Menopause: Why is Everyone Talking About it Now?

Abstract

There is an interest in menopause that demands answers and solutions. Menopause affects each women differently and hence it is unique and needs to be talked about. This focus has led to improvement in women's health bringing about better outcome in physical and mental health. Increase in life expectancy has led to menopausal health care, an important issue. Menopause is not disease but causes symptoms that can differ individually. Occasionally, surgery, radiation, and medications can cause menopause. Menopause hormone therapy (MHT), nonhormonal therapy, and lifestyle modifications under supervision can improve menopausal outcome. It also gives window of opportunity to evaluate and reduce risk of cardiovascular, bone, and urogenital health. Menopausal women should be provided with all options that are suitable and feasible for improvement in their life.

Introduction

There is intense interest in menopause because they see void in menopause and are demanding answers and solutions. Is there any big deal about it? Menopause affects each woman uniquely and in many ways with different experience. It was not talked about in past because of stigma attached to it. Menopause is ubiquitous, then why ignore? It seems to have finally come out of shadow and now being discussed on public platform. Why such new-found interest? Has this focus led to any improvement in care for women? Changes in hormones impact physical and mental health. Every woman experiences it, but few talk about it.

The implications are caused by negative attitude toward menopausal women. There is prejudice around it, hence it is seen as negative rather than what it is. They are considered older because of no fertility hence less valuable and washed up. Menopause is not end for women but just beginning of new phase of life. They should be as much respected as before. Many feel lingering symptoms after menopause that may be less intense or disappear. These are caused by low levels of reproductive hormones. It is challenging to remove taboo but not difficult.

Global Scenario

By 2025, there will be 1.1 billion menopausal/post-menopausal women [1]. Women in prime of life and height of career experience transitions apart from physical ones. It hits at a time when life is changing—parents are aging, children are leaving home and taking new responsibilities at work. Medical or other help is not taken as they are uncomfortable. They need to regulate symptoms, so this natural phase can go smoothly.

Indian scenario may be little different in terms of longevity being less and menopause setting in little early, average age being 47 years [2]. Co-morbidities appear little early, hence they continue during menopause. WHO data (2018) [3] state life expectancy for females in India is 70.3 years and is expected to increase to 77 years by 2050. Non-communicable disease (NCD) accounts for 60% deaths in India. With little support system and limited menopausal healthcare schemes, it is difficult to get proper guidance with regards to menopausal therapies.

Then, what is Menopause?

Menopause is not disease or disorder. It is normal process involving permanent cessation of menstruation for at least 12 months. It is diagnosis that is made retrospectively. It occurs due to cessation of production of reproductive hormones from ovaries causing estrogen deficiency. Generally, it occurs between 45 and 56 years of age, most common being 50 [3]. Many experience symptoms several years before menopause. Most common being vasomotor symptoms, however, can affect other systems like urogenital, bone health, cardiovascular and psychogenic. With increase in longevity, women spend 40% of their lives are in post-menopausal years, corresponding to approximately 30 years.

Menopause can occur because of surgical procedures like bilateral oophorectomy. It can occur because of cancer therapy, endometriosis treatment, radiation, illnesses like HIV, antiestrogenic therapy.

Stages

Menopause symptoms start few years before last period and can continue for few months to several years. It varies from women to women. Perimenopause, where hormones begin to change, can occur after mid-40 s. Early menopause is between 40 and 45 years (5%), and premature is before 40 years of age (1%).

Ovarian aging causes decrease in number of follicles with decrease in quality of oocytes. Decrease in estrogen level causes vaginal and vulval inflammatory changes with erythema and friability, narrowing of vagina with labial thinning.

Symptoms

Most woman experience menopausal symptoms, but it varies individually. Symptomatic variation is because of factors like diet, smoking, ethnicity, medical problem, exercises, socio-economic background, BMI and overall gynecologic health. Common symptoms of perimenopause would be less frequent, light or heavy periods, vasomotor—hot flushes, night sweats, flushing.

