MENOPAUSE

INTRODUCTION
Menopause is a term used to describe the permanent cessation of the primary functions of the human ovaries: the ripening and release of ova and the release of hormones that cause both the creation of the uterine lining and the subsequent shedding of the uterine lining (a.k.a. the menses or the period). Menopause typically (but not always) occurs in women in midlife, during their late 40s or early 50s, and signals the end of the fertile phase of a woman's life. The transition from reproductive to non-reproductive is the result of a major reduction in female hormonal production by the ovaries. This transition is normally not sudden or abrupt, tends to occur over a period of years, and is a natural consequence of aging. However, for some women, the accompanying signs and effects that can occur during the menopause transition years can significantly disrupt their daily activities and their sense of well-being. In addition, women who have some sort of functional disorder affecting the reproductive system (i.e. endometriosis, polycystic ovary syndrome, cancer of the reproductive organs) can go into menopause at a younger age than the normal timeframe; the functional disorders often significantly speed up the menopausal process and create more significant health problems, both physical and emotional, for the affected woman. The word "menopause" literally means the "end of monthly cycles" from the Greek word pausis (cessation) and the root men- (month), because the word "menopause" was created to describe this change in human females, where the end of fertility is traditionally indicated by the permanent stopping of monthly menstruation or menses. However, menopause also exists in some other animals, many of which do not have monthly menstruation;[1] in this case, the term is synonymous with "end of fertility".

The date of menopause in human females is formally medically defined as the time of the last menstrual period (or menstrual flow of any amount, however small), in those women who have not had a hysterectomy. Women who have their uterus removed but retain their ovaries do not immediately go into menopause, even though their periods cease. Adult women who have their ovaries removed however, go immediately into surgical menopause, no matter how young they are. Menopause is an unavoidable change that every woman will experience, assuming she reaches middle age and beyond. It is helpful if women are able to learn what to expect and what options are available to assist the transition, if that becomes necessary. Menopause has a wide starting range, but can usually be expected in the age range of 4258.[2] An early menopause can be related to cigarette smoking, higher body mass index, racial and ethnic factors, illnesses, chemotherapy, radiation and the surgical removal of the uterus and/or both ovaries.[3] Menopause can be officially declared (in an adult woman who is not pregnant, is not lactating, and who has an intact uterus) when there has been amenorrhea (absence of any menstruation) for one complete year. However, there are many signs and effects that lead up to this point, many of which may extend well beyond (hot it too. These night include: sweats), irregular atrophy menses,vasomotor instability flashes and

of genitourinary tissue, increased stress, breast tenderness, vaginal dryness, forgetfulness, mood changes, and in certain cases osteoporosis and/or heart disease.[4] These effects are related to the hormonal changes a womans body is going through, and they affect each woman to a different extent. The only sign or effect that all women universally have in common is that by the end of the menopause transition every woman will have a complete cessation of menses.

DEFINITIONS
2

Menopause means permanent cessation of menstruation at the end of reproductive life due to loss of ovarian follicular activity Dutta Menopause is defined as the time when there has been no menstrual periods for 12 Consecutive months and no other biological or physiological cause can be identified. It is the end of fertility, the end of the child bearing years. Medical dictionary The word menopause derived from greek word; Men month and Pausis cessation And menopause literally means the end of monthly cycles

TERMINOLOGIES
Climacteric : It is the phase of aging process during which a women passess from the reproductive to the non reproductive stages. This phase covers 5-10 years on either side of the menopause Premenopause : It is the part of the climacteric before menopause, when the menstruation cycle is likely to be irregular Menopausal transition : The time from the late reproductive stage and entry into post menopause Post menopause : It is the phase of life that comes after the menopause

Peri menopause : It is the period around menopause occurs during the years before and one year after the last menstrual period Pre mature menopause : The occurrence of menopause before the age of 40 years AGE OF MENOPAUSE It has been estimated that the onset of menopause usually begins between the ages of 45-55 years, with a world wide average of about 51 years

According to the National Family Health Survey conducted in 1998 and 1999, the mean age of onset of menopause in Indian women is about 44.3nyears. with the average life span of an women increasing in the recent years, women will lead to one third of their life in the post menopausal stage

The age of menopause occurs is genetically predetermined and it is not related to the following factors
a.

Number of pregnancy and lactation

b. Use of oral pills c. Socioeconomic condition and race d. Height and weight e. Age at menarche However cigarette smoking and severe malnutrition may cause early menopause

CAUSES OF MENOPAUSE

The

causes

of

menopause

can

be

considered

from

complementary proximate (mechanistic) perspectives (how it happens) or from ultimate (adaptive evolutionary) perspectives (why it happens). The latter group is hypotheses only. Proximate perspective Natural or physiological menopause occurs as a part of a woman's normal aging process. It is the result of the eventual depletion of almost all of the oocytes and ovarian folliclesin the ovaries. This causes an increase in circulating follicle stimulating hormone (FSH) and luteinizing hormone (LH) levels because there are a decreased number of oocytes and follicles responding to these hormones and producing estrogen. This decrease in the production of estrogen leads to the perimenopausal symptoms of hot flashes, insomnia and mood changes. Long term effects may include osteoporosis and vaginal atrophy. Evolutionary theories of menopause In contrast to males, females invest more in their gametes, making them a highly valuable resource. Selection should therefore in theory favour a quantity of ova that would be sufficient for the female lifespan. Over-investment is resourcefully wasteful and under-investment leads to reduced fitness. Human females, however, spend over one third of their lifespan in a post-reproductive phase. Possible evolutionary explanations for survival beyond reproductive maturation range from the non-adaptive to the adaptive. Non-adaptive hypotheses The high cost of female investment in offspring may lead to physiological deteriorations that amplify susceptibility to becoming infertile. This hypothesis suggests the reproductive lifespan in humans has been optimized, but it has proven more difficult in females and thus their reproductive span is shorter. If this hypothesis were true however, age at menopause should be negatively correlated with reproductive effort and the available data does not support this.
5

A recent increase in female longevity due to improvements in the standard of living and social care has also been suggested. It is difficult for selection, however, to favour aid from offspring to parents and grandparents Irrespective of living standards, adaptive responses are limited by physiological mechanisms. In other words senescence is programmed and regulated by specific genes. Adaptive hypotheses The mother hypothesis The mother hypothesis suggests that menopause was selected for in humans because of the extended development period of human offspring and high costs of reproduction so that mothers gain an advantage in reproductive fitness by redirecting their effort from new offspring with a low survival chance to existing children with a higher survival chance. The grandmother hypothesis The Grandmother hypothesis suggests that menopause was selected for in humans because it promotes the survival of grandchildren. According to this hypothesis, post reproductive women feed and care for children, adult nursing daughters, and grandchildren whose mothers have weaned them. Human babies require large and steady supplies of glucose to feed the growing brain. In infants in the first year of life, the brain consumes 60% of all calories, so both babies and their mothers require a dependable food supply. Some evidence suggests that hunters contribute less than half the total food budget of most huntergatherer societies, and often much less than half, so that foraging grandmothers can contribute substantially to the survival of grandchildren at times when mothers and fathers are unable to gather enough food for all of their children. In general, selection operates most powerfully during times of famine or other privation. So although grandmothers might not be necessary during good times, many grandchildren cannot survive without them during times of famine. Arguably, however, there is no firm consensus on the supposed evolutionary
6

advantages (or simply neutrality) of menopause to the survival of the species in the evolutionary past. Indeed, analysis of historical data found that the length of a females post-reproductive lifespan was reflected in the reproductive success of her offspring and the survival of her grandchildren.Interestingly, another study found comparative effects but only in the maternal grandmother paternal grandmothers had a detrimental effect on infant mortality (probably due to paternity uncertainty). Differing assistance strategies for maternal and paternal grandmothers have also been demonstrated. Maternal grandmothers concentrate on offspring survival, whereas paternal grandmothers increase birth rates. A problem concerning the grandmother hypothesis is that it requires a history of female philopatry and yet present day evidence shows that the majority of hunter-gatherer societies arepatriarchal. In addition, all variations on the mother, or grandmother effect fail to explain longevity with continued spermatogenesis in males (oldest verified paternity is 94 years, 35 years beyond the oldest documented birth attributed to females). It also fails to explain the detrimental effects of losing ovarian follicular activity, such as osteoporosis, osteoarthritis,Alzheimers disease and coronary artery disease.

ENDOCRINE CHANGES
1. Hypothalamo pituitory gonadal axis During few years prior to menopause, the effective folliculogenesis is impaired with diminished Estradiol production. As a defence mechanism, hypothalamo pituitory axis increases the follicular stimulating hormine and leutinizing hormone. However due to depletion of the ovarian follicles and increased resisitence of follicles to the gonadotrophins, follicular stimulating hormone fails to stimulate sufficient estradiol secretion and estradiol levels steadily declines eventually

resulting in the failure of endmetrial development and absence of uterine bleeding. 2. Estrogens Ther is a significant fall in the level of serum estradiol from 50-300pg/ml before menopause to 10-20 pg/ml after menopause. With times the sources fail to supply the precursors of estrogen and about 5-10 years after menopause sharp fall in estrogen then the women said to be on state of true menopause 3. Androgens After menopause the stomal cells of the ovary continues to produce androgens because of increase in leutinizing hormone. They are produced partly by the adrenal and partly by the ovary. Thus cumulative effect is a decrease in estrogen and androgen ratio. This results in increased hair growth and changes in the voice 4. Progesterone A trace amount of progesterone detected is propably adrenal origin 5. Gonadotrophins The secretions of both follicular stimulating hormone and leutinizing hormone are increased are due to absent negative feed back effec of estradiol due to enhanced responsiveness of pituitory GnRH. Follicular stimulating hormone rises about 10-20 fold where as LH rises about 3 fold. Ultimately due to physiological aging GnRH and bothe follicular stimulating hormone and leutinizing hormone decline along with decline of estrogens.

ORGAN CHANGES

 Ovaries shrink in size, become wrinkled and white. Thinning of cortex with increasing medullary components. Stromal cells have got secretory activity Fallopian tubes shows feature of atrophy. The muscle coat become thinner and the cilia dissappear The uterus becomes smaller the endometrium becomes thin and atrophic the cervical secretion becomes scanty

Vagina becomes narrower due to gradual loss of elasticity, flatten rugae, absence of doderlines bacilli and the vaginal Ph becomes alkaline

The vulva shows features of atrophy , the labia becomes flattened, pubic hair becomes scantier and narrow introitus The breast fat is reabsorbed and the glands become atrophic. The nipples decrease in size ultimately breasts become flat and pendulous Bladder and urethra epithelium becomes thin and more prone to infection and damage Loss of muscle tone leads to pelvic cellular tissue and ligaments supporting the uterus and vagina lose their tone Bones losses its mass by about 3-5% per year due to deficiency of estrogen leads to osteoporosis

PRE MENOPAUSE
Any of the following patterns are observed a. Sudden cessation of menstuation b. Gradual hypomenorrhoea ( scanty mens) or infrequent cycles ( oligomenorrhoea) c. Irregular with or without excessive bleeding

SIGNS AND SYMPTOMS OF MENOPAUSE

Symptoms are divided into physiological, psychological and social
9

I Physiological aspect 1. Vasomotor symptoms The characteristic symptom of menopause is hot flush. Hot flush is characterized by sudden feeling of heat followed by profuse sweating. It affects the chest area and spreads upwards to the facial skin and generally lasts less than one minute Palpitation, weakness , fatigue Perspiration, cutaneous vasodilation Pulse rate rises 20 beats per minute These vasomotor changes is due to instability of hypothalamus where thermoregulatory centre situated 1. Cental Nervous System Symptoms Estrogen known to regulate the synthesis and the rate of release of many neurotransmitters A deficiency of estrogen reduces seratonin synthesis in the brain and which leads to the development of insomnia during menopause Along with normal aging, estrogen plays a role in the decline of the cognitive functions in the women. Dementia and mainly Alzheimers disease are more common 1. Reproductive tract symptoms

Vaginal dryness: Vaginal symptoms occur as a result of the lining tissues of the vagina becoming thinner, drier, and less elastic as estrogen levels fall. Symptoms may include vaginal dryness, itching, or irritation and/or pain with sexual intercourse (dyspareunia). The vaginal changes also lead to an increased risk of vaginal infections.

Dyspareunia Uterine descensus Cystocele , rectocele and or enterocele

Fibroids
10

 Loss of Libido Sex therapists say tha low libido becomes a problem that should be addressed only when it is perceived as a problem. "It's usually only in the framework of a relationship that it becomes an issue" Dr. Zussman says. "It's when there is a discrepancy in desire between the person and partner, or when people feel there's something wrong with them because they have a low level of desire." Everyone experiences peaks and valleys in sexual desire, an ebb and flow in libido that could be caused by any of a variety of factors. Occasionally, a hormonal imbalance or prescription drug will sap sex drive. And, of course, there's a difference between sexual drive and sexual function. Problems related to orgasm Endometriosis Infections

Breast Pain :Pain, soreness, or tenderness in one or both breasts often precedes or accompanies menstrual periods but can also occur during pregnancy, breast-feeding, and menopause. It can be resumed in a generalized discomfort and pain associated with touching or application of pressure to breast. Consult your doctor if the pain is severe or persists for two months or more, also if the breast pain that is accompanied by a breast lump or nipple discharge. Click here for more information about Breast Pain. Also it is important to read about Breast Tenderness.

1. Urinary symptoms Urgency and frequency of urination Dysuria Urinary tact infection

Stress incontinence

that is Incontinence, especially upon Sneezing,

Laughing, UrgeIncontinence : Incontinence falls into three main categories, although people can leak through because of a combination of
11

causes. First, there's stress incontinence, in which you urinate accidentally when you laugh, cough, sneeze or exert yourself. This happens either when the bladder neck shifts position out of reach of the internal muscles that put pressure on it or when those muscles themselves fail to work effectively, because of age, surgery or childbirth. The second one is urge incontinence, in which the bladder develops a "mind of its own," contracting and emptying whenever full despite an individual's conscious efforts to resist. And last, overflow incontinence, in which you completely lose the sensation that you have to go. You should see your doctor if you urinate when you shouldn't, because you have no sensation that your bladder is full. Urethral syndrome Itching Dryness 5. Cardio Vascular System symptoms

Oxidation of low density lipoprotein and foam cell formaion cause vascular endothelial injury and smooth muscle proliferation. All these lead to vascular atherosclerosis changes, vasoconstriction and thrombus for motion

Risk of ischemic heart disease, coronary artery disease and stroke are increased 6. Skeletal system symptoms Bone mass loss and deterioration of bone tissue

Bone loss: Rapid bone loss is common during the perimenopausal years. Most women reach their peak bone density when aged 25-30 years. After that, bone loss averages 0.13% per year. During perimenopause, bone loss accelerates to about a 3% loss per year. Later, it drops off to about a 2% loss per year. No pain is usually associated with bone loss. However,
12

bone loss can cause osteoporosis, a condition that increases the risk of bone fractures. These fractures can be intensely painful and can interfere with daily life. They also can increase the risk of death. Bone mass increases to 5% per years during menopause Back pain, joint pain Loss of height and kyphosis

Aching, Sore Joints, Muscles and Tendons : Aching Joints and muscle problems is one of the most common symptoms of menopause. It is thought that more than half of all postmenopausal women experience varying degrees of joint pain. Joint pain is basically an unexplained soreness in muscles and joints, which are unrelated to trauma or exercise, but may be related to immune system effects mostly caused by fluctuating hormone levels. It is not wise to ignore these aches and pains. Early treatment can often bring about a cure and prevent further development of arthritis. Getting plenty of rest, using herbal aids, eating nutritious foods, preferably organic food, fruits and vegetables-and avoiding known toxins and stimulants, are healthy strategies for fighting joint pains.

Fracture may involve the vertibral body, femoral neck or distal forearm
1.

Changes in Fingernails-Softer, Crack or Break Easier : A black or blue nail tells the world that you and your hammer had a problem. Reddish yellow nails demonstrate that you change your nail polish often. Nails that split and break can be a sign that you're spending too much time with your hands in the sink. Nails that take on a convex, spoon like appearance may mean respiratory deficiency or simply that you're not getting enough iron. Nibbled nails and hangnails can betray your anxiety level. Fingernail and toenail problems are usually caused by inflammation of the skin around the nail or by an infection. A persistently painful and inflammed fingernail or toenail requires your doctor's attention.

2. Skin, Hair and Soft tissue

13

Hair Loss or Thinning, Head, Pubic, or Whole Body; Increase in Facial Hair : Connected to estrogen deficiency, since the hair follicles need estrogen; some women notice this before any other sign because it is obvious. Hair loss can be sudden or gradual loss or thinning of hair on your head or on other parts of your body. You'll notice hair in your brush, your hair may also get drier and more brittle or notice a thinning or loss of pubic hair. A gradual loss or thinning of hair without any accompanying symptoms is common. However, hair loss that is accompanied by general ill health requires your doctor's attention. The thickness of skin decreases 1-2% per year Purse string wrinkling around mouth and crow feet around eyes are the characteristics Loss of pubic and axillary hair and slight balding Breast atophy Breast tenderness

Itching, Crawly Skin : When your estrogen levels drop, your collagen production usually slows down as well. Collagen is responsible for keeping our skin toned, fresh-looking, resilient. So when you start running low on collagen, it shows in your skin. It gets thinner, drier, flakier, less youthful-looking. This is another of those symptoms of menopause that makes you feel older before your time and, in this case, it's clear why. You may look a little older than you used to. Worst, this sign often shows up early in menopause. Collagen loss is most rapid at the beginning of menopause. It is possible that premature menopause also leads to more rapid collagen loss.

tingling of skin Dryness

14

1. Digestive Problems, Gastrointestinal Distress,

Indigestion, Flatulence, Gas Pain, Nausea Changes in gastrointestinal function with excessive gas production, gastrointestinal cramping and nausea.A certain amount of flatulence is perfectly natural, but people who switch to a healthy diet sometimes worry unnecessarily that they're producing too much. So if you're eating lots of whole grains, fruits and vegetables, which means a healthy diet, it's likely that your digestive system is churning out a healthy amount of gas. If you have gas and stomach or abdominal pain for more than three days, or if the pain is more severe than before, you should see your doctor immediately.

Burning Tongue, Burning Roof of Mouth, Bad Taste in Mouth: Change in Breath Odor :Burning mouth syndrome is a complex, vexing condition in which a burning pain occurs on your tongue or lips, or over widespread areas involving your whole mouth without visible signs of irritation. The disorder has long been associated with a variety of other conditions, including menopause. It affects up to 5 percent of U.S. adults, women seven times more often than men. It generally occurs after age 60. But it may occur in younger people as well. If you have persistent pain or soreness in your tongue, lips, gums or other areas of your mouth, see your doctor.

Weight gain: A three year study of healthy women nearing menopause found an average gain of five pounds during the three years. Hormonal changes and aging are both possible factors in this weight gain.

Gum Problems, Increased Bleeding :The most common gum problem is bleeding, and it's a sign of inflamed gums, or what dentists call gingivitis. But gingivitis is just the overture for more serious problems. Bleeding and sore gums are the same as most health problems: If you catch them before they get too bad, they're easy to reverse. "Gingivitis is absolutely reversible in the earlier stages," says Dr.
15

Allen.To put bleeding gums in reverse, put your hands on floss and a toothbrush. But make sure to hold that toothbrush the right way. You have to worry if sores develop under your dentures or if there is swelling, puffiness, soreness in your bleeding gums. Take advice from your doctor in these cases. Click here for more information about gum problems during menopause.
Sudden Bouts of Bloat :A puffy bloated feeling that seems to come out of

nowhere; usually you'll notice bouts which are periodic increases in fluid retention and abdominal distension. Doctors call the gassiness, bloating and discomfort that occur after eating dairy foods lactose intolerance. It means your stomach is unable to digest the lactose -or milk sugar- in dairy foods. Unfortunately, most adults have this problem to some degree, according to Jay A. Perman, M.D., as people age, they produce less lactase -the enzyme needed to digest lactose. Without lactase, the undigested milk sugar ferments and gases form. The trapped gas makes your stomach bloat. If you have persistent, unexplained bloating or stomach pain for more than three days, then you should contact you doctor.
1. Increase in Allergies : Many types of allergy have their basis in hormone

reactions. This is particularly true of ladies who experience increasing symptoms as they undergo hormone changes, usually in their late twenties or after the babies are born. Hormone imbalance is a type of allergic reaction experienced by women from before puberty to old age. It is a heightened reaction to the normal function of hormones. II. Psychological aspect
Anxiety: Anxiety can be a vague or intense feeling caused by physical or

psychological conditions. A feeling of agitation and loss of emotional control that may be associated with panic attacks and physical symptoms
16

such as rapid heartbeat, shortness of breath and palpitations. The frequency of anxiety can range from a one-time event to recurring episodes. Early diagnosis may aid early recovery, prevent the disorder from becoming worse and possibly prevent the disorder from developing into depression. Click here for more information about Anxiety.
Irritability :A significant change in mood for an extended period of time

associated with loss of interest in usual activities, sleep and eating disorders, and withdrawal from family and friends. "Occasional irritability is a normal part of being human," says Paul Horton, M.D., a psychiatrist in Meriden, Connecticut. "But irritability also can go hand in hand with almost any illness. Very often, people who are falling ill will become irritable but don't know why." If your irritability persists more than a week and is adversely affecting your job performance and relationships with your family, friends and co-workers, better see your doctor. Click here for more information about irritability during menopause.

Depression ; Feelings of sadness can be normal, appropriate and even necessary during life's setbacks or losses. Or you may feel blue or unhappy for short periods of time without reason or warning, which also is normal and ordinary. But if such feelings persist or impair your daily life, you may have a depressive disorder. Severity, duration and the presence of other symptoms are the factors that distinguish ordinary sadness from a depressive disorder. This is called: Depression, or irritability, which is a significant change in mood for an extended period of time associated with loss of interest in usual activities, sleep and eating disorders, and withdrawal from family and friends. Depression can happen to anyone of any age. It afflicts almost 19 million Americans each year, and up to one in five American women will suffer from clinical depression at some point in her life. Women are
17

two to three times more likely than men to suffer from depression. Many women first experience symptoms of depression during their 20s and 30s. irritability due to altered hormonal levels or disturbed sleep cycles or vasomotor changes

Headache : Though headaches can be caused by a variety of factors such as muscle tension, drinking too much alcohol or can occur with common illnesses such as the flu. During the early stages of menopause, you may find that you're getting more and worse headaches. This is often caused by your dropping estrogen levels. Many women with regular menstrual cycles get headaches just before their periods or at ovulation. These headaches, sometimes called "menstrual migraines" occur when estrogen levels plunge during the menstrual cycle. So, when your body begins slowing down its production of estrogen due to premature menopause, you may wind up getting one of these hormonally-induced headaches. Severe headaches that are accompanied by confusion or high fever can indicate a serious health condition and require your doctor's immediate attention.

Menopause Sleep Disorders (With or Without Night Sweats): If you're waking up a lot at night, tossing and turning, and generally suffering with insomnia, it might be connected with menopause. When you begin going through menopause, you may find that your sleep is less and less restful, when you sleep at all. In the past, doctors believed that interrupted sleep was a consequence of night sweats, but recent studies indicate that you can also have problems with sleep that aren't connected to hot flashes. Typically, the frequency of insomnia doubles from the amount you may have had before you entered premature menopause. And research also indicates that women begin to experience restless sleep as many as five to seven years before entering menopause. Again, though, the problem is

18

recognizing that the insomnia you're suffering from has its roots in changes in your hormone levels.

Mood Swings, Sudden Tears : A person with a mood problem is like a human roller coaster. One minute he's up, the next minute he's down. He never seems to be able to get off the ride. His mood swings are intense, sudden and out of control. Chronic and severe mood swings are a psychological disorder, a health problem every bit as real as a physical ailment. In fact, sometimes they're the result of a physical problem, like a premenstrual syndrome. And just like a physical problem, they can be treated. You should contact your doctor to get more advice.

dysphagia

Memory loss :Memory loss affects most people in one way or another. More often than not, it is a momentary memory lapse; nothing to worry about - it happens to the best of us. However, when memory lapses begin to become a regular occurrence, it is wise to dig a little deeper and seek medical advice. Women approaching menopause often complain of memory loss and an inability to concentrate. Misplaced car keys, skipped appointments, and forgotten birthdays, but these memory lapses are a normal symptom of menopause. It is mostly associated with low levels of estrogen and with high stress levels. Difficulty Concentrating, Disorientation, and Mental Confusion: During early menopause, many women are troubled to find they have difficulty remembering things, experience mental blocks or have trouble concentrating. Not getting enough sleep or having sleep disrupted can contribute to memory and concentration problems. If your doctor determines that your disorientation isn't caused by a serious medical condition, then you might consider these possibilities: -Investigate your drugs. -Disorientation is a side effect of some drugs. -Learn to relax. -Practice stress-reduction techniques, such as
19

deep breathing exercises, yoga and meditation and try to be physically active on a regular basis.

Fatigue : "Fatigue is second only to pain as the most common symptom doctors see in patients," says David S. Bell, M.D., a chronic fatigue researcher at Harvard Medical School and the Cambridge Hospital in Massachusetts. "One-fourth of all Americans will have long episodes of lethargy and tiredness." Particularly common in women undergoing the menopausal transition, chronic fatigue can have a drastic impact on daily life, putting a strain on relationships, work productivity, and quality of life. Fatigue, one of the most common menopause symptoms, is defined as an ongoing and persistent feeling of weakness, tiredness, and lowered energy level. This should be distinguished from drowsiness, which implies an actual urge to sleep. Fatigue involves lack of energy rather than sleepiness. If the fatigue comes on suddenly, it could be a sign of crashing fatigue. To learn more about Crashing Fatigue, click here. Other characteristics may include apathy, irritability, and decreased attention.

Dementia / forgetfullness

Tempting to drink alcohol

Tiredness Inability to concentrate Dizziness, Light Headedness, Episodes of Loss of Balance :Dizziness is a transient spinning sensation and/or a feeling of lightheadedness or unsteadiness; also, the inability to maintain balance upon standing or walking. Dizziness is a symptom of many medical conditions. There are things that people can do to cope with their dizziness. But if you experience an unexplained dizzy spell, see your doctor, because you can't be sure if it's a trivial problem or a symptom of a serious illness.

20

Tingling Extremities : This may feel like the "creepy-crawlies" as if bugs were walking all over you, a burning sensation like an insect sting, or just super-sensitivity. In most cases, tingling is harmless. It usually occurs after you pinch a nerve or press on an artery and reduce blood flow in your arm or leg causing it to "fall asleep." When you change body position and relieve the compression, the tingling quickly goes away. But tingling can also be a symptom of any number of problems, including anxiety, a herniated spinal disk, poor blood circulation, diabetes, heart disease, stroke, arthritis, multiple sclerosis, carpal tunnel syndrome or a tumor. Any unexplained tingling that affects an entire side of your body or is accompanied by muscle weakness, warrants immediate medical attention.

Panic Disorder, Feelings of Dread, Apprehension, Doom : A significant and debilitating emotional state characterized by overwhelming fear and anxiety. These feelings can be vague or intense caused by physical or psychological conditions. The frequency can range from a one-time event to recurring episodes. If your life is totally disrupted by this symptom, better contact your doctor. Click here for more information about panic disorderduring menopause.

III. Social aspects Lonliness Social isolation

Lack of interest in family, friends and the society

DIAGNOSTIC EVALUATION
History collection presence of typical symptoms along with amenorrhoea for more than 12 months Physical examination appearance of menopausal symptoms hot flushes , night sweats
21

Serum FSH levels excess of 30 IU confirms the diagnosis Vaginal cytology features of low estrogen

Serum estradiol - < 20 pg/ml

Pelvic examination indicate the changes in the vaginal lining Pap smear to detect precancerous lesions and hidden tumours Bone density studies - to detect osteoporosis Lipid profile Thyroid profile because thyroid disease can mimic the symptoms of menopause

TREATMENT
The treatment includes 1. Non hormonal treatment 2. Hormonal replacement therapy

1. NON HORMONAL TREATMENT

Nutritious diet : balanced with calcium and protein is helpful Supplementary calcium : daily intake of 800-1000 mg can reduce osteoporosis and fracture Exercise : walking, jogging Vitamin D : supplementation of vitamin D3 (400IU/ day) along with calcium can reduces osteoporosis and fractures. Exposure to sunlight enhances the synthesis of cholesterol (vitamin D3) in the skin Biophosphanates : prevent osteoclastic bone resorption Alendronate,

pamidronate, risedronate are the drug of choice

22

Fluoride : prevents osteoporosis and increases bone matrix. It is given at a dose of 1mg / kg for short term Calcitonin : inhibits bone resorption. 50-100IU daily given by subcutaneous injection Selective estrogen receptor modulators (SERMs) : are tissue specific in action. Raloxifene has shown to increase bone mineral density, reduces serum LDL and rises HDL2 level. And also inhibits the estrogen receptors at the breast and endometrial tissues thus it prevents breast and endometrial cancer. Hypnotics , Tranquilizers and Sedatives : usually prescribed. These can allay the psychologic symptoms but cannot relieve true symptoms Clonidine : an alpha adrenergic agonist may be used to reduce hot flushes Thiazides : reduce urinary calcium excretion
1.

HORMONE REPLACEMENT THERAPY ( HRT )

The hormonal replacement therapy is indicated in menopausal women to overcome the short term and long term consequences of estrogen deficiency The OBJECTIVE of HRT is to ensure the potential benefits and minimize the risks. Indications of HRT Hormone replacement therapy is generally adviced for women who are symptomatic and are at high risk of developing cardiovascular disorders, osteoporosis, alzhemiers disorders or colonic cancer Premature ovarian failure Gonadal dysgenesis

Surgical radiation menopause

Contraindications of HRT
23

 Undiagnosed genital tract bleeding Estrogen dependent cancer History of venous thromboembolism Active liver disease Gall bladder disease Benefits of HRT Improvement of vascular symptoms (70%-80%) Improvement of urogenital atrophy Increase in bone mineral density ( 2%-5%) Decreased risk in vertebral and hip fractures (25%-50%) Reduction in colorectal cancer ( 20%) Possibly cardio protection Various forms of HRT a. Oral estrogen regime Commonly used estrogens are conjugated equine estrogen 0.625 mg or 1.25 mg is given daily for women who had hysterectomy. Oral estrogen therapy causes risk in plasma estrone levels b. Estrogen and cyclic progestin For a women with intact uterus estrogen is given continuously for 25 days and progestin is added for last 12- 14 days. Because women with intact uterus only estrogen therapy leads to endometrial hyperplasia and endometrial carcinoma. c. Subdermal implants Implants are inserted subcutaneously over the anterior abdominal wall using local anesthesia. 17 beta estradiol implants 25mg 50mg or 100mg are

24

available and can be kept for 6 months. This method suitable mostly for patients after hysterectomy
d.

Percutaneous estrogen gel

1gm applicator of gel , delivering 1mg of estradiol daily, is to be applied on to the skin over the anterior abdominal wallor thighs. It maintains blood level of estradiol 90-120pg/ml e. Trans dermal pouch It contains 3.2mg of beta estradiol , releasing about 50 microgram of estrdiol in 24 hours. It should be applied below the waist line and changed twice a week. Skin reaction, irritation and itching have been noted with their use f. Vaginal cream Conjugated vaginal estrogen cream 1.25mg daily is very effective specially when associated with vaginal atrophy Tibolone is a steroid, a dose of 2.5mg given having weakly estrogenic , progesterone and androgenic properties Monitoring prior to and during HRT A base level parameter of the following and their subsequent checkup annually are mandatory Blood pressure recording Breast examination Pelvic examination Cervical cytology Pelvic ultrasonography to measure endometrial thickness Mammography Serum level of estradiol
25

Risks of hormone replacement therapy (HRT) Endometrial cancer Breast cancer Venous thromboembolic disease Coronary heart disease Lipid metabolism Dementia

Alzheimers disease

ALTERNATIVES TO HARMONAL THERAPY There are some medications available to help with mood swings, hot flashes, and other symptoms. These include low doses of antidepressants such as paroxetine (Paxil), venlafaxine (Effexor), bupropion (Wellbutrin), and fluoxetine (Prozac), or clonidine, which is normally used to control high blood pressure. Gabapentin is also effective for reducing hot flashes. Other therapies

Lack of lubrication is a common problem during and after perimenopause. Vaginal moisturizers can help women with overall dryness, and lubricants can help with lubrication difficulties that may be present during intercourse. It is worth pointing out those moisturizers and lubricants are different products for different issues: some women feel unpleasantly dry all of the time apart from during sex, and they may do better with moisturizers all of the time. Those who need only lubricants are fine just using the lubrication products during intercourse.

Low-dose prescription vaginal oestrogen products such as oestrogen creams are generally a safe way to use oestrogen topically, in order to help vaginal thinning and dryness problems (see vaginal atrophy) while only minimally increasing the levels of oestrogen in the bloodstream.
26

 In terms of managing hot flashes, lifestyle measures, such as drinking cold liquids, staying in cool rooms, using fans, removing excess clothing layers when a hot flash strikes, and avoiding hot flash triggers such as hot drinks, spicy foods, etc., may partially supplement (or even obviate) the use of medications for some women. Individual counselling or support groups can sometimes be helpful to handle sad, depressed, anxious or confused feelings women may be having as they pass through what can be for some a very challenging transition time. The bisphosphate drug alendronate can help prevent loss of bone mass, reducing the risk of fractures, according to a Cochrane review of studies. This applies both to women that have suffered bone loss but have not yet suffered fractures, and women that have suffered both bone loss and fractures. LIFESTYLE CHANGES Lifestyle advice at menopause. Many women only see health care practitioners for advice about their health when they are approaching or are at the menopause. They have concerns about living well for the rest of their lives. Some say that they do not want to grow old the way their mother or grandmother did. When women present with these concerns, it is a good opportunity to review their lifestyle with them. Women want sensitive, unbiased and up-to-date information and an explanation of normal menopausal changes. General health advice is the same throughout a womans life, but there is a particular emphasis on certain factors for menopausal woman: mainly the effects that the menopause has on cardiovascular and bone health as well as the day-to-day symptoms. The key areas to cover are: smoking status diet and nutrition
27

 exercise alcohol consumption weight control psychological aspects of the menopause breast and cervical screening reducing the impact of symptoms. Stopping smoking Smoking has many negative effects: cigarette smoking can increase the risk of having a heart attack by two or three times. Coronary heart disease (CHD) is the most common cause of death in women smokers are 1.5 times more likely to have a stroke smoking tends to increase blood cholesterol levels Diet and nutrition Nutrition is important for all women around the time of the menopause, and a healthy, balanced diet should below in fat, low in salt and rich in calcium. Facts about nutritional health calcium and salt: high salt intake is linked with the development of high blood pressure hypertensives excrete higher amounts of calcium in their urine than people with low blood pressure It is thought that calcium lost in the urine is replaced through calcium stripped from the bone, and that salt plays an important role in speeding calcium loss

