Menopause what is it??
Menopause is a natural biologic event, not an "estrogen deficiency disease." Menopause represents the permanent cessation of menses resulting from loss of ovarian follicular function. Menopause is also a psychosocial passage. At menopause, the decline in ovarian hormones (particularly estrogen) may result in short-term, unpleasant effects such as hot flashes that adversely affect quality of life, and may increase the risk of osteoporosis and possibly coronary heart disease.
Menopause happens to all women, but affects each woman uniquely. For some, the end of fertility (and the end of concerns about contraception and menstrual periods) brings a sense of freedom. Menopause is a bridge to a part of life when many women report feeling more confident, empowered, involved, and energized than in their younger years. For some women, however, menopause -- coupled with midlife emotional and social crises -- can contribute to serious health problems. It is a time before and during whhich women should be concerned about bone loss and osteoporosis. Calcium intake is an important supplement to be taking at a rate of about 1200mg per day. Bone loss can attribute to hip fractures and vaious broken bones.
One thing is true for all women: menopause is a signal to start -- or continue -- a good health program. Clinicians are urged to utilize an individualized approach to "menopause management or hormone therapy ( HRT ) ," because no intervention is appropriate for every woman and each option has a risk/benefit profile unique to each woman.
Because of current population shifts, a woman's health after menopause has assumed greater importance than ever before. The ideal goal is that of maximum vigor until death. Although some decline is unavoidable, much of what is considered as normal aging can be modified with lifestyle and pharmacologic interventions. Menopause is a time for women to evaluate their health and lifestyle practices.
Menopause can occur naturally (ie, spontaneously) or be induced through a medical intervention (ie, surgery, chemotherapy, or pelvic radiation therapy).
DEFINITIONS - The Council of Affiliated Menopause Societies (CAMS) of the International Menopause Society (IMS) has developed standardized definitions for menopause-related events. In October 1999, the IMS voted to use these definitions worldwide (See Figure 1).
Menopause (natural menopause) - Menopause (ie, "natural" or spontaneous menopause) is defined by CAMS as the following: "The permanent cessation of menstruation resulting from the loss of ovarian follicular activity. Natural menopause is recognized to have occurred after 12 consecutive months of amenorrhea, for which there is no other obvious pathologic or physiologic cause. Menopause occurs with the final menstrual period, which is known with certainty only in retrospect a year or more after the event. An adequate independent biological marker for the event does not exist."
In the Western world, menopause occurs at a median age of 51.4 years, with a Gaussian distribution ranging from 40 to 58 years. Some women reach menopause in their 30s, and a few in their 60s. Although there has been an increase in life expectancy over the years, the age of menopause has not changed over the past few centuries -- unaffected by improving nutrition and reduction of disease. In previous centuries, few women lived beyond menopause; today, women spend one-third to one-half of their lives after menopause.
Two factors have been identified as influencing when menopause occurs: Familial factors as well as genetic polymorphisms of the estrogen receptor influence the age of onset of perimenopause (as well as infuencing the risk for surgical menopause).
Current smoking has been identified as a cause of earlier menopause, producing a shift of approximately 1.5 years. There is a dose-response relationship with the number of cigarettes smoked and the duration of smoking.
Limited data support the association of the timing of menopause with the following: Multiparity (ie, more than one pregnancy) and increased body mass index (BMI) are associated with menopause occurring later than average. Nulliparity (ie, history of no pregnancy), medically treated depression, toxic chemical exposure, and treatment of childhood cancer with pelvic radiation and alkylating agents are associated with menopause occurring earlier than average.
Higher cognitive scores in childhood are associated with a later menopause.- No link has been found between menopause age and use of oral contraceptives, socioeconomic or marital status, race, or age at menarche. Menopause (permanent ovarian failure) means the end of natural childbearing (without assisted reproductive techniques). Menopause is one point in time. The misnomers "in menopause" and "going through menopause" accurately describe perimenopause. It is appropriate to say that one "reaches" menopause.
Premenopause - According to CAMS, the term premenopause "is often used ambiguously, either to refer to the 1 or 2 years immediately before menopause or to the whole of the reproductive period prior to menopause." CAMS recommends that this term "should be used consistently in the latter sense, and should encompass the entire reproductive period up to the final menstrual period." However, CAMS has indicated that this term "can be confusing and preferably should be abandoned."
Perimenopause - According to CAMS, the term perimenopause includes "the period immediately prior to menopause (when the endocrinologic, biologic, and clinical features of approaching menopause commence) and the first year after menopause." The median age for the onset of perimenopause is 47.5 years. For most women, perimenopause lasts approximately 4 years. Only about 10% of women cease menstruating abruptly with no period of prolonged irregularity. Perimenopause is the correct term for what some call "being in" or "going through" menopause.
Menopausal transition - According to CAMS, the term menopausal transition "should be reserved for that time before the final menstrual period when variability in the menstrual cycle is usually increased."
Premature menopause - According to CAMS, "ideally, premature menopause should be defined as menopause that occurs at an age less than two standard deviations below the mean estimated age for the reference population. In practice, in the absence of reliable estimates of the distribution of age at natural menopause in populations in developing countries, the age of 40 is frequently used as an arbitrary cutoff point, below which menopause is said to be premature." Premature menopause can be the result of genetics or autoimmune processes. It has been linked to both familial and non familial X-chromosome abnormalities. Premature menopause can also be caused by medical interventions, such as bilateral oophorectomy, chemotherapy, or pelvic radiation therapy. Premature menopause and premature ovarian failure (POF) can be synonymous. Strictly speaking, however, menopause is by definition the very last menses. POF (ie,
hypergonadotropic amenorrhea), while having all the characteristics of menopause, may not be permanent.