Hot flushes lasts for 5.2 years starting around a year before menopause and persists after menopause though less and affects 70–80%. It can worsen with alcohol, smoking, obesity, stress and physical inactivity.

Other symptoms are genito-urinary (GSM), neuropsychiatric and somatic. These include vaginal dryness, decreased libido—sex drive, urinary incontinence (GSM)—insomnia, depression, anxiety, difficulty in concentration, memory problem—‘brain fog’, migraine, restless leg syndrome (psychogenic), headache, palpitation—weight gain, dry skin–mouth–eyes, UTI, stiff joints, heaviness–sagging of breasts, reduced muscle & bone mass (imbalance between osteoclastic and osteoblastic activity), thin hair–hair loss, occasionally hirsutism—excess androgen effect may be present. Symptoms start from perimenopausal period till menopause and beyond.

Diagnosis is made from age and symptoms. However, FSH > 30 mIU/ml and Estrogen < 20 pg/ml are suggestive of menopause. AMH levels are not very useful in making diagnosis of menopause. For woman on menopausal hormone therapy (MHT), hormonal levels should be done, after 2 weeks of stopping of therapy.

Facts

Mission menopause is to engage, educate and empower, minimize disruptive symptoms and prevent long-term complications.

Lifestyle modifications like exercise–yoga, balanced diet, no smoking, limited alcohol, caffeine and salt are helpful.

With advancing age, fat increases and muscle mass decreases. Exercise not only increases muscle mass but also improves bone mineral density (BMD). Exercise should include endurance, flexibility, balance and strength building. Walking is the best form of exercise. Yoga combines exercise and meditation that helps reduce irritability, hot flushes and insomnia. Exercise and yoga help protect against non-communicable diseases (NCD).

Diet

Weight management is challenge, as metabolism slows down with advancing age. Mindful balanced diet plays pivotal role in decreasing non-communicable diseases (NCD) and increasing overall well-being. Holistic approach to mindful eating includes protein, vegetables, fruits in meal, good hydration and avoid over-eating.

Sleep disturbances causes sickness, mental health issues and chronic diseases. Triggering factors like hot beverages, spicy food, alcohol, stress, hot weather should be avoided. Relaxation techniques like deep breathing and massage are helpful. Healthy life-style—good sleep, nutrition, exercise, relaxation, quality time with loved ones and friends—is needed.

Non-Hormonal Therapies

Phytoestrogens: Natural estrogens like isoflavones and lignans are helpful. Isoflavones are found in soybeans, lentils, chickpeas, other legumes and lignans in flaxseeds, whole grains, fruits and vegetables. Isoflavones pills can be taken only after consultation with doctor.

Calcium and vit D supplementations are helpful.

Menopausal Hormone Therapy (MHT)

If MHT is started within 10 years of last menstrual period or before age of 60 years, there are less chances of menopause related complications. Duration of MHT varies individually; however, relief of symptoms with least dose is recommended.

Hormonal treatment is most beneficial therapy for bothersome vasomotor symptoms [4]. Systemic hormonal therapy is available in various forms—oral medication, sprays, gels, vaginal rings, patches. It can be given continuous or cyclic, as estrogen or progesterone alone, estrogen–progesterone combination or estrogen–bazedoxifene (combination is not yet available in India). Patient with intact uterus is advisable to add progesterone with estrogen to prevent endometrial hyperplasia. Bazedoxifene, selective estrogen receptor modulator, has been used to reduce endometrial hyperplasia as an alternative to progesterone. It is also helpful in preventing osteoporosis, reducing genito-urinary symptoms and sleep disturbances.

Systemic hormonal therapy should be used for shortest possible time with lowest possible effective dosage. There could be risk of venous thrombosis and stroke with estrogen and breast cancer with combination therapy. However, risk is minimal with its usage in women with early menopause.

Hormones usage within 10 years of menopause has been shown to have beneficial effect on cardiovascular system, but it is not recommended for prevention of heart disease. Early versus Late Intervention Trial with Estradiol—ELITE Study (2015) [5]—supports ‘Timing Hypothesis’ for estrogen. KEEPS study—Kronos Early Estrogen Prevention study (2019)—was designed to address gap and understanding timely MHT in cardiovascular health and other effects. It supports value and safety of MHT in recent post-menopausal women to manage symptoms, reduction in bone loss, no risk on cardiovascular factor or negative impact on cognition. Investigators are encouraged to continue KEEPS cohort for future research [6].

Transdermal usage has fewer/no effect on coagulation and inflammatory markers, thereby decreasing risk of thrombosis. It can be used in patients with migraine, mood changes and also in perimenopausal age group.

Usage of systemic MHT is limited to treat menopausal symptoms only.

Pre-MHT workup is needed. Detailed history of breast–uterine cancer or strong family history of the same is relevant. Clinical examinations should include BMI, waist circumference, breast and pelvic examinations. Complete blood count, sugar, lipid profile, liver and thyroid tests are advisable. Pelvis sonography, cervical cytology and mammography (if indicated) should be done.

Counseling is very important and regular annual follow up is advisable.

Contra-indications for MHT are endometrial/gynecological hormone related cancer, breast cancer—high risk, liver disease with impaired liver function, venous thrombosis, cardiovascular disease—high risk, suspected pregnancy, undiagnosed abnormal vaginal bleeding.

Non-Hormonal Therapy

SSRI—Selective Serotonin Reuptake Inhibitors, SNRI—Selective Norepinephrine Reuptake Inhibitors and Gabapentin are used to relieve vasomotor symptoms. Gabapentin in high doses (900–2400 mg/day) is effective in reducing vasomotor symptoms like estrogen but is not FDA approved. Clonidine is useful in relieving mild symptoms but is not recommended.

Newer drugs like NKR3 receptor (neurokinin 3 receptors) have shown safe and encouraging results. Fezolinetant is FDA approved with dose of 45 mg/day, with headache as most common side effect. Oxybutynin, from 2.5 to 15 mg dosage, is useful in relieving vasomotor symptoms.

Alternative Medication

Phytoestrogens, Vit E, Omega 3 Fatty acids are useful in treating vasomotor symptoms and are safe. Relaxation therapy, exercise, acupuncture and supplements like wild yam, ginseng, evening primrose oil and black cohosh are not useful in relieving vasomotor symptoms. Weight loss, hypnosis, cognitive behavioral therapy is useful in relieving symptoms in some.

Local Estrogen Therapy

Menopausal women not on systemic MHT may develop genito-urinary symptoms (GSM). Those who are on MHT may need additional local estrogen therapy for relief of GSM. Recurrent UTI may be treated by additional local therapy. Local therapy increases blood flow, reverses vaginal atrophy and improves vulvo-vaginal health after 8 to 10 weeks of proper usage. Many women who are unable to take systemic MHT can still use local estrogen therapy. Intra-vaginal dehydroepiandrosterone has been used to treat local vaginal symptoms. Oral ospemifene has been approved for improvement in dyspareunia in menopause but cannot be used in those with breast cancer or thrombo-embolism (TE) risk. Cosmetic gynecology laser therapy of vagina may cause skin resurfacing, but its long-term effects are not known.

SERMs—Selective Estrogen Receptor Modulators—raloxifene, tamoxifen, bazedoxifene and ospemifene have varying action and may be used. Paroxetine is FDA approved drug but cannot be used with Tamoxifen.

Treatment for Osteoporosis

FDA has approved systemic MHT for prevention but not for treatment of osteoporosis. Bisphosphonates, denosumab, calcium and vit D supplementations are recommended. Bisphosphonates are safe and efficacious but with risk of developing adynamic bone for long time. Hence, timely discontinuation of drug is recommended, as bone density is retained for few years. Denosumab reduces osteoclastic activity, bone resorption decreases and bone density increases. It is given as subcutaneous (SC) injection every 6 months and helps in reducing fracture in women with osteoporosis. WHO has devised OSTA score which is risk assessment score based on age and body weight to identify women at risk for osteoporosis. Body weight (kg) – age (years) × 0.2 –– Low < 1, Moderate 1–4, