Menopause is the period in a woman’s life when her menses cease because the ovaries stop producing estrogen. Menopause marks the end of the reproductive years. It can happen naturally at an average of 51 years old. Menopause can also be induced as in surgical menopause when the ovaries are removed by bilateral oophorectomy, either alone or with the removal of the uterus. Menopause can also be induced when the ovaries are severely damaged by exposure to radiation, chemotherapy or other medications or toxins. Perimenopause are the years leading up to menopause. It may occur up to 10 years prior to menopause when the amount of estrogen produced by the ovaries begins to fluctuate.

How is Menopause Diagnosed?

According to the NICE Guidelines, if a woman is aged over 45 years and has not had a period for at least 12 months, or has vasomotor symptoms and irregular periods or who experiences symptoms after her uterus has been removed, this is adequate information to diagnose menopause even without the use of any laboratory tests. Hormonal tests should not routinely be used when diagnosing the menopause. In particular, the FSH test is deemed inappropriate for women taking combined hormonal contraception or a high-dose progestogen, nor should it be used for women aged over 45 years. Blood levels of FSH fluctuate markedly during the years leading up to menopause and they therefore do not help when forming what is actually a clinical diagnosis. The NICE Guidelines also does not advocate measuring the ff: antiMüllerian hormone (an indicator of ovarian reserve), inhibin A or B (which inhibit FSH production), estradiol, antral follicle count and ovarian volume. However, an FSH test should be considered for women aged 40–45 years with menopausal symptoms, including a change in their menstrual cycle, and in women under 40 years when the menopause is suspected, in whom premature ovarian insufficiency is a possibility. ¹

What are the Signs and Symptoms of Menopause?
Common signs and symptoms include the following:

Vasomotor symptoms (VMS) such as hot flushes, cold sweats, night sweats, palpitations are experienced by peri- and menopausal women. A hot flush is a sudden feeling of heat that rushes to the upper body and face which may for a few seconds to several minutes. Some women have hot flushes a few times a month. Others have them several times a day. Hot flushes that happen at night (night sweats) may interrupt sleep and cause you to feel tired the following day. A cold sweat refers to sudden perspiration that does not come from heat or exertion, accompanied by a chill or cold sensation. All these symptoms may or may not be accompanied by palpitations which is the sensation that your heart is beating too hard or too fast.

• Sleep problems—Insomnia can manifest either as trouble falling asleep, or you may wake up in the middle of the night and being unable to sleep again. Night sweats can wake you and disturb your sleep.
• Vaginal and urinary tract changes—As estrogen levels decrease, the lining of the vagina may become thinner, dryer, and less elastic. Vaginal dryness may cause dyspareunia or pain during sexual intercourse. This may also increase the woman’s susceptibility to vaginal infections. The urethra can likewise become dry, inflamed, or irritate resulting in frequent urination and increased risk of urinary tract infections. ³
• Dryness of the skin – women experience dry skin in menopause as a result of the decline of estradiol, responsible partly for the growth and maintenance of blood capillaries in the dermis. With the decline in blood flow through the dermal capillaries, and less nutrients and oxygen are available to the the epidermis. This thins out the epidermis and slows the turnover rate of the cells, leading to increased trans-epidermal
  water loss resulting in skin dryness
• Acne & Facial hair– estradiol normally discourages acne formation by stimulating a more fluid sebaceous gland secretion during the reproductive years. However, because of the decline of estrogen in menopause, the testosterone produced by the adrenal glands is no longer masked. This results in a greater expression of testosterone in the woman’s body by stimulating sebaceous glands to secrete thicker sebum, giving the appearance
  of oily skin which can manifest as acne in the perimenopause and menopausal period as well as abnormal facial hair, esp. in the chin area.
• Wrinkling of the skin – In menopause, skin thickness decreases by 1.13% per postmenopausal year, with an associated decrease in collagen content (2% per post-menopausal year). ⁴ As the supportive fat below the skin of the face, neck, hand and arms diminishes and gets redistributed over the abdomen and/or on the thighs and buttocks, this results in sagging skin & wrinkles.
• Cerebral symptoms – some menopausal women may start complaining of headaches, migraines, anxiety, memory loss and difficulty in concentration which can all result from a drop in estradiol levels.
• Osteoarthritis – Osteoarthritis is the most common form of arthritis in adults and is characterized by radiographic and functional deterioration of joints. The most recognized feature is loss of articular bones, tendons, ligaments and muscles may also be commonly involved. Osteoarthritis is defined radiographically by findings of loss of joint space, the presence of bony spurs known as osteophytes, sclerosis of the subchondral
  bone and bony cyst formation. Clinically, these findings on x-ray are associated with joint pain and stiffness in many patients typically involving large weight-bearing joints (such as the knee and hip), small joints (including the distal and proximal interphalangeal joints, the base of the thumb, and the big toe), and the cervical and lumbar spines. Patients typically complain of stiffness and difficulty in rising up from bed upon waking up
  or arising from a chair after a long period of sitting or prolonged immobility, a symptom termed as gelling. Soft tissue swelling is not common, and more often bony deformities are found but large joint effusions can occur. ⁵
• Osteoporosis – the word actually means “porous bones.” As a result of this weakened structure from a loss of density, the risk of fractures increase, especially in the hip, spinal vertebrae, and wrist. Normally, bone tissue is constantly being renewed, and new bone replaces old, damaged bone. In this way, the body maintains bone density and the integrity of its crystals and structure.Bone density depends on how much bone was deposited via diet and activity till the person is around 25. Then from around 35 years and older, the bone density begins to decline since the bone eating cells are more active than the bone-depositing cell. Especially after menopause, without estrogen, the bone breaks down faster than it builds. This results in osteoporosis.

