sweats, subsequent changes in sleep patterns resulting in insomnia and lack of sleep resulting in irritability, mood disturbances, depression, and then further along we start seeing changes in the urogenital tract accounting for atrophy, changes in bladder function, and changes in overall skin texture, and then the long term sequelae of estrogen depravation can result in cardiovascular disease, osteoporosis, dementia of the Alzheimer’s type and also certain types of cancer. It’s a complex event that is occurring because during this time, we are weighing quality of life issues versus medical conditions versus various propensities for heart disease and cancers. Perhaps the most common or cardinal feature of the menopause is the hot flash. Viagra professional. This affects some 75 to 80% of women, usually occurring within the first year of the menopause, although it can occur earlier. We don’t quite understand it, we know it has to do with abrupt changes in estrogen that change the neural chemicals of the brain, or the catechol estrogens, it is a very brief event, lasting only 3 to 5 minutes and it’s associated with changes that occur at the nipple line and work their way up to the top of the head. It is associated with skin flushing, associated with palpitations, however, no change in the heart rhythm, and then a perspiration that occurs. Some women have one to two hot flashes, other women have 50 to 60 hot flashes and there are no factors that associate which woman will have more hot flashes versus others. We do know that there is a difference in vasomotor symptoms, and those women who undergo a natural menopause versus those who undergo a surgical menopause or those that have had both ovaries removed. In a surgical menopause, there is an abrupt drop in all of the estrogens as well as the testosterone. As a result, 100% of women who undergo a surgical menopause have some type of vasomotor symptomatology. Their symptoms tend to be much more severe, seeking medical attention much more frequently, and last a lot longer.
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During the natural menopause, duration of symptoms are usually three to four years. After surgical menopause, women will continue to have vasomotor symptoms up to 10 years, so leaving them on some type of hormone replacement for five or six years may not be enough. These women may require prolonged treatment with various agents such as hormone replacement, or estrogen alternatives. The estradiol levels and testosterones levels are characteristically much less in these patient’s, and often times, this is basis for the use of an estrogen androgen preparation, particularly in the surgical menopause patient.