Menopause
Menopause is the time when menstrual periods permanently stop, marking the end of the reproductive stage for the female human. It typically occurs between the ages of 45 and 55, although the exact timing can vary. Menopause is usually a natural change related to a decrease in circulating blood estrogen levels. It can occur earlier in those who smoke tobacco. Other causes include surgery that removes both ovaries, some types of chemotherapy, or anything that leads to a decrease in hormone levels. At the physiological level, menopause happens because of a decrease in the ovaries' production of the hormones estrogen and progesterone. While typically not needed, measuring hormone levels in the blood or urine can confirm a diagnosis. Menopause is the opposite of menarche, the time when periods start.
In the years before menopause, a woman's periods typically become irregular, which means that periods may be longer or shorter in duration, or be lighter or heavier in the amount of flow. During this time, women often experience hot flashes; these typically last from 30 seconds to ten minutes and may be associated with shivering, night sweats, and reddening of the skin. Hot flashes can recur for four to five years. Other symptoms may include vaginal dryness, trouble sleeping, and mood changes. The severity of symptoms varies between women. Menopause is also known to cause thinning and drying of the skin as 30% of the skins collagen is lost during the first five years of menopause. Menopause before the age of 45 years is considered to be "early menopause", and ovarian failure or surgical removal of the ovaries before the age of 40 years is termed "premature ovarian insufficiency".
In addition to symptoms, the physical consequences of menopause include bone loss, increased central abdominal fat, and adverse changes in a woman's cholesterol profile and vascular function. These changes predispose postmenopausal women to increased risks of osteoporosis and bone fracture, and of cardio-metabolic disease.
Medical professionals often define menopause as having occurred when a woman has not had any menstrual bleeding for a year. It may also be defined by a decrease in hormone production by the ovaries. In those who have had surgery to remove their uterus but still have functioning ovaries, menopause is not considered to have yet occurred. Following the removal of the uterus, symptoms of menopause typically occur earlier. Iatrogenic menopause occurs when both ovaries are surgically removed along with the uterus for medical reasons.
Medical treatment of menopause is primarily to ameliorate symptoms and prevent bone loss. Mild symptoms may be improved with treatment. With respect to hot flashes, avoiding nicotine, caffeine, and alcohol is often recommended; sleeping naked in a cool room and using a fan may help. The most effective treatment for menopausal symptoms is menopausal hormone therapy. Non-hormonal therapies for hot flashes include cognitive-behavioral therapy, clinical hypnosis, gabapentin, and fezolinetant or selective serotonin reuptake inhibitors. These will not improve symptoms such as neurocognitive impairments, joint pain or vaginal dryness, which affect over 55% of women. Neurocognitive symptoms of menopause can be treated with lisdexamfetamine. Exercise may help with sleep disturbances. Many of the concerns about the use of MHT raised by older studies are no longer considered barriers to MHT in healthy women. High-quality evidence for the effectiveness of alternative medicine has not been found.
Signs and symptoms
During early menopause transition, the menstrual cycles remain regular but the interval between cycles begins to lengthen. Hormone levels begin to fluctuate. Ovulation may not occur with each cycle.The term menopause refers to a point in time that follows one year after the last menstruation. During the menopausal transition and after menopause, women can experience a range of symptoms. However, for women who enter the menopause transition without having regular menstrual cycles the menopause cannot be identified by bleeding patterns and is defined as the permanent loss of ovarian function.
Vagina, uterus and bladder (urogenital tract)
During the transition to menopause, menstrual patterns can show shorter cycling ; longer cycles remain possible. There may be irregular bleeding. Dysfunctional uterine bleeding is often experienced by women approaching menopause due to the hormonal changes that accompany the menopause transition. Spotting or bleeding may simply be related to vaginal atrophy, a benign sore, or may be a functional endometrial response. The European Menopause and Andropause Society has released guidelines for assessment of the endometrium, which is usually the main source of spotting or bleeding.In post-menopausal women, however, any unscheduled vaginal bleeding is of concern and requires an appropriate investigation to rule out the possibility of malignant diseases.
Urogenital symptoms may appear during menopause and continue through postmenopause and include painful intercourse, vaginal dryness and atrophic vaginitis. There may also be considerable shrinking and loss in elasticity of all of the outer and inner genital areas. Urinary urgency may also occur and urinary incontinence in some women.
