Menopause and Climacteric
Definition. Menopause refers to the final cessation of menstruation, while the climacteric signifies the period in which the woman gradually changes from reproductive life to that of senescence. Milk also refers to menopause as “the change of life.” However, both terms are often used synonymously, with menopause being the popular term used. These are physiological processes due to the cessation of ovarian follicular function.
Etiology. Menopause occurs as a result of the depletion of eggs from the ovarian follicles and consequent estrogen deprivation.
Physiological changes at climacteric or menopause and postmenopausal age.
Genital. Progressive atrophy of the genital organs occurs with more and more deposition of fibrous tissue on them.
Ovary. They are small (5 gm. each), fibrotic with furrowed surface, The follicles are exhausted. The ovarian vessels become sclerosed. Cortical stromal hyperplasia is a frequent finding due to the high level of LH in women aged 40 to 46 years. The ovarian stroma becomes a source of small amounts of androgens.
Fallopian tubes shrink with decreased mortality.
The uterus becomes small and fibrotic due to atrophy of the muscle. The endometrium becomes thin and atrophic (senile). In some women, endometrial. hyperplasia can occur after menopause as a result of constant estrone stimulation. The cervix atrophies and reddens with the vaginal vault. Cervical discharge becomes scanty, thick, and then 4is appears. The vaginal epithelium atrophies with loss of roughness. The vaginal smear shows atrophic changes. The vagina contracts to a shallow depth of the fornix. The vulva gradually atrophies with narrowing of the introitus: the pelvic cell tissue gradually becomes lax.
Secondary sexual characteristics. The breasts show a gradual atrophy of glandular tissue resulting in sagging. These become pendulous due to the deposition of fat around them. Pubic and underarm hair becomes sparse.
Physical. Body weight decreases after age 65. There is a decrease in the cell mass of the organs. The skin wrinkles, becomes less elastic, and hair appears on the face. Subcutaneous fat deposit. occurs on the hip and thighs. Height decreases after the enopause after the age of 65. Kyphosis can develop due to spinal osteoporosis.
metabolic. Osteoporosis occurs as a result of estrogen deprivation. The reduction of trabecular bone (collagen matrix) (osteoblasts) and calcium leads to osteoporosis due to lack of estrogen. The premenopausal woman is protected against ischemic heart disease due to high HDL cholesterol and low LDL cholesterol. The latter increases after menopause, so the incidence of ischemic heart disease also increases. Natural premature menopause or ovariectomy has a higher risk of cardiovascular disease (cardiac and cerebral stroke) and osteoporosis.
digestive. Hypochlorhydria develops. The motor activity of the entire alimentary tract decreases, which leads to dyspepsia and constipation in postmenopausal women. Atrophy of the bladder and urethral epithelium.
Psychosexual. Emotional disturbances are common. At menopause the sexual drive can increase. After the age of 60, the sexual drive decreases as an aging process.
Endocrine. There is gonadal failure at menopause. The plasma estradiol level falls, estrone remains normal, however, the ovarian stroma produces andostenedione. Extraglandular conversion of androstenedione to estrone occurs in adipose tissue. After menopause, the adrenal cortex becomes the source of the androstenedione-derived estrone. Estrone becomes the predominant estrogen after menopause. Daily postmenopausal estrone formation has been estimated at 15-100 ug/day (MacDonald et al, 1973) and the serum level at 30-70 pg/ml. The secretion of progesterone ceases from the ovary due to the lack of ovulation. The total urinary estrogen level falls to about 6 Pg1 24 hours in the postmenopausal period. Androstenedione level mainly from adrenal cortex, little . of the ovary reaches half of what was seen before menopause. The testosterone level does not drop appreciably because the postmenopausal ovary secretes more testosterone.
Pituitary gonadotropins. FHS and LH are secreted in increased amounts due to the lack of negative feedback control by ovarian steroids. The ovulatory LH surge disappears, mean menopausal gonadotropin levels in basal serum are in the range of 50-150 mn LU/ml FSH and 50-100 mIU/ml LH. The FSH level is 15 times higher than the premenopausal level between 3 and 5 years after menopause, while the LH level increases 3 times. Prolactin level drops.
Moment. The climacteric process may begin gradually 2-3 years before menopause but may continue 2-5 years later. The age at which menopause occurs varies widely from 40 to 55 years with a median age of around 47 years. Genetic makeup, race, and climate influence age at menopause. Women in the tropics go through earlier menopause than those in colder climates. Some believe that the earlier menarche begins, the later menopause would occur, while late menarche is associated with early menopause. Early or late menopause is considered when menopause occurs before the age of 35 or after the age of 55, respectively. Early menopause may be due to ovarian failure, oophorectomy, or ovarian irradiation.
Delayed menopause is usually due to some pelvic pathology such as uterine fibroid or in association with a disease, eg diabetes mellitus.