28

 You should be able to get all the calcium you need from a healthy diet. Adults need 700 mg a day, although those with osteoporosis may need more (DH, 1998) vitamin D is necessary for the effective absorption of calcium from the gut, most being obtained from direct sunlight; a smaller amount is obtained from the diet. Supplements of 10 mcg vitamin D may be necessary for elderly and housebound people, those on a restricted diet, and where there is little exposure to sunlight The following table lists foods that are valuable sources of calcium. Food Milk (skimmed) Milk skimmed) Quantity 100 mls mg of calcium 122 120 118 89 739 140 100 500 860 680 33 250 287 56

(semi 100 mls 100 mls 100 mls 100 g 100 g 100 g

Milk (whole)

Milk(soya) Cheese (cheddar)

Yoghurt low fat)

(fruit 100 g 100 g 100 g 1 slice 100 g 100 g 100 g

Ice cream (dairy) Sardines in oil Whitebait (fried) Tahini paste) White bread (sesame

29

 Figs (dried)

Cheese omelette

Green/french beans

Facts about nutritional health general: diet should be high in fruit and vegetables, containing at least five portions daily fruit and vegetables contain antioxidant vitamins and minerals which are crucial in preventing the damaging effects of free radicals smokers use antioxidants faster you should aim for at least two portions of fish a week, one of which should be oily fish maintaining a healthy weight is important. Obesity is a major risk factor for CHD and is associated with high blood pressure, heart attacks, heart failure and diabetes. Women should aim for a health body mass index (BMI) of 20 25. Exercise Regular exercise is necessary to remain active, healthy and independent. Physical activity reduces the both the risk of developing CHD and of having a stroke by lowering blood pressure. Exercise increases energy levels, muscle strength and bone density. Exercise can reduce stress, anxiety and likelihood of depression. Exercise helps weight loss and improves sleep.
30

 Weight-bearing exercise such as brisk walking, dancing, skipping, aerobics, tennis and running stimulate bone to strengthen itself. Cycling and swimming are both good cardiovascular exercises. Exercise should be varied and should be taken for at least 30 minutes on five or more days of the week for maximum benefit. Weight control

It is not inevitable that women will put on weight at the menopause, but many do.

This is in part due to a decline in muscle mass and a subsequent slowdown in the basal metabolic rate, without reducing the amount of food and alcohol and while taking little or no exercise.

Women should be advised to: eat a healthy diet exercise regularly; start slowly and gradually increase lose extra weight slowly and steadily. Psychological aspects Depression, anxiety, tiredness, loss of concentration and memory problems are all common experiences during or after the menopause. To help these aspects, note that: regular mental stimulation seems to maintain cognitive ability regular exercise can make sleeping easier a balanced diet will ensure an adequate intake of essential minerals and vitamins social activity improves mental function
31

 concentration can be improved with crosswords, puzzles, quizzes etc. learning new skills or languages improves mental function moderating alcohol intake is important for good memory function. Health screening It is important to encourage women to attend breast and cervical screening as per NHS guidelines. Women should also be encouraged to be aware of any changes intheir breasts, seeking help promptly if they occur. Education Many women arrive at their menopause transition years without knowing anything about what they might expect, or when or how the process might happen, and how long it might take. Very often a woman has not been informed in any way about this stage of life; it may often be the case that she has received no information from her physician, or from her older female family members, or from her social group. There appears to be a lingering taboo which hangs over this subject. As a result, a woman who happens to undergo a strong perimenopause with a large number of different effects may become confused and anxious, fearing that something abnormal is happening to her. There is a strong need for more information and more education on this subject. Treatment of osteoporosis The goal of osteoporosis treatment is the prevention of bone fractures by slowing bone loss and increasing bone density and strength. Although early detection and timely treatment of osteoporosis can substantially decrease the risk of future fracture, none of the available treatments for osteoporosis are complete cures for the condition. Therefore, the prevention of osteoporosis is as important as treatment. Osteoporosis treatment and prevention measures are:

32

Lifestyle changes including cessation of cigarette smoking, curtailing alcohol intake, exercising regularly, and consuming a balanced diet with adequate calcium and vitamin D.

Calcium and vitamin D supplements may be recommended for women who do not consume sufficient quantities of these nutrients.

Medications

that

stop

bone

loss

and

increase

bone

strength

includealendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva),z oledronicacid (Reclast), raloxifene (Evista),and calcitonin (Calcimar).Teripar atide (Forteo) is a medication that increases bone formation.

Complementary therapies A wide range of complementary therapies can be used to reduce or stop the short term symptoms of the menopause, but not to prevent or treat osteoporosis.
1.

Acupuncture and acupressure Acupuncture uses needles put into the skin at specific points on the body, whereas acupressure uses pressure on these points.

2.

Hypnotherapy : Hypnotherapy aims to improve health of a patient through inducing a trance-like state, with therapist and patient working together to reduce anxiety and stress.

3.

Aromatherapy : Aromatherapy treats illness with concentrated plant oils ( ginger, jasmine, lavender oils ) most commonly applied through massage. The oils can also be administered as an inhalation or in a bath to reduce insomnia, anxiety, depression, headache, muscle pain etc. ABNORMAL MENOPAUSE
33

There are two types of abnormal menopause 1. Premature menopause If the menopause occursat or below age of 40, it is said to be premature. Often there is familial diathesis. Treatment by substitution therapy is of value 2. Delayed menopause If the menopause fails to occur even beyond 55 years it is called delayed The common causes are constitutional, uterine fibriods, diabetes mellitus and estrogenic tumour of the ovary The cases should not be neglected. In the absence of pelvic pathology, diagnostic curettage should be done and an early decision of hysterectomy should be taken to prevent incidence of endometrial cancer. ARTIFICIAL MENOPAUSE Artificial menopause is of two types 1. RADIATION MENOPAUSE The ovarian function may be suppressed external gama radiation in women below the age of 40. The menopausal symptoms are not so intense as found in surgical menopause. The menstuation may resume after 2 years and even conception is possible
2.

SURGICAL MENOPAUSE

While most women go through natural menopause about 50 years of age, there are some who undergo menopause in their 40s and even as early as 30s and 20s. Approximately 600,000 women in the US have a hysterectomy which is the second most common major surgery among women. About 55% of women who have had hysterectomies also undergo bilateral oopherectomy. This means they experience surgical menopause as well. What is surgical menopause?
34

The ovaries produce oestrogen, progesterone and androgens which are essential to the regulation of the menstrual cycle. When a hysterectomy done, these hormones get suddenly interrupted and their levels fall resulting in symptoms of menopause. This is termed surgical menopause.