Induced menopause - According to CAMS, the term induced menopause is defined as "the cessation of menstruation that follows either surgical removal of both ovaries (with or without hysterectomy) or iatrogenic ablation of ovarian function (eg, by chemotherapy or radiation)." A medical intervention will not cause menopause unless it causes severe damage to both ovaries. In women who experience surgically induced menopause, fertility ends immediately. With other types of induced menopause, fertility may end immediately or over several months.
Surgical menopause - The term surgical menopause refers to induced menopause caused by surgical removal of both ovaries (bilateral
oophorectomy) in a woman who is still menstruating. Bilateral oophorectomy is the most common cause of induced menopause.
The following surgical procedures could include a bilateral oophorectomy:
Hysterectomy . A hysterectomy is the surgical removal of the uterus performed for benign conditions (such as endometriosis, uterine fibroids) and for various forms of cancer (endometrial, ovarian, cervical). Depending on age and diagnosis, an oophorectomy may be performed simultaneously. A hysterectomy without oophorectomy does not usually cause menopause, but menstrual bleeding will stop. Occasionally, a hysterectomy will result in menopause, even if one or both ovaries are left in place. Some experts believe this occurs because removal of the uterus lessens the blood supply to the ovaries.
Abdominoperineal resection. This is a surgical procedure for colon cancer. It involves removal of the lower colon and rectum and may require resection of the uterus, ovaries, and rear wall of the vagina.
Total pelvic exenteration. This procedure is primarily performed when cervical cancer has recurred after surgery or radiation. It involves resection of the uterus, cervix, ovaries, fallopian tubes, vagina, urethra, urinary bladder, and rectum. |
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Chemotherapy-induced menopause - The term chemotherapy commonly refers to the use of drugs to treat cancer. Chemotherapy is a systemic treatment that can destroy cancer cells that have metastasized to other parts of the body. Chemotherapy can cause severe damage to both ovaries, thereby making them unable to produce sufficient levels of hormones to prevent menopause. Following chemotherapy, a woman may experience months or even years of irregular ovarian function. Depending on the woman's age and the type of chemotherapy used, normal ovarian function may resume after a period of time. Permanent amenorrhea is more likely when an alkylating drug is used, when chemotherapy drugs are used in combination, or when the woman is close to natural menopause.
Radiation-induced menopause - Radiation therapy uses high-energy particles or waves-such as x-rays, gamma rays, and alpha and beta particles -- to damage or destroy cancer cells. Radiation therapy is one of the most common cancer treatments. It can be used alone or in combination with chemotherapy, biologic therapy, and/or surgery. While some normal cells surrounding the tumor may be affected by radiation therapy, most appear to recover fully after treatment. Unlike chemotherapy, which exposes the entire body to anticarcinogenic agents, radiation therapy affects only the tumor and the surrounding area. Pelvic radiation therapy is more likely to cause permanent ovarian failure if the ovaries receive high doses of radiation (such as for treatment of cervical cancer). If smaller doses of pelvic radiation are used (such as for Hodgkin's disease), the ovaries may recover.
Temporary menopause - The term temporary menopause describes a period when normal ovarian function is interrupted. The ovaries are functional, but they are unable to produce oocytes and the accompanying normal levels of hormones. Some POF patients and some women following chemotherapy or pelvic radiation therapy experience temporary menopause. Women who over-exercise or over-diet can experience amenorrhea due to a hypoestrogenic state, but gonadotropin levels are usually normal to low normal. Drug therapy can also result in temporary menopause.
GnRH analogues - The gonadotropin-releasing hormone (GnRH) analogues are used to treat endometriosis and severe premenstrual syndrome. They are also sometimes used before certain types of surgeries, such as myomectomy. GnRH analogues can cause the ovaries to temporarily stop hormone production. GnRH analogues do not directly cause menopause. They inhibit secretion of gonadotropins, which consequently suppresses ovarian function. Women who take short-acting forms of GnRH analogues (administered daily subcutaneously) usually resume normal ovarian function shortly after injections are stopped. In women taking the long-acting forms of the drugs (given as intramuscular injections or as an implant), normal ovarian function may take 2 or more months to resume.
Postmenopause - According to CAMS, the term post menopause is defined as "dating from the final menstrual period, regardless of whether menopause was induced or spontaneous."
Climacteric - According to CAMS, the term climacteric describes "the phase during the aging of women marking the transition from the reproductive phase to the nonreproductive state. This phase incorporates the perimenopause by extending for a longer, variable period before and after the perimenopause." Thus, climacteric is a process, rather than a specific point in time. According to CAMS, "climacteric is sometimes, but not necessarily always, associated with symptomatology. When this occurs, it may be termed the 'climacteric syndrome'."
EPIDEMIOLOGY
Three factors make the health decisions made at menopause a significant public health issue:
1.menopause affects every woman,
2.an unprecedented number of women are reaching midlife, and
3.women are living longer than ever before, with the elderly population also reaching unprecedented numbers.
Therefore, treating this population gives clinicians an excellent opportunity to make a significant impact on public health.
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