Acc to Ramoso-Jalbuena way back in 1994, In a survey of Filipino women aged 40-50 years, of various professions and residing mostly in Metropolitan Manila, the average age of menopause was estimated at 48 years. The climacteric symptoms were seen to affect 83% of the respondents. Sixty-three percent reported menopause-related circulatory or vasomotor disorders and 79% mentioned psychological disorders. The incidence and frequency of climacteric symptoms were highest among the perimenopausals. Headache was the most common climacteric symptom, while the hot flush was the least prevalent. Only 31% consulted a physician for menopause-related ailments. Eighty-six percent of those who consulted were prescribed medication, however, only 52% of these followed the prescription. Eleven percent
reported dyspareunia and only 36% consulted a doctor. Thirty-one percent suffered from urinary stress incontinence and only 16% consulted a doctor. The findings of this study suggest that the average Filipino woman has an attitude of forbearance towards the climacteric syndrome. ⁶ In a study was conducted in seven south-east Asian countries, namely, Hong Kong, Indonesia, Korea, Malaysia, the Philippines, Singapore and Taiwan, the median age at menopause (51.09) appeared to be within the ranges observed in western countries. ⁷ There is a school of thought that believes that menopausal symptoms are a peculiarly ‘Western’ phenomenon, not experienced by women from other regions and particularly not from Asia where, it has been claimed, dietary, social and cultural factors afforded protection for women living in that region. More recently, studies conducted in multi-ethnic communities living in Western countries as well as in Asian communities have found that the menopause and its consequences are similar world-wide. ⁸

Management:
For women experiencing vasomotor symptoms, do not routinely offer s elective serotonin
reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs) or
clonidine as first-line treatment. Instead, estrogen and progestogen therapy may be offered to
women with a uterus and estrogen therapy alone to women without a uterus. The short term (up
to 5 years) and longer-term benefits & risks must be discussed. For women afraid to take
hormones, explain to them that there is some evidence that isoflavones or black cohosh may
relieve vasomotor symptoms. However, multiple preparations are available, their safety is
uncertain & interactions with other medicines have been reported. For women with urogenital
atrophy, vaginal estrogen may be offered even if they are already on hormone replacement
therapy (HRT). ⁹
For vulvovaginal issues of menopausal women who are afraid to use hormones, ospemifene, a
tissue-selective estrogen receptor modulator (SERM), was recently approved for the treatment
of vulvovaginal atrophy and dyspareunia . Ospemifene relieves moderate to severe symptoms
of vulvovaginal atrophy, like dryness, irritation and soreness around the genital area, and painful
sexual intercourse, in menopausal women. It is well tolerated, and it has neutral effects on
endometrium and coagulation. Clinical trials and even long-term studies on breast cancer
effects support the overall safety of ospemifene. ¹⁰

