Chapter 18 The Menopause
The menopause
The word menopause means the cessation of menstruation, but it is commonly also used to describe events leading up to, and following, the final menstrual period. For about 10% of women, menses cease suddenly, but for a majority of women, the final period is preceded by several years of erratic periods. This phase is known as the perimenopause.
Oestrogen levels fall over the 5 years preceding ovarian failure, which occurs usually between 45 and 55 years of age, with an average of around 50 years. The fall in oestradiol has a positive feedback effect on the pituitary, increasing the production of follicle stimulating hormone (FSH) and luteinising hormone (LH). Once menopause has occurred, the FSH level is usually above 30 iu/l. FSH levels increase in the perimenopause but levels can fluctuate. The anti-Müllerian hormone (AMH) is a better marker of ovarian reserve. The ovary eventually produces only androstenedione, also produced by the adrenals, which is converted in the peripheral fat to the weak oestrogen, oestrone.
Cause of Menopause
Ovarian failure occurs when only a few thousand primordial follicles remain – an insufficient number to stimulate cyclical activity. Now that women in developed countries have a life expectancy of around 80 years, at least one-third of a woman’s life is spent in the post-reproductive, ‘menopausal’ phase.
Premature menopause may occur due to surgical removal of the ovaries, radiotherapy or chemotherapy; however, for most women, the cause is less clear. Premature ovarian failure is associated with auto-immune conditions, but in some women there may be a genetic element.
There is a slightly higher chance that conserved ovaries may fail following a hysterectomy. Menopause occurs 6–18 months earlier in smokers.
Signs and symptoms
These are related to changes in circulating oestrogen levels, and the symptoms may start to occur some years before menstruation ceases.
Common menopausal symptoms
Vasomotor Symptoms
Hot flushes are the classic menopausal symptom. When they occur at night, they are known as night sweats. This often affects sleep quality and this in turn can affect the quality of life. In a vast majority of women, these will settle within the first few years of menopause, but for some women there will be a long-term problem.
Urogenital Atrophy
The epithelium of the genital tract and lower part of the urethra is highly sensitive to oestrogen deprivation. Symptoms include:
Vaginal dryness and dyspareunia
The greene climacteric scale
Please indicate the extent to which you are troubled at the moment by any of these symptoms by placing a tick in the appropriate box.
This scale may be used to measure climacteric symptoms and their response to treatment or to compare different treatment regimes.
An Anxiety score of 10 or more indicates severe, and possibly clinical, anxiety. A Depression score of 10 or more indicates severe, and possibly clinical, depression.
Changes in the genital tract
These changes are of atrophic type and affect the external genitalia as well as the internal organs. These changes occur over a number of years.
Not only are the main pelvic structures reduced in size but, more importantly, the fascial framework and the intrapelvic ligaments supporting the bladder and genitalia are weakened; this may lead to vaginal prolapse and urinary incontinence.
Vulva: There is flattening of the labia majora, the minor labia become more evident. Sexual hair becomes grey and sparse. The clitoris shrinks.
Uterus: The uterus becomes small with a relatively large cervix – a return to infantile proportions.
Tubes and ovaries: These show great shrinkage, the tubes becoming thin while the ovaries are reduced to small white wrinkled bodies, about 2–3 cm in length.
In addition to shrinkage of the vaginal introitus, the vagina diminishes in length and its secretions are limited, leading to vaginal dryness and dyspareunia. Changes in the vaginal epithelium are also seen. There is loss of rugosity and the epithelium becomes atrophic, with petechial haemorrhages in some cases and loss of glycogen.
Normal premenopausal vaginal epithelium. Note the thick cornified layer.
Smear of premenopausal vaginal epithelium. The cells are large with small nuclei and characteristic folded edges. Polymorphs are few in number.
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