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. If clinical symptoms of menopause are present, treatment is necessary (for example, hormone therapy or the administration of selective serotonin inhibitors).

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Causes menopause

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

With age, the ovarian response to FSH and LH declines, resulting in a shorter follicular phase (with shorter, more irregular cycles) and fewer ovulatory cycles, all of which lead to decreased progesterone production. Eventually, the follicles become unresponsive to hormonal stimulation and produce reduced amounts of estradiol. Estrogens (mainly estrone) still circulate in the blood; they are synthesized by peripheral tissues (eg, subcutaneous fat, skin) from androgens (eg, androstenedione, testosterone). However, total estrogen levels remain significantly lower. At menopause, plasma androstenedione levels are reduced by half, but the decline in testosterone levels, which begins gradually at younger ages, does not accelerate during menopause because the stroma of the postmenopausal ovaries and adrenal glands continues to secrete hormones.

Decreased levels of ovarian inhibin and estrogens result in blockade of pituitary production of LH and FSH, leading to a significant increase in circulating LH and FSH.

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

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Risk factors

Predisposing factors may include smoking, living in high altitude areas, and poor nutrition. Iatrogenic (artificial) menopause occurs as a result of medical interventions (e.g., ovarian removal, chemotherapy, pelvic radiation, and any intervention that reduces blood flow to the ovaries).

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Pathogenesis

Physiologic menopause is defined as the absence of menstruation for 1 year. In the United States, the average age of physiological menopause is 51 years. Perimenopause is the period of time during the year before and after the last menstrual period. Perimenopause is usually characterized initially by an increase in the frequency of menstrual periods with decreased blood loss (oligomenorrhea), but other manifestations are possible. Conception is possible during perimenopause.

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Symptoms menopause

Perimenopausal changes in the menstrual cycle usually begin in women in their 40s. Periods become irregular, and the length of the cycle may change. Large daily fluctuations in estrogen levels usually begin about 1 year before menopause, and this is what causes perimenopausal symptoms. Symptoms can last from 6 months to 10 years, and they may worsen with age.

Hot flashes and sweating due to vasomotor lability occur in 75-85% of women, usually before the cessation of menstruation. Hot flashes last 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 increased body temperature.

Hyperemia of the face and neck appears. Episodic hot flashes lasting from 30 seconds to 5 minutes may be accompanied by attacks of chills. Hot flashes may intensify at night and in the evening. The mechanism of hot flashes is not fully known, but they may be caused by cigarette smoking, hot drinks, food containing nitrites or sulfites, spicy foods, alcohol and possibly caffeine.

Neuropsychiatric changes (eg, poor concentration, memory loss, depression, anxiety) may occur during menopause, but their occurrence is not directly related to decreased estrogen levels. Severe evening hot flashes may interrupt sleep and lead to insomnia, fatigue, irritability, and poor concentration.

A decrease in estrogen levels leads to vaginal dryness and thinning of the vulva, which contributes to the development of inflammation of the vaginal mucosa (atrophic vaginitis). Atrophy can cause irritation, dyspareunia and dysuric disorders, and increase the pH of the vaginal contents. The labia minora, clitoris, uterus and ovaries decrease in size. Transient dizziness, paresthesia and palpitations may occur. Nausea, constipation, diarrhea are also observed, arthralgia, myalgia and coldness of the hands and feet are possible.

Weight gain with increased fat mass and decreased muscle mass is common. Although menopause, the symptoms of which are a physiological period, may cause health problems and a deterioration in quality of life in some patients. The risk of osteoporosis increases due to decreased estrogen levels; bone resorption by osteoclasts increases. The most rapid loss of bone mass occurs within 12 years after estrogen levels begin to decrease.

Complications and consequences

All problems are related to decreased estrogen levels.

• Often, due to anovulatory cycles, menstruation becomes irregular until it disappears.
• Vasomotor disorders cause hot flashes, sweating and increased heart rate. Hot flashes are a short-term condition, but they cause a lot of inconvenience. Hot flashes can recur at intervals of several minutes, interfering with a woman's sleep and normal life for many years (more than 10).
• Atrophy of estrogen-dependent tissues (genitals, mammary glands). Dryness in the vagina leads to the development of infection in it and in the urinary tract, dyspareunia, traumatic bleeding, depressing urinary incontinence and prolapse.
• Osteoporosis. Menopause worsens bone structure disorders that predispose to fractures of the femoral neck, radius, ribs, and spine.
• After menopause, women are more likely to suffer from arterial disease.

Attitudes towards menopause vary widely; the onset of menopause exacerbates or is exacerbated by certain psychological problems, such as irritability, depression, and empty nest syndrome.

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Diagnostics menopause

The diagnosis is made on the basis of clinical manifestations. Menopause is probable if the frequency of menstruation gradually decreases and menstruation is absent for 6 months. Women with amenorrhea under 50 years of age are always examined to exclude pregnancy and also to exclude ovarian tumors (to assess amenorrhea. Tumors in the small pelvis are determined. If patients aged 50 years have a history of irregular menstruation or absence of menstruation with or without symptoms of estrogen deficiency and no other pathological disorders are identified, no further diagnostic testing is carried out. FSH levels can be determined. A consistent increase in hormone levels predicts menopause, sometimes many months before it occurs.

Postmenopausal women who have risk factors for osteoporosis and all women aged 65 years should be screened for osteoporosis.

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Treatment menopause

20% of women require medical care.

• Is it menopause? Thyroid disease or mental disorders may equally be observed. In younger women, it is necessary to determine the FSH level (it increases significantly during menopause).
• Discussing problems promotes psychological relaxation and helps the woman cope with the symptoms more easily. Does the patient's family understand her?
• Menorrhagia can be corrected. Irregular bleeding requires diagnostic curettage (the decision can be difficult).
• You should continue taking contraceptives for a year after your last period. You can also use progestin-only pills (POPs), IUDs, and barrier methods of contraception.
• For hot flashes, clonidine at a dose of 50-75 mcg every 12 hours orally or hormone replacement therapy are effective.
• For vaginal dryness, estrogens are indicated.

It is very important to discuss with patients the physiological causes of menopause and 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. Cimicifuga (in homeopathic dilutions), which has an estrogen-like effect, is used, although the long-term results of treatment are unknown. Soy protein is used, but its effectiveness has not been confirmed. Medicinal herbs, vitamin E and acupuncture are prescribed. Regular gymnastic exercises prevent tension and promote better sleep, reduce irritability and reduce vasomotor manifestations. Non-hormonal pharmacotherapy for hot flashes includes the use of selective serotonin inhibitors (eg, fluoxetine, paroxetine, sertraline), inhibitors of norepinephrine and serotonin uptake (eg, venlafaxine) and clonidine 0.1 mg transdermally 1 time per day. Treatment doses for selective serotonin inhibitors may vary; starting doses may be lower than those used to treat depression, then the drug dose may be increased depending on the situation.

Prescribing vaginal lubricants and moisturizers reduces vaginal dryness. Creams are used when vaginal symptoms are present, such as 0.1% cream with estriol (Oestriol). Prescribed per vagina, one application twice a week. The ointment is absorbed, but with intermittent use, progesterones may not be needed.

Skin patches are less of a "medicine" but are more expensive and women without a history of hysterectomy should take progesterone tablets in addition to the skin patches. Esfadiol patches contain 25-100 mcg per 24 hours and are intended for 3-4 days. Side effects: dermatitis.

Estradiol implantation requires surgical intervention. 25 mg of the drug is enough for about 36 IU, 100 mg - for 52 weeks. The cost of "treatment" for women in menopause will be enormous.

Measures are taken to prevent and treat osteoporosis.

Treatment with hormonal therapy

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

Women with an intact uterus should be given progesterones, such as norgestrel 150 mcg orally every 24 hours for 12 days out of 28 days, to reduce the risk of endometrial carcinoma; the drug may cause bleeding even though menses has stopped.

Contraindications to HRT: estrogen-dependent tumors, liver disease, severe cardiovascular diseases. Blood pressure, the condition of the mammary glands and pelvic organs should be checked annually, and unusual bleeding should be detected. Tablets containing natural conjugated estrogens are prescribed at a dose of 0.625-1.25 mg every 24 hours or synthetic estrogens, such as estradiol at a dose of 1-2 mg every 24 hours. Start with a low dose, gradually increasing until symptoms disappear.

Hormone therapy is used when menopausal symptoms are moderate to severe. Women who have had a hysterectomy are given estrogens orally or as transdermal patches, lotions, or gels. Women who have a uterus are also given progestins when taking any type of estrogen because estrogens without progestins may increase the risk of endometrial cancer. For most women, the risks of oral hormone therapy outweigh the benefits. Benefits include shorter hot flashes, improved sleep, and decreased vaginal dryness. Combination estrogen/progestin therapy reduces the risk of osteoporosis (from 15 to 10 cases per 10,000 women treated) and reduces the risk of colorectal cancer (from 16 to 10 cases). In women with asymptomatic menopause, hormone therapy does not have a significant impact on quality of life.

The risk of hormonal therapy is associated with an increased incidence of breast cancer (30 to 38 cases per 10,000 women treated), ischemic stroke (21 to 29), pulmonary embolism (16 to 34), dementia (22 to 45), and coronary artery disease (30 to 37). The risk of coronary artery disease increases almost 2-fold during one year of treatment and is especially high in women with elevated levels of low-density lipoproteins; the use of aspirin and statins does not prevent the risk of developing this pathology. In addition, metastatic breast cancer is most often developed, in which case mammograms are false-positive.

Pure estrogen therapy does not increase the risk of coronary artery disease, but it increases the risk of ischemic stroke (32 to 44 cases per 10,000 treated women) and reduces the incidence of hip fractures (17 to 11 cases). The effects of pure estrogen therapy on breast cancer, dementia, colorectal cancer, and pulmonary embolism are less well understood.

In case of vaginal dryness or atrophic colpitis, the use of estrogens in the form of creams, vaginal tablets or rings is as effective as oral forms. If a woman has a uterus, progestin-type drugs are used in parallel with the use of creams with estrogens. Hormonal therapy is not recommended for the prevention and treatment of osteoporosis, because there are other effective measures (for example, the use of bisphosphonates).

Progestins (eg, megestrol acetate 10-20 mg orally once daily, medroxyprogesterone acetate 10 mg orally once daily, or depot medroxyprogesterone acetate 150 mg intramuscularly once monthly) may reduce hot flashes but do not affect vaginal dryness.

Progestins have side effects: bloating, increased breast tenderness and tenderness, headaches, increased low-density lipoproteins, decreased high-density lipoproteins; microdosed progesterone has fewer side effects. There is no data on the long-term effects of using progestins to treat conditions such as menopause.