Although removal of ovaries becomes unavoidable in most hysterectomy surgeries, even effort is made by the surgeon to leave the ovaries intact in order to avoid the sudden absence of hormones. Surgical menopause occurs in women who have not yet had natural menopause

Most often surgical menopause is caused quite dramatically when there is surgical interference like hysterectomy, bilateral oophorectomy and total abdominal hysterectomy with bisalpingo oophorectomy. In case of hysterectomy when the uterus is removed and ovaries remain, menstrual periods stop but significantly the menopausal symptoms occurs at the same age as would naturally. Surgery is warranted in conditions such as endometriosis, ovarian cysts, fibroids, ovarian cancer and pelvic organ prolapse Planning a surgical menopause Surgical menopause is a difficult decision especially at a younger age. The younger the women, the more problems she will encounter

A complete hormonal check up is essential for every woman who have to undergo hysterectomy. This way a baseline reading of the hormonal needs is obtained and one can always try to achieve these normal levels with the right hormones again

Post care has to be planned and it is important for a young women undergoing hysterectomy to be under the care of a hormonal therapy specialist who can handle the side effects of surgical menopause Research is still at an infant stage seeking to determine the long time effects of surgical menopause on heart diseases, osteoporosis and general health especially on young women
35

Symptoms of surgical menopause Since there is abrupt disruption of hormones after hysterectomy, the menopausal symptoms are more severe, more frequent and last longer when compared to natural menopause. The symptoms are triggered by the bodys sudden inability to make certain hormones due to removal of ovaries

Hot flushes and night sweats are commonest symptoms of surgical menopause. It is estimated that about 75-90% of women who have had surgical menopause experience them. This is due to disturbance of the central thermostat located in the hypothalamus which is kept stable by normal circulating oestrogen

Other symptoms of surgical menopause range from sleepless nights, vaginal dryness , itching, decrease in sexual desire and dyspareunia (painful intercourse )

Depression is another common result of low oestrogen level

Thyroid dysfunction Bladder infections Incontinence of uterine Weight gain Migraine and irritability Management of surgical menopause

Estrogens are immediately given after surgery to try to prevent the intense changes especially the hot flushes that can occur in women undergoing hysterectomy. Estrogens replacement therapies like estrogel have found to relieve many women experiencing surgical menopause

Various forms of oestrogen replacement therapies like vaginal creams, sub dermal implants, oestrogen gel , HRT patches are also prescribed

Risks of surgical menopause

36

 Women with surgical menopause are seven times more prone to cardiovascular disease risks

They run the risk of osteoporosis as oestrogen plays a vital role in bone formation and without oestrogen, calcium is lost from the bones which when not replaced breaks easily

It is found that after surgical menopause in particular, bones loose roughly 3% of their mass per year for the first 5 years and then 1-2% a year thereafter. Increased bone loss associated with oophorectomy results in fracture risk as well Some studies have found that reduced levels of testosterone in women are predictive of weight loss which may occur as a result of reduced bone density

Gum tissues are affected and regular dental checkups are advised to tide over this problem Women younger than 45 years of age and who have had their ovaries removed face a mortality risk 170% higher than women who have retained their ovaries after oophorectomy. Hormone replacement therapy is commonly advised as it is believed by many doctors to mitigate the mortality risks.

There is a definite lowering the sexual desire in women who have undergone surgical menopause. This reduction is greater than that seen in women undergoing natural menopause Surgical menopause is definitely difficult and different when compared to the natural menopause. But it is important to say positive, one can also join a local or internet menopause support group, take breaks throughout the day, relax mentally and keep physically fit by exercising and eating a healthy diet.

37

PREVENTION Menopause is a natural and expected part a womens development and does not need to be prevented But artificial menopause induced by surgery or radiation during reproductive period can to some extent be preventable However there are ways to reduce or eliminate some of the symptoms of menopause. We can also reduce the risk of long term problems like osteoporosis, heart diseases and breast cancer by taking the following steps. Control blood pressure , cholesterol and other risk factors for heart disease Encourage for avoidance of smoking , because cigarette use can cause early menopause Eat low fat diet Regular exercise, which strengthens the bones and improves balance Nutritious diet rich in vitamin D and calcium Supplementary calcium and vitamin D Early detection and treatment for bone loss Avoidance of stress or over exert Frequent mammogram and breast examination is advisable at least once in a year.

COUNSELLING AND GUIDANCE:

Women at the menopausal stage need to be supported emotionally; they may need c ou nsel in g t o be educated about the condit ion and e xp la na ti on ab ou t th e nor mal physiologic changes that they are undergoing This may also help them to overcome the symptoms of anxiety and depression.
38

Certain life style modification is necessary to prevent the occurrence or minimize the effects of the associated condition. The life style modification is advised include: Diet Smoking cessation Decreased alcohol intake Relaxation Stress reduction.

ROLE OF MIDWIFE:

Midwives provide health care and counseling through the perimenopausal years and beyond, including: Preventive measures for conditions that is increasingly common as a woman ages, particularly those (like heart disease and osteoporosis) that have an increased risk with the reduced estrogen levels found in a womans body after menopause.#

Th e ad va nt ag es a nd d isadvant ages of hor mone r epl acem ent t her ap y a nd sel f- he lp measures The importance of a healthy diet (low in fat, high in calcium) and exercise aerobic for the cardiovascular system and weightbearing for the bones.

The role of herbal therapies.

S ig ns a nd sy mp to ms t hat m ight si gnal a seri ous healt h pr ob le m (suc h a s b le eding between periods).

She gives following advice to reduce menopausal symptoms 1. To reduce hot flushes: Not too warm. Lower heat. Use cotton clothes. Use the fan,
39

Replace coffee, tea, cola beverages by natural juices. No smoking. Take plenty of fluids.

learn to relax, exercise on a regular basis helps to reduce anxiety,

1. To reduce vaginal dryness : In sexual relations while devoting more time.

Loving (necking) as this will increase vaginal lubrication on naturally.

Using specific lubricants that are sold in pharmacies, Vaseline or oil. 1. To control urinary incontinence :

Exercises to strengthen pelvic muscles: When the bladder is empty, try to cut the flow of urine for a few seconds ( the muscles are contracted) and then relax. Perform this exercise several times a day

1. To prevent osteoporosis :

Physical exercise moderately and regularly, where all the joints work and thus hinder the process of decalcification of bone.

A diet rich in calcium, by increasing the intake of dairy products ( especially for skimmed not gain weight),

Some calcium rich fish such as sardines, anchovies, anchovy, and tuna.

Healthy diet low in fat and rich in fruits and vegetables. Sun to create enough vitamin D. which is required for proper calcium absorption. Avoid snuff, alcohol and stimulant beverages ( coffee, tea and cola drinks) and that interfere with calcium metabolism
1.

Preventing psychological disorders:

Keep a positive attitude in life. Teach a relaxation technique to reduce stress and anxiety.
40

 Using their own chores to relax. Have more time for the couple.

Teach him how to overcome the losses (fertility, loss of roles, leaving the house by children, lost parents, relatives and friends etc.

The promotion of social relationships (friends, womens groups and associations), to avoid isolation and loneliness.

Mental health referral if you look at some pathology such as anxiety, stress etc. 1. To prevent the Gynecologic Cancer: Autoexploracines perform breast. Annual clinical examination, mammography every two years. Exfoliative cervico vaginal cytology 1. Cardiovascular disorders : Fat diet rich in olive oil helps regulate cholesterol. Healthy diet rich in fruits and vegetables. Control of blood pressure to rule out hypertension. Exercise. Hormone replacement therapy.