In addition, women with urogenital atrophy may benefit from cutting-edge technology called
Laser Vaginal Rejuvenation. This involves the use of lasers to thicken the vaginal walls,
promoting the deposition of collagen and reversing the atrophy. This also results in more
transudation of fluid which promotes lubrication as well. Laser therapy may be valuable as a
nonhormonal therapeutic modality in the management of GSM. ¹¹

The clinical effects of using hormone replacement therapy for a year or longer must be
discussed. This review included 22 double-blinded randomised controlled trials (RCTs) (43,637
women). The evidence is current to September 2016. ⁹

HRT is given for control of menopausal symptoms. It has also been used for the management
and prevention of chronic diseases such as cardiovascular disease, osteoporosis and dementia.
In relatively healthy postmenopausal women, using combined continuous HT for 1 year
increased the risk of a heart attack from about 2 per 1000 to between 3 and 7 per 1000, and
increased the risk of venous thrombosis (blood clot) from about 2 per 1000 to between 4 and 11
per 1000. With longer use, HRT also increased the risk of stroke, breast cancer, gallbladder
disease and death from lung cancer.

Estrogen-only HRT increased the risk of venous thrombosis after 1 to 2 years’ use: from 2 per
1000 to 2 to 10 per 1000. With longer use, it also increased the risk of stroke and gallbladder
disease, but it reduced the risk of breast cancer (after 7 years’ use) from 25 per 1000 to
between 15 and 25 per 1000.

Among women over 65 years of age taking continuous combined HRT, the incidence of
dementia was increased.

Risk of fracture was the only outcome for which results showed strong evidence of clinical
benefit from HRT (both types).

Women with intolerable menopausal symptoms may wish to weigh the benefits of symptom
relief against the small absolute risk of harm arising from short-term use of low-dose HT,
provided they do not have specific contraindications. HT may be unsuitable for some women,
including those at increased risk of cardiovascular disease, increased risk of thromboembolic
disease (such as those with obesity or a history of venous thrombosis) or increased risk of some
types of cancer (such as breast cancer, in women with a uterus). The risk of endometrial cancer
for women with a uterus who take oestrogen-only HT is well documented.

HRT is not indicated to prevent or treat cardiovascular disease or dementia, nor can it be used
for preventing deterioration of cognitive function in postmenopausal women. Although HT is
considered effective for prevention of postmenopausal osteoporosis, it is generally
recommended as an option only for women at significant risk, for whom non-oestrogen
therapies are unsuitable. Data are insufficient for assessment of the risk of long-term HT use in
perimenopausal women or postmenopausal women younger than 50 years of age.

Hormone therapy may be used to manage troublesome menopausal symptoms, but is currently
recommended to be given at the lowest effective dose and regularly reviewed by a woman and
her doctor. In women with an intact uterus, hormone therapy using estrogen and progestogen is
recommended to minimize the risk of endometrial hyperplasia , which can develop into
endometrial cancer. Low-dose estrogen plus progestogen (minimum of 1 mg norethisterone
acetate or 1.5 mg medroxyprogesterone acetate) taken daily (continuously) appears to be safe
for the endometrium. For women who had their last menstrual period less than one year ago
low-dose estrogen combined sequentially with 10 days of progestogen (1 mg norethisterone
acetate) per month appears to be safe for the endometrium . ¹²

In contrast to progestins, recent findings relating to the use of natural progesterone, are
reassuring. These findings come from two cohort studies carried out in France, where oral
micronized progesterone has been used by large numbers of menopausal women since over
two decades. ¹³

Th ere is good evidence that adding testosterone to hormone therapy (HT) has a beneficial
effect on sexual function in postmenopausal women. However, the combined therapy is
associated with a higher incidence of hair growth and acne and a reduction in high-density
lipoprotein (HDL) cholesterol. These adverse events may vary with different doses and routes of
administration of testosterone. Adding testosterone to HT did not increase the number of
women who stopped HT therapy . ¹⁴

For women with osteoporosis, management focuses first on nonpharmacologic measures, such
as a balanced diet, adequate calcium and vitamin D intake, adequate exercise, (a minimum of
40 mins/day brisk walking 2-3 times your normal walking pace), smoking cessation, avoidance
of excessive alcohol intake, and fall prevention. If pharmacologic therapy is indicated,
government-approved options are bisphosphonates, a selective estrogen-receptor modulator,
parathyroid hormone, estrogens, and calcitonin. ¹⁵

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