Menopause

The clinical diagnosis is confirmed following stoppage of menstruation (amenorrhea) for twelve consecutive months without any other pathology. As such, a woman declare to have attained menopause only retrospectively. Premenopausal refers to the period prior to menopause, post menopause to the period after menopause and perimenopause to the period around menopause (40–55 years), Climacteric is the period of time during which a woman passes from the reproductive to the nonreproductive stage. This phase covers 5–10 years on either side of menopause. Perimenopause is the part of the climacteric when the menstrual cycle is likely to be irregular. Post menopause is the phase of life that comes after the menopause.[1]

Age of Menopause

Age at which menopause occurs genetically predetermine. The age of menopause is not relate to age of menarche or age at last pregnancy. It is also not relate to number of pregnancies, lactation, use of oral pill, socioeconomic condition, race, height or weight. Thinner women have early menopause. However, cigarette smoking and severe malnutrition may cause early menopause. The age of menopause ranges between 45–55 years, average being 50 years.[1]

Clinical Importance

Due to increased life expectancy, especially in affluent society, about one-third of life span will be spent during the period of estrogen deprivation stage with long-term symptomatic and metabolic complications.[1]

Endocrinology of Climacteric and Menopause

Hypothalamopituitary Gonadal Axis

Few years prior to menopause, along with depletion of the ovarian follicles, the follicles become resistant to pituitary gonadotropins. As a result, effective folliculogenesis impaire with diminished estradiol production.

This decreases the negative feedback effect on hypothalamo-pituitary axis resulting in increase in FSH. The increase in FSH also due to diminish inhibin. Inhibin, a peptide, secrete by the granulosa cells of the ovarian follicle. The increase of LH occurs subsequently. Disturbed folliculogenesis during this period may result in anovulation, oligo-ovulation, premature corpus luteum or corpus luteal insufficiency. The sustained level of estrogens may even cause endometrial hyperplasia and clinical manifestation of menstrual abnormalities prior to menopause. The mean cycle length is significantly shorter. This is due to shortening of the follicular phase of the cycle. Luteal phase length remaining constant. Ultimately, no more follicles are available and even some exist, they are resistant to gonadotropins. Estradiol production drops down to the optimal level of 20 pg/mL → no endometrial growth → absence of menstruation.

Androgens:

After menopause, the stromal cells of the ovary continue to produce androgens because of increase in LH. The main androgens are androstenedione and testosterone. Though the secretion of androgens from postmenopausal ovary are more, their peripheral levels reduce due to conversion of androgens to estrone in adipose tissue. However, the cumulative effect is a decrease in estrogenic: androgen ratio. This Results in increased facial hair growth and change in voice. As the higher weight patient converts more androgens into estrone, they are less likely to develop symptoms of oestrogen deficiency and osteoporosis. But they are Vulnerable to endometrial hyperplasia and endometrial carcinoma.[1]

Indian epidemiology then other

This refers to the initiating factors that trigger a disease process.

• Examples of causes include:
  • Pathogens: Viruses, bacteria, fungi, parasites (infectious diseases)
  • Genetic mutations: Inherited or spontaneous changes in genes (genetic diseases)
  • Environmental factors: Toxins, radiation, nutritional deficiencies
  • Lifestyle choices: Smoking, unhealthy diet, lack of exercise (contributing factors)

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Risk factors are things that make you more likely to develop a disease in the first place.

Pathogenesis refers to the development of a disease. It’s the story of how a disease gets started and progresses.

This is the entire journey of a disease, encompassing the cause but going beyond it.

Pathophysiology, on the other hand, focuses on the functional changes that occur in the body due to the disease. It explains how the disease disrupts normal physiological processes and how this disruption leads to the signs and symptoms we see.

Imagine a car accident. Pathogenesis would be like understanding how the accident happened – what caused it, the sequence of events (e.g., one car ran a red light, then hit another car). Pathophysiology would be like understanding the damage caused by the accident – the bent fenders, deployed airbags, and any injuries to the passengers.

