MENOPAUSE IN A NUTSHELL

Menopause is generally presumed when a woman has stopped her period for the last 12 months.  It is a normal aging process in every woman’s life.  It commonly occurs at the age of 45 to 55 years old.

From the medical point of view, menopause is associated with depletion of eggs (follicles) in the ovaries.  Every woman is born with a finite number of eggs.  These eggs grow and mature every month and ovulates to enable conception.  They also serve to produce the estrogen and progesterone hormones.  The estrogen hormone gives the woman its female characteristics.  Once this egg reserve is exhausted, there is a state of low estrogen (hypoestrogenism). This eventually leads to menopause.

The menopausal state is associated with initial troublesome vasomotor symptoms, followed by health risks including osteoporosis and heart complications in later years.

With better nutrition and medical advancement, women now spend almost a quarter of their life in this menopausal state. In order to age gracefully and live a fulfilled life, it is necessary for women to be aware of menopause and its consequences, and more importantly, to overcome its complications.

Menopausal consequence

The acute symptoms

Besides cessation of menses, the vasomotor symptom (hot flashes), vaginal dryness and sleep disturbance are regarded as core menopausal symptoms.  Most women experience a mild discomfort that eventually passed without much fanfare.  Only a small group of women requires medical treatment.  The severity of these symptoms are affected by variation in cultural and ethnicity (Asian over Caucasian), psychological wellbeing (attitude towards self and life) as well as psychosocial factors.

A hot flash is described as a sudden feeling of heat that rushes to the upper body and face.  It may last for a few seconds to several minutes and is associated with a troublesome sweating.  It is also common to experience vaginal dryness and painful intercourse.  The menopausal woman may have sleep disturbance (trouble falling asleep), reduced interest in sex (libido) and putting on weight.

Menopause Health risks

The estrogen hormone in women helps in absorption of calcium and maintains the bone density.  The low estrogen environment associated with menopause leads to a rapid bone loss and osteoporosis (brittle bone).  This is linked to pathological fracture (especially the spine and hip), and has a high morbidity and mortality in the elderly.

The estrogen hormone has a protective effect on the heart and blood vessel.  The low estrogen level during menopause exposes the women to risks of heart attack and stroke.

Aging gracefully

Menopause marks the end of a woman’s reproductive capacity.  The acute symptoms are usually troublesome but transient.  Many women overcome them through a positive life attitude and lifestyle modifications, rarely needing medical intervention. The long-term consequence of menopause has a more serious implication and medical prevention is helpful.

 

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ENDOMETRIOSIS: COMMONEST CAUSE FOR MENSTRUAL PAIN

What is endometriosis?

It is a condition which occurs when endometrial tissue (tissue that lines the womb), grows outside the uterus (womb).  These lesions can develop into painful growth in the form of peritoneal endometriosis or endometrioma. It is a hormone dependent condition.

 

What causes it?

The exact cause of endometriosis remains unclear.  It is widely believed that the backflow of menstrual fluid (via the fallopian tubes) into the peritoneal cavity during menses causes implantation of endometrial tissue.  This is known as the “Retrograde menstruation theory”.  However, researchers have also found that retrograde menstruation is a common occurrence in women yet not all women would develop endometriosis.

 

There is also other explanation from immunology aspect.  The susceptible woman may be associated with failure of the immune cells whose function is to remove this endometrial debris (from retrograde menstruation). This failure can be due to “defective/dysfunctional” of the immune cells.

 

Endometriosis has been reported to occur in any part of the woman’s body.  However, the commoner sites are ovary, peritoneal lining around the pelvic region and uterosacral ligaments.

 

What are the symptoms of Endometriosis?

Any woman who is still menstruating is at risk of developing endometriosis.  The most common symptoms include:

  1. Painful menses (Dysmenorrhea)
  2. Pain during sexual intercourse (Dyspareunia)
  3. Heavy or irregular bleeding
  4. Chronic pelvic pain
  5. Difficulty to conceive (subfertility)

 

 

What are the effects of endometriosis?