RESEARCH STUDIES
1. Management of Menopause-Related Symptoms

March 2005 Structured Abstract Objectives: To describe the evidence about symptoms associated with menopause, factors that influence these symptoms, benefits and adverse effects of therapies, factors that influence therapies, and future research needs.

41

Data Sources: Searches of MEDLINE, PsycINFO, DARE, the Cochrane database, MANTIS, and AMED; and from recent systematic reviews, reference lists, reviews, editorials, Web sites, and experts. Review Methods: The target population includes adult women in the U.S. undergoing the menopausal transition. All cohort studies reporting menopausal symptoms in >100 subjects were reviewed and relevant data were extracted, entered into evidence tables, and summarized by descriptive methods. Studies of nonmenopausal women, of aging, or not published in English were excluded. Results: Forty-eight studies conducted among 14 cohorts and 22 studies from other populations provide data about symptoms. Vasomotor symptoms and vaginal dryness are most consistently associated with menopause; sleep disturbance, somatic complaints, urinary complaints, sexual dysfunction, mood, and quality of life are inconsistently associated. No studies provide data on cognition and uterine bleeding problems, duration and severity of specific symptoms, or conclusive data on the influence of race/ethnicity, age of onset of menopause, body mass index, oophorectomy status, depression, or smoking. Results of 192 randomized, controlled trials of therapies indicate that for vasomotor symptoms, estrogen is effective; tibolone demonstrates benefit, but most studies are poor-quality; paroxetine, veralipride, gabapentin, soy isoflavones, and other phytoestrogens report benefit in some trials. Results for other symptoms are mixed, adverse effects are inadequately reported, and placebo effects are large. No trials describe the influence of bilateral oophorectomy, premature ovarian failure, use of potentially interacting agents, lifestyle and behavioral factors, recent discontinuation of hormones, or body mass index. For women with breast cancer, clonidine, venlafaxine, and megestrol acetate improve vasomotor symptoms, but results for other symptoms are mixed. Conclusions: Vasomotor symptoms and vaginal dryness are most consistently associated with the menopausal transition. Results of treatment trials are
42

consistent and conclusive only for estrogen. For other agents, the evidence base is limited by the lack of studies demonstrating effectiveness, poor quality of existing studies, and incomplete information on adverse effects. 2. Menopause Working Memory Study This study focuses on the role that estrogen may play in memory in healthy menopausal women and is funded by the National Institute on Aging. The purpose of this study is to look at how estrogen affects memory, emotions, and brain activity in menopausal women. The length of time you'll be on estrogen or placebo (sugar pill) is approximately 3 months. This is also a brain imaging study in which you will participate in 4 fMRI scans; 2 before beginning estrogen or placebo treatment and 2 after starting estrogen or placebo treatment. PCWBW is looking for menopausal women who meet the following criteria: Are between the ages of 48-60 and in good health Have irregular periods or have stopped having a period Are within 10 years of last menstrual period Are a non-smoker Are not on any psychiatric medication including antidepressants Are NOT taking any hormones including birth control pills You can help researchers at UP enn to learn more about estrogen's effects on mood, memory and attention by being a participant. You may earn up to $1250 if you qualify.

SUMMARY
Till now we discussed about definition of menopause, causes, changes, signs and symptoms, diagnostic evaluation, treatment, life style changes, complimentary therapies, surgical menopause, prevention, guidance and counseling for menopausal women and role of midwife in care of menopausal women.

CONCLUSION
43

Though menopause is normal physiologic process, it will lead to many complications for women in aging if we are unaware of it. So as a midwife we should know about what are the changes occurs in the body due to menopause, measures to treat signs and symptoms and prevention of complications, which makes the women to lead a healthy life.

BIBLIOGRAPHY
Books :
1. 2. 3. 4. 5.

Boback teals (1995) Gynaecological nursing ( 4th edition) Philadelphia , Mosby publications ; page no 203-261 D.C dutta (2006) Text book of Gynecology (6th edition) new Delhi, new central book agency ; page no. 51-57 Myles (1992) Text book of midwives (11th edition) Calcutta, Longman groups pvt ltd ; page no. 215-220 Annama Jacob (2002) Text book of comprehensive midwifery (2nd edition) new Delhi , jaypee brothers pvt ltd ; page no. 115-119 Williams (2005) Text book of gynecology (23rd edition) new Delhi ; McGraw hill publications; page no. 341-346

Journals 1. Journal of nurse midwifery (2004) jan-feb (44),vol.1 page no. 6 2. Journal of nursing research and midwifery (2006) November, vol 18, page no. 20-22 3. An international journal of obstetrics and gynecology 4. (2007) vol. 109, march ; page no. 44-56 5. International journal of nursing studies (2008) vol. 54, September ; page no. 535-538 Web site
1. 2. 3.

http:// www.medicinet.com http:// www.medplus.com http:// www.wilkipedia.com

44

OBJECTIVES GENERAL OBJECTIVE: At the end of the class group will gain in-depth knowledge regarding menopause, its signs and symptoms and management. SPECIFIC OBJECTIVE:At the end of the class the student will able to: Define menopause Explain terminologies regarding menopause

Recognize age of menopause for women Describe endocrine regulation prior to menopause

Assess signs and symptoms of menopause Identify diagnostic tests of menopause

Explain treatment, life style changes and complimentary therapies for menopause Describe surgical menopause and its management List out the preventive measures of menopausal complications

Perform counseling and guidance Explain the role of midwife in care of menopausal women

45

Name of the student teacher: Miss. B. Karuna kumari Course & Class: M.Sc Nursing, 1st year Subject: Obstetrical & Gynecological Topic: Menopause Group: Pear group Date: 9.8.2011 Time: 2-4pm Duration: 2hours Venue: M.Sc Nursing 1st year Class Room Method of teaching: Lecture cum Discussion Av Aids: Black board - changes due to menopause - Hormonal replacement therapy Power point life style changes - signs and symptoms of

46

menopau se Chart forms estrogen therapy flash cards - indications of HRT - Contraindications of HRT Handout - research studies and calcium rich food for menopausal women HOD : Mrs. Rafath Razia madam, Professor Supervised by : Mrs. B. Valli Madam, Assist.Professor,Govt.College of Nursing - various

SEMINAR ON MENOPAUSE
47

INDEX
Topic
Introduction Definition Terminology Causes of menopause Endocrine changes Organ changes Premenopause Signs and symptoms of Menopause Diagnostic Evaluation Treatment for Menopause Life style changes for menopausal women Treatment for Osteoporosis

Page no.
1-2 3 3-4 5-7 8-9 9 9-10 10-22 22 23-28 28-34 34
48

Complimentary Therapies Abnormal Menopause Surgical Menopause Prevention of Complications due to menopause Guidance and Counselling for menopausal women Role of Midwife Research studies related to menopause Summary Conclusion Bibliography

35 35-36 36-39 40 40 -41 41-43 44-46 46 47 47

49