In simpler terms, pathogenesis is about the "why" of a disease, while pathophysiology is about the "how" of the disease’s effects.

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Generally, In majority, apart from cessation of menstruation, no more symptoms are evident. In some women symptoms appear. The important symptoms and the health concerns of menopause are i.e.:

• Vasomotor symptoms
• Urogenital atrophy
• Osteoporosis also fracture Osteopenia (WHO) refers to bone mineral density
• Cardiovascular disease
• Cerebrovascular disease
• Psychological changes
• Skin and Hair
• Sexual dysfunction
• Dementia and cognitive decline.[1]

Vasomotor symptoms:

The characteristic symptom of menopause is “hot flush”. Hot flush characterize by sudden feeling of heat followed by profuse sweating. There may also the symptoms of palpitation, fatigue and weakness. The physiologic changes with hot flushes are perspiration and cutaneous vasodilatation. Both these two functions are under central thermoregulatory control. Low oestrogen level is a prerequisite for hot flush. Hot flush coincides with GnRH pulse secretion with increase in serum LH level. It may last for 1–10 minutes, and may at times unbearable. Sleep may be disturbed due to night sweats. The thermoregulatory centre in association with GnRH Centre in the hypothalamus involve in the ethology of hot flush.

Gonadotropins (LH) are Thought involve.[1]

Genital and urinary system:

Steroid receptors have identify in the mucous membrane of urethra, bladder, vagina also the pelvic floor muscles. oestrogen plays an important role to maintain the epithelium of vagina, urinary bladder also the urethra. oestrogen deficiency produces atrophic epithelial changes in these organs. All in all, This may cause dyspareunia and dysuria.

Vagina:

Minimal trauma may cause vaginal bleeding. Dyspareunia, vaginal infections, dryness, pruritus and leukorrhea are also common. The urinary symptoms are: urgency, dysuria and recurrent urinary tract infection and stress incontinence.[1]

Sexual dysfunction:

Oestrogen deficiency often associate with decreased sexual desire. This may due psychological changes (depression anxiety) as well as atrophic changes of the genitourinary system.

Skin and hair:

There are thinning, loss of elasticity and wrinkling of the skin. Skin collagen content and thickness decrease by 1–2% per year. “Purse string” wrinkling around the month and “crow feet” around the eyes are the characteristics. oestrogen receptors are present in the skin and maximum are present in the facial skin. oestrogen replacement can prevent this skin loss during menopause. After menopause, there is some loss of pubic and axillary hair and slight balding. This may due to low level of oestrogen with normal level of testosterone.

Psychological changes:

There increase frequency of anxiety, headache, insomnia, irritability dysphasia and depression. They also suffer from dementia, mood swing and inability to concentrate. oestrogen increases opioid (neurotransmitter) activity in the brain and is known to important for memory.

Dementia:

oestrogen thought to protect the function of central nervous system. Dementia and mainly Alzheimer disease are more common in postmenopausal women.[1]

Osteoporosis and fracture:

Following menopause there are decline in collagenous bone matrix resulting in osteoporotic changes. Bone Mass loss and microarchitectural deterioration of bone tissue occurs primarily in trabecular bone (vertebra, distal radius) and in cortical bones. Bone loss increases to 5% per year during menopause. Osteoporosis may primary (Type 1) due to oestrogen loss, age, deficient nutrition (calcium, vit. D) or hereditary. It may secondary (Type 2) to endocrine abnormalities (parathyroid, diabetes) or medication.

Osteoporosis may lead to back pain, loss of height and kyphosis. Fracture of bones is a major health problem. Fracture may involve the vertebral body, femoral neck, or distal forearm (Colles’ fracture). Morbidity and mortality in elderly women following fracture is high.[1]

Detection of osteoporosis:

Computed tomography (CT) and specially the dual-energy X-ray absorptiometry (DEXA) are reliable methods to assess the bone-mineral density. Total radiation exposure is high with CT than DEXA.