Other physical effects
The most common physical symptoms of menopause are heavy night sweats, and hot flashes. Sleeping problems and insomnia are also common. Other physical symptoms may be reported that are not specific to menopause but may be exacerbated by it, such as lack of energy, joint soreness, stiffness, back pain, breast enlargement, breast pain, heart palpitations, headache, dizziness, dry, itchy skin, thinning of the skin, tingling skin, rosacea, weight gain.Mood and memory effects
Psychological symptoms are often reported but they are not specific to menopause and can be caused by other factors. They include anxiety, poor memory, inability to concentrate, depressive mood, irritability, mood swings, and less interest in sexual activity.Menopause-related cognitive impairment can be confused with the mild cognitive impairment that precedes dementia. There is evidence of small decreases in verbal memory, on average, which may be caused by the effects of declining estrogen levels on the brain, or perhaps by reduced blood flow to the brain during hot flashes. However, these tend to resolve for most women during the postmenopause. Subjective reports of memory and concentration problems are associated with several factors, such as lack of sleep, and stress.
Long-term effects
Cardiovascular health
Exposure to endogenous estrogen during reproductive years provides women with protection against cardiovascular disease, which is lost around 10 years after the onset of menopause. The menopausal transition is associated with an increase in fat mass and metabolic dysfunction–associated steatotic liver disease, an increase in insulin resistance, dyslipidaemia, and endothelial dysfunction. Women with vasomotor symptoms during menopause seem to have an especially unfavorable cardiometabolic profile, as well as women with premature onset of menopause. These risks can be reduced by managing risk factors, such as tobacco smoking, hypertension, increased blood lipids and body weight.Bone health
The annual rates of bone mineral density loss are highest starting one year before the final menstrual period and continuing through the two years after it. Thus, post menopausal women are at increased risk of osteopenia, osteoporosis and fractures.Causes
Menopause is a normal event in a woman's life and a natural part of aging. Menopause can also be induced early. Induced menopause occurs as a result of medical treatment such as chemotherapy, radiotherapy, oophorectomy, or complications of tubal ligation, hysterectomy, unilateral or bilateral salpingo-oophorectomy or leuprorelin usage.Age
Menopause typically occurs at some point between 47 and 54 years of age. According to various data, more than 95% of women have their last period between the ages of 44–56. 2% of women under the age of 40, 5% between the ages of 40–45 and the same number between the ages of 55–58 have their last bleeding. The average age of the last period in the United States is 51 years, in Russia is 50 years, in Greece is 49 years, in Turkey is 47 years, in Egypt is 47 years and in India is 46 years. Beyond the influence of genetics, these differences are also due to early-life environmental conditions and associated with epigenetic effects. The menopausal transition or perimenopause leading up to menopause usually lasts 3–4 years.Undiagnosed and untreated coeliac disease is a risk factor for early menopause. Coeliac disease can present with several non-gastrointestinal symptoms, in the absence of gastrointestinal symptoms, and most cases escape timely recognition and go undiagnosed, leading to a risk of long-term complications. A strict gluten-free diet reduces the risk. Women with early diagnosis and treatment of coeliac disease present a normal duration of fertile life span.
Women who have undergone hysterectomy with ovary conservation go through menopause on average 1.5 years earlier than the expected age.
Premature ovarian insufficiency
In rare cases, a woman's ovaries stop working at a very early age, ranging anywhere from the age of puberty to age 40. This is known as premature ovarian failure or premature ovarian insufficiency and affects 1 to 2% of women by age 40. It is diagnosed or confirmed by high blood levels of follicle stimulating hormone and luteinizing hormone on at least three occasions at least four weeks apart.Premature ovarian insufficiency may be related to an auto immune disorder and therefore might co-occur with other autoimmune disorders such as thyroid disease, , and diabetes mellitus. Other causes include chemotherapy, being a carrier of the fragile X syndrome gene, and radiotherapy. However, in about 50–80% of cases of premature ovarian insufficiency, the cause is unknown, i.e., it is generally idiopathic.
Early menopause can be related to cigarette smoking, higher body mass index, racial and ethnic factors, illnesses, and the removal of the uterus.