The pain from endometriosis may cause the women to require painkiller and risk addiction/ dependent on it.  They are also less productive, missing from work and confined to bed during menstrual pain.  Others have reported symptoms of depression and mood swing associated with this condition

 

Women with endometriosis also can have problem with fertility.   The pain during sexual intercourse (due to distortion of internal pelvic anatomy) can cause anxiety during coitus.

 

The repeated inflammation process of endometriosis causes adhesion and distortion of the fallopian tube.  Endometrioma also affect the quality of ovarian function.  All these pathological process and infrequent coitus due to pain contributes to difficulty to conceive (subfertility).

 

How is a diagnosis made?

A typical medical history and pelvic examination findings will probably suggest the diagnosis. However, in order to define endometriosis, a diagnostic laparoscopy is needed.  During laparoscopy, the condition of pelvic organs (uterus, fallopian tubes, ligaments and ovaries) can be assessed, endometriosis lesion and extent of the disease noted.  The severity of disease is scored according to AFS (revised) criteria.

 

Treatment

1.  Analgesia (painkiller)

This is usually gives during the acute phase (menstrual pain). It provides useful symptom relief but does not change the course of the disease.  These analgesia can be in the form of oral or injectables.

 

2.  Hormonal

The hormonal therapy seeks to modify the course of the disease by suppression of the estrogen hormone.  The deprivation of estrogen hormone will shrink the endometriosis lesion.  Some of the hormonal treatment include Danazol, oral contraceptive pills (OCP), progestogen injection (Depo Provera), Progestogen-IUD (Mirena) and GnRH agonist (Lucrin, Zoladex).

 

3.  Surgery

Conservative approach

Conservative surgical treatment is designed to preserve the ability of a woman to bear children in the future. The approach focuses on removing/ destroying the endometriosis lesion and restores the pelvic anatomy.

 Non- conservative approach

This approach includes the removal of the uterus and ovaries and renders the woman menopausal.  It is the definitive treatment for endometriosis but does not preserve fertility.  Non- conservative surgery should only be considered in woman who does not want to conceive or age more than 40 years (with option of HRT).

 

Summary

Treatment of endometriosis is individualized to the woman’s priority.  The presenting symptom, need to preserve fertility and age are the main consideration when deciding on the treatment choice.

WOMAN WITH SEVERE MENSTRUAL CRAMPS (DYSMENORRHEA)

Menstrual cramps (dysmenorrhea) are used to describe pain over the lower abdomen during menstrual period. It is a common condition affecting most women. This symptom varied in severity. It can be just a mild discomfort or an excruciating experience. The debilitating effect of this menstrual cramps results in absenteeism and loss of productivity.

Menstrual cramps can be broadly classified into primary and secondary dysmenorrhea. This allows differentiation between a ‘physiological cause’ from one that needs further investigations.

Primary dysmenorrhea results from the uterus (womb) trying to expel the menstrual blood. This symptom is common among women who has not conceived before. The strong uterine contractions resulted in release of pain substance. The pain is felt during the day of heaviest flow, usually on second day of menses. This symptom is observed to improve following childbirth.

Secondary dysmenorrhea refers to menstrual cramps that occur before and may last until after menses. It usually indicates the presence of underlying pelvic disease that needs further investigations.

This above differentiation generally allows doctors to make clinical decision whether to proceed with other investigations. However, there are certain exceptions which your doctor may want to exclude pelvic diseases even though the symptom is mild or of primary dysmenorrhea. Therefore, it is important to consult your doctor.

Among the common causes are endometriosis, chronic pelvic inflammatory disease, adenomyosis and uterine fibroid. The pelvic ultrasound scan and laparoscopy are useful tools to investigate this condition.

Doctors often use painkiller and advise hot compress to relieve the painful symptom. The definitive treatment will depends on cause of dysmenorrhea.

(See also Endometriosis)  Link below:

https://womenshealthtoday.wordpress.com/womens-health/endometriosis/