Biochemical parameters to detect bone loss are measurement of urinary calcium/creatinine and hydroxyproline/creatinine ratios.

Cardiovascular and cerebrovascular effects:

Oxidation of LDL and foam cell formation cause vascular endothelial injury, cell death and smooth muscle proliferation. All these lead to vascular atherosclerotic changes, vasoconstriction and thrombus formation.

Risks of ischemic heart disease, coronary artery

disease and strokes are increased.[1]

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1. Cessation of menstruation for consecutive 12 months during climacteric.
2. Appearance of menopausal symptoms ‘hot flush’ and ‘night sweats.
3. Vaginal cytology – showing maturation index of at least 10/85/5 (Features of low estrogen).
4. Serum estradiol : < 20 pg/mL.
5. Serum FSH and LH: >40 mlU/mL (three values at weeks interval required).

Complications are what happen after you have a disease. They are the negative consequences of the disease process.

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Treatment

Lifestyle modification i.e.:

Physical activity (weight bearing), reducing high coffee intake, smoking and excessive alcohol. There should be adequate calcium intake (300 mL of milk), reducing medications that causes bone loss (corticosteroids)

Nutritious diet i.e.

balanced with calcium and protein is helpful [1]

Supplementary calcium i.e.

daily intake of 1–1.5 g can reduce osteoporosis and fracture

Exercise i.e.

weight bearing exercises, walking, Jogging

Vitamin D—supplementation of vitamin D3 i.e.

(1500–2000 IU/day) along with calcium can reduce osteoporosis and fractures. Exposure to sunlight enhances synthesis of cholecalciferol (vitamin D3) in the skin,

Cessation of smoking and alcohol [1]

Bisphosphonates i.e.

Bisphosphonates prevent osteoclastic bone resorption. It improves bone density and prevents fracture. It is preferred for older women. Women should be monitored with bone density measurement. Drug should be stopped when there is severe pain at any site. Commonly used drugs are etidronate and alendronate. Alendronate is more potent. Ibandronate and zoledronic acid are also effective and have less side effects. Bisphosphonates when used alone cannot prevent hot flushes, atrophic changes and cardiovascular disease. It is taken in empty stomach. Nothing should be taken by mouth for at least 30 minutes after oral dosing. Patient should remain upright for 30 minutes. Side effects include gastric and oesophageal ulceration, osteomyelitis and osteonecrosis of the jaw.

Fluoride i.e.

It prevents osteoporosis and increases bone matrix. It give at a dose of 1 mg/kg for short-term only. Calcium supplementation should continue. Long-term therapy induces side effects (brittle bones).

Calcitonin inhibits bone resorption i.e.

Simultaneous therapy with calcium and vitamin D should be given. It give either by nasal spray (200 IU daily) or by injection (SC) (50–100 IU daily). It use when oestrogen therapy contraindicate.[1]

Selective oestrogen receptor modulators i.e.

(SERMs) are tissue specific in action. Of the many SERMs, raloxifene has shown to increase bone mineral density, reduce serum LDL and to raise HDL2 level. Raloxifene inhibits the oestrogen receptors at the breast and endometrial tissues. Risks of breast cancer and endometrial cancer are therefore reduced. Raloxifene does not improve hot flushes or urogenital atrophy. Evaluation of bone density (hip) should do periodically. Risks of venous thromboembolism increase.

Clonidine, an alpha-adrenergic agonist may use to reduce the severity and duration of hot flushes. It is helpful where oestrogen contraindicate (hypertension)

Thiazides i.e.

It reduce urinary calcium excretion. It increases bone density specially when combined with oestrogen.

Paroxetine i.e.

It is a selective serotonin reuptake inhibitor, is effective to reduce hot flushes (both the frequency and severity).

Gabapentin i.e.

It is an analogy of gamma-aminobutyric acid. It is effective to control hot flushes.

Phytoestrogens i.e.

It containing isoflavones are found to lower the incidence of vasomotor symptoms, osteoporosis and cardiovascular disease. It reduces the risk of breast and endometrial cancer.

Soy protein i.e.

It is also found effective to reduce vasomotor symptoms. Soy protein acts as SERMS.[1]

Spontaneous menopause is unavoidable. However, artificial menopause induced by surgery (bilateral oophorectomy) or by radiation (gonadal) during reproductive period can to some extent be preventable or delayed.

Counselling: Every woman with postmenopausal symptoms should be adequately explained about the physiologic events. This will remove her fears, and minimize or dispel the symptoms of anxiety, depression and insomnia. Reassurance is essential.[1]

Homeopathic treatment is based on individualization in which a doctor selects a medicine according to your/ patients constitution rather than matching only symptoms similarity, so before taking any homoeopathic medicine you have to firstly consult a homoeopathic physician for your concern problem’s, there are so many remedies are useful for this condition but some few therapeutic indications of homeopathic remedies in the cases of Menopause are as below

Lachesis

Suits especially women who never get well from the change of life; "have never felt well since that time." It corresponds to many climacteric troubles, such as hemorrhoids, hemorrhages, vertigo, burning on the vertex and headaches. It is remedy for women worn out by frequent pregnancies, with sudden cessation of the menses, trembling pulse, headache, flushing of the heat and rush of blood to the head, cold feet and constriction about the heart

Amyl nitrite.

Flushes of heat at change of life. The 30th potency acts well here.

Strontiana carbonica.

Flushes of heat with head symptoms relieved by wrapping head up warmly.

Sanguinaria.

Flushes at climax’s; headache with profuse menses.

Caladium.

Pruritus at menopause.

Aconite.

Derangements of circulation at menopause. Hughes also praises Glonoine for these conditions. Veratrum viride. Perhaps no remedy controls the flushes of heat, so annoying to women at the change of life, as well as Veratrum viride.[2]

Cimicifuga [Cimic]

is very often the remedy for the suffering incident to the change of life. There is sinking at the stomach, pain at the vertex and irritability of disposition. The patient is restless and unhappy, feels sad and grieved. Bayes prefers the 6th and 12th potencies to the lower dilutions. It is but just to state that many have been disappointed in the use of this remedy. Caulophyllum 3X. Dr. Ludlam praises this remedy for nervous conditions following the climax’s, when there is "great nervous tension and unrest with a propensity to work and worry over little things." Sepia. Congestion at the climax’s, in characteristic Sepia constitutions, are quickly benefited by the remedy. [2]

Bellis perennis [Bell]

Our English confreres use this remedy quite extensively in what is termed a "fagged womb." The patients are very tired, want to lie down, have a backache. There is no real disease, but a marked tiredness all the time. Carduus is of supreme importance for liver troubles at the climax’s Ustilago. Often rivals Lachesis in controlling the flooding during the climaxes. Vertigo is characteristic.[2]

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[1] DC Dutta text book of gynaecology

[2] Therapeutics from Zomeo Ultimate LAN

Frequently Asked Questions

What is Menopause?

Menopause means permanent cessation of menstruation at the end of reproductive life due to loss of ovarian follicular activity. It is the point of time when Last and final menstruation occurs.

Homeopathic Medicines used by Homeopathic Doctors in treatment of Menopause?

• Lachesis
• Amyl nitrite
• Sanguinaria
• Caladium
• Aconite
• Veratrum viride
• Cimicifuga

What are the symptoms of Menopause?

• Vasomotor symptoms
• Urogenital atrophy
• Osteoporosis and fracture
• Osteopenia
• Cardiovascular disease
• Cerebrovascular disease
• Psychological changes
• Skin and Hair
• Sexual dysfunction
• Dementia and cognitive decline

What is the age of Menopause?

The age of menopause ranges between 45–55 years, average being 50 years.