Clinical features of menopause and climacteric
Menstrual symptoms. This occurs in the forms of (a) progressive scanty menstrual loss followed by cessation of menses, (b) menses at long intervals which finally ceases, (c) sudden cessation of menses. Before menopause, menstrual cycles become anovulatory. Any excessive menstrual loss or irregular bleeding is not menopausal as is commonly believed by the general public, but rather is due to some pelvic pathology.
Other symptoms. Most women remain asymptomatic. They adapt very well to the physiological changes of menopause. Some may have mild symptoms of weight gain, joint pain, increased sexual desire followed by its gradual decrease.
signs. The following signs appear gradually in a normal woman in the menopausal period and thereafter.
1. General signs. Weight gain, fat deposits on the hips, buttocks, around the breasts. The breasts are examined.
2. Genital signs.
vulva. Progressive atrophy with sparse hair with narrowing of the vaginal introitus.
vagina. This becomes narrow with “tent” of the vaginal vault, thinning of the mucous membrane, and 18ss of rugae.
Cervix. Portio vaginalis atrophies and reddens with the vaginal vault.
Uterus. The body feels small and hard.
Annexes. The ovaries become impalpable.
Diagnosis. This can be done from the clinical features aided by an atrophic vaginal smear and an elevated serum FSH level of 50 mIU/ml or more. Elevated plasma LH level is less helpful. The urinary or serum estrogen level shows a value similar to that of the follicular phase and, therefore, less reliable for diagnosis.
Differential diagnosis. The interruption of menstruation due to menopause can be simulated by that due to pseudocyesis or pregnancy.
Treatment. Psychotherapy. Explanations about the condition and reassurance should be given to the woman going through the climacteric when she seeks advice for the cessation of menstruation. Improved health should be ensured by dietary adjustment, adequate rest and exercise, and regular bowel evacuation. For sleep disorders, diazepam (Valium) 5 mg. or Lorazepam 1 or 2 mg. It is taken orally at bedtime.
Menopausal or Climacteric Syndrome
Menopause syndrome refers to the group of symptoms that some women experience during the climacteric. Hot flashes (symptom of vasomotor instability) that last one year in 80% are characteristic of the menopausal syndrome. It decreases by itself in 3-4 years. The cause of hot flashes is unclear but follows estrogen withdrawal in women with poor vascular control. Increased hypothalamic endorphin is implicated. It is experienced by 25% of women with a psychological history, particularly after ovariectomy or ovarian irradiation at a younger age.
Flush is dependent on the rate of estrogen loss and extragonadal estrone formation. The body gradually adjusts to the natural decline in estrogen, and the hot flashes gradually disappear.
Symptoms. These appear as follows: Vasomotor and other symptoms generally follow, but even precede, the cessation of menses.
1. Menstruation. Menstruation stops as already described in menopause. A proportion of premenopausal women present with emotional symptoms, loss of libido, and dry vagina during sexual intercourse. Some women complain of hot flashes and sweats with scanty and late periods.
2. Vasomotor. “Hot flashes” (sensation of heat) due to cutaneous vasodilation are commonly experienced by these women on the face and neck and extend throughout the body; this feeling of heat may be followed by sweating. They may come once a day, but sometimes every hour; They come particularly at night. These are characteristic manifestations of the menopausal syndrome.
3. Emotional. This is manifested by headache, irritability, insomnia, dizziness, fatigue, depression, palpitations. There may be “pins and needles” sensations in the sole of the foot and palm. Disturbed sleep can be due to hot flashes and sweats.
4. sexual. These are decreased libido and dyspareunia due to atrophic vaginitis and lack of vaginal lubrication during intercourse.
5. Musculoskeletal. These appear as back pain, joint pain due to laxity of ligaments and muscles.
signs. These are the same as those described in menopause.
Diagnosis. This has already been described in menopause.
Differential diagnosis. The patient may confuse false pregnancy pseudocyesis with menopausal syndrome. In the former there is amenorrhea, enlargement of the breasts and abdomen due to fat deposits as in pregnancy; there is also the false sensation of fetal movements due to flatulent dyspepsia. The patient should be assured that her symptoms are menopausal. In all of these cases, pregnancy can also occur and must be carefully excluded by a complete examination, urine immunological pregnancy test, and pelvic ultrasound.
premature menopause
Definition. The menopause that reaches a patient under 35 years of age is called premature menopause. Cause. The poor stock of ovarian follicles is depleted. Clinical Features, Symptoms, Secondary amenorrhea for more than 6 months. In some hot flashes, mood instability, sleep disturbances, loss of libido (menopausal syndrome). hair drying. signs. Atrophic vaginal epithelism, uterus of normal or small size. Research. Elevated serum FSH above 50 mIU/ml.; An ovarian biopsy that does not show ovarian follicles is not done. Guarantee of treatment, diazepam for lack of sleep. Estrogen therapy is given for menopausal syndrome. Menstruation cannot be caused by hormone therapy.
male climacteric. About 10 percent of men experience climacteric symptoms at a later age than women due to androgen deprivation. The remaining 90 percent adjust gradually without symptoms.
