Menopause

Menopause is a physiological or iatrogenic cessation of menstruation (amenorrhea) due to decreased ovarian function. The following clinical manifestations are noted: hot flashes, atrophic vaginitis and osteoporosis. Clinical diagnosis: absence of menstruation for 1 year. In the presence of clinical symptoms of menopause, treatment (for example, hormone therapy or the administration of selective serotonin inhibitors) is necessary.

[1], [2], [3], [4], [5], [6], [7], [8], [9]

Causes of the menopause

The climacteric takes a longer time, in which women lose their reproductive capacity. This period begins before the perimenopause.

With age, the response of the ovaries to FSH and LH decreases, which is accompanied by a shortening of the follicular phase (with shorter and irregular cycles), fewer ovulatory cycles occur, and all this leads to a decrease in progesterone production. Ultimately, the follicles do not respond to hormonal effects and produce a reduced amount of estradiol. Estrogens (mainly estrone) are still circulating in the blood; they are synthesized by peripheral tissues (such as subcutaneous fat, skin) from androgens (for example, androstenedione, testosterone). However, the overall level of estrogen remains significantly lower. In the menopause period, the content of androstenedione in the blood plasma is reduced by half, but the decrease in testosterone levels, which begins gradually at a younger age, does not accelerate during menopause, because the stroma of postmenopausal ovaries and adrenal glands continues to secrete hormones.

Reduced levels of ovarian inhibin and estrogens lead to blockade of pituitary production of LH and FSH, which leads to a significant increase in circulating LH and FSH.

Premature menopause (premature ovarian aging) is the cessation of menstruation due to non-yrogenic ovulation failure before the age of 40.

[10], [11], [12], [13], [14]

Risk factors

Predisposing factors can be smoking, living in high mountains and lack of nutrition. Iatrogenic (artificial) menopause develops as a result of medical interventions (for example, ovarian removal, chemotherapy, pelvic irradiation and any intervention that leads to a worsening of the blood flow in the ovaries).

[15], [16], [17], [18], [19], [20], [21], [22], [23], [24]

Pathogenesis

Physiological menopause is established if menstruation is absent for 1 year. In the US, the average age of physiological menopause is 51 years. The perimenopausal period is the period during the year before and after the last menstrual period. The perimenopausal period is usually characterized initially by an increase in the frequency of menstruation with reduced blood loss (oligomenorrhea), but other manifestations are possible. During the perimenopause period, conception is possible.

[25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35]

Symptoms of the menopause

Perimenopausal changes in the menstrual cycle usually begin in women aged 40 years. Menses become irregular, and the cycle time can change. Large daily fluctuations in estrogen levels usually begin 1 year before menopause, and this is the cause of perimenopausal symptoms. Symptoms can last from 6 months to 10 years, and their manifestations may increase with age.

Tides and sweating due to vasomotor lability appear in 75-85% of women, and usually before the termination of menstruation. Tides continue for more than 1 year, but most women report hot flashes for 5 years or more (more than 50% of patients). Patients complain of hot flashes, sometimes profuse sweating and fever.

Appears hyperemia of the face and neck. Episodic inflows lasting from 30 s to 5 min can be accompanied by attacks of chills. Tides can intensify at night and in the evening. The mechanism of the appearance of tides is unknown until the end, but they can be caused by cigarette smoking, the reception of hot drinks, food products containing nitrites or sulfites, spicy food, alcohol and, possibly, caffeine.

Psychoneurological changes (eg, low concentration, memory loss, depression, anxiety) may appear in the menopause period, but the appearance of these symptoms is not directly related to a decreased level of estrogen. Heavy evening tides can interrupt sleep and lead to insomnia, fatigue, irritability and poor concentration of attention.

Decrease in the level of estrogen leads to dryness of the vagina and thinning of the vulva, this contributes to the development of inflammation of the mucous membrane of the vagina (atrophic vaginitis). Atrophy can cause irritation, dyspareunia and dysuric disorders, increase the pH of the vaginal contents. Small labia, clitoris, uterus and ovaries decrease in size. There may be transient dizziness, paresthesia and palpitations. There is also nausea, constipation, diarrhea, possible arthralgia, myalgia and coldness of hands and feet.

Often there is an increase in body weight with an increase in fat and a decrease in muscle mass. Although the menopause symptoms are a physiological period, some patients may have health problems and worsen quality of life. The risk of osteoporosis is increasing due to lower estrogen levels; bone resorption with osteoclasts increases. The fastest loss of bone mass occurs within 12 years after the level of estrogen begins to decrease.

Complications and consequences

All problems are associated with a decrease in estrogen levels.

• Often due to anovulatory cycles of menstruation, until the moment of their disappearance, they become irregular.
• Vasomotor disorders cause "hot flashes", sweating and rapid heartbeat. "Tides" - a short-term state, but causing a lot of inconvenience. "Tides" can be repeated at intervals of a few minutes, interfering with sleep and the normal life of a woman for many years (more than 10).
• Atrophy of estrogen-dependent tissues (genital organs, mammary glands). Dryness in the vagina leads to the development in it and in the urinary tract of infection, dyspareunia, traumatic bleeding, depressing urinary incontinence and prolapse.
• Osteoporosis. With menopause, the bone structure is aggravated, predisposing to fractures of the femoral neck, radius and ribs, spine.
• After the onset of menopause, women are more likely to suffer from artery disease.

Attitude towards menopause is very different; the onset of menopause aggravates some psychological problems, for example irritability, depression, "empty nest syndrome", or is intensified by them.

[36], [37], [38], [39]

Diagnostics of the menopause

Diagnosis is based on clinical manifestations. Menopause is likely if the frequency of menstruation gradually decreases and the menstrual period is absent for 6 months. Women with amenorrhoea up to age 50 are always screened for the exclusion of pregnancy, and to exclude ovarian tumors (for amenorrhea evaluation, tumors in the small pelvis are identified.) If patients at the age of 50 have a history of irregular menstruation or lack of menstruation with symptoms of estrogen deficiency or without them and no other pathological abnormalities are detected, no further diagnostic tests are performed, FSH levels can be determined. A gradual increase in hormone levels predicts menopause sometimes for many th months before its onset.

Patients in the postmenopausal period who have risk factors for the development of osteoporosis, as well as all women aged 65 years, should be examined for osteoporosis.

[40], [41], [42], [43], [44], [45], [46], [47]

Treatment of the menopause

Medical care is required by 20% of women.

• Is it a menopause? Thyroid disease or mental disorders can equally be observed. In women of a younger age, it is necessary to determine the level of FSH (significantly increases with menopause).
• Discussion of problems contributes to psychological relaxation and helps a woman to tolerate symptoms more easily. Do they understand the patient in the family?
• Menorrhagia is amenable to correction. With irregular bleeding, a diagnostic curettage is required (it can be difficult to make a decision).
• Within a year after the last menstruation, you should continue taking the contraceptives. You can also use pills containing only progesterone (PEP), IUD and barrier methods of contraception.
• With "hot flashes", clonidine is effective at a dose of 50-75 μg every 12 hours or hormone substitution therapy.
• When dry in the vagina, estrogens are shown.

It is very important to discuss with the patients the physiological causes of menopause and the possible symptoms of its manifestation. Treatment is symptomatic. In the presence of hot flashes, it is recommended to wear light clothing and avoid provoking factors. It is used tsimitsifuga (in homeopathic dilutions), which has an estrogen-like effect, although the long-term results of treatment are unknown. Soy protein is used, but its effectiveness has not been confirmed. Assign medicinal herbs, vitamin E and acupuncture. Regular gymnastic exercises prevent tension and improve sleep, reduce irritability and reduce vasomotor manifestations. Non-hormonal pharmacotherapy for hot flashes involves the appointment of selective serotonin inhibitors (eg, fluoxetine, paroxetine, sertraline), noradrenaline and serotonin uptake inhibitors (eg, venlafaxine) and clonidine 0.1 mg transdermally once a day. Treatment doses for selective serotonin inhibitors may vary; starting doses may be lower than those used to treat depression, then the dose of the drug may increase depending on the situation.

The appointment of vaginal lubricants and moisturizing creams reduces dryness in the vagina. Creams are used when there are symptoms on the side of the vagina, for example 0.1% cream with estriol (Oestriol). Assign per vaginum for one application 2 times a week. The ointment is absorbed, but with intermittent administration, the appointment of progesterones may not be necessary.

Neck patches are less of a "medicament" remedy, but they are more expensive, and women who do not have a history of hysterectomy, in addition to skin patches should take progesterone tablets. Esfadiol patches contain 25-100 μg for 24 hours and are designed for 3-4 days. Side effects: dermatitis.

Implantation of estradiol requires surgical intervention. 25 mg of the drug is sufficient for about 36 ued, 100 mg for 52 weeks. The cost of "treating" women who are in menopause will be enormous.

Measures are being taken to prevent and treat osteoporosis.

Treatment with hormonal therapy

Estrogens do not serve as a panacea for all problems, but are very effective for "hot flashes" and atrophic vaginitis. They prevent osteoporosis and protect against arterial pathology. However, the risk of breast cancer increases.

Women with an unrefined uterus should be prescribed progesterones, eg norgestrel (150 mcg) every 24 hours inside for 12 days out of 28 days to reduce the risk of endometrial carcinoma; the drug may cause bleeding, although the menstruation has already stopped.

Contraindications to HRT: estrogen-dependent tumors, liver diseases, severe cardiovascular diseases. Every year it is necessary to check blood pressure, the condition of the mammary glands and pelvic organs, and to detect uncommon bleeding. Assign tablets containing natural conjugated estrogens at a dose of 0.625-1.25 mg every 24 hours or synthetic estrogens, for example estradiol at a dose of 1-2 mg every 24 hours. Start with a low dose, gradually increasing until the symptomatology disappears.

Hormone therapy is prescribed in the presence of manifestations of symptoms of the menopausal period in moderate or severe form. Patients who have undergone a hysterectomy are prescribed estrogens inwards or as transdermal patches, lotions or gels. For women who have a uterus, with the appointment of any type of estrogen, progestins are also shown, because estrogens without progestins can increase the risk of developing endometrial cancer. For most women, the risk of oral hormone therapy exceeds positive points. Positive effects include a reduction in tidal durations in the night and evening hours, improved sleep and a decrease in dryness in the vagina. Therapy with a combination of estrogens and progestins reduces the risk of developing osteoporosis (10,000 treated women experience a decrease in osteoporosis from 15 to 10 cases) and reduces the likelihood of colorectal cancer (16 to 10 cases). In women with asymptomatic course of menopause hormonal therapy does not significantly affect the quality of life.

The risk of hormonal therapy is associated with an increase in breast cancer cases (from 30 to 38 cases per 10,000 treated women), ischemic stroke (21 to 29), pulmonary embolism (16 to 34), dementia (22 to 45) and coronary artery disease (from 30 to 37). The risk of coronary artery disease increases almost 2-fold during one year of treatment and is particularly high in women with elevated levels of low-density lipoproteins; the appointment of acetylsalicylic acid and statins does not prevent the risk of this pathology. In addition, breast cancer of a metastatic nature most often develops, mammograms are false-positive at the same time.

Therapy with pure estrogens does not increase the risk of developing coronary artery disease, but increases the risk of developing ischemic stroke (10,000 treated women from 32 to 44 cases) and reduces the number of hip fractures (17 to 11 cases). The effect of pure estrogen therapy on the development of breast cancer, the development of dementia, colorectal cancer and pulmonary embolism is less studied.

With dryness in the vagina or atrophic colpitis, the appointment of estrogens in the form of cream, vaginal tablets or rings is just as effective as oral forms. If a woman has a uterus in parallel with the appointment of creams with estrogens, progestin preparations are used. Hormone therapy is not recommended for the prevention and treatment of osteoporosis, because there are other effective measures (for example, the use of bisphosphonates).

The administration of progestins (eg, megestrol acetate 10-20 mg orally once a day, medroxyprogesterone acetate 10 mg orally once or day medroxyprogesterone acetate depot 150 mg intramuscularly once a month) can reduce hot flashes, but do not affect the dryness in the vagina .

Progestins have side effects: bloating, increased stress and tenderness of the mammary glands, headaches, an increase in low-density lipoproteins, a decrease in high-density lipoproteins; microdosed progesterone has fewer side effects. There are no data on the long-term effects of using progestins in treating a condition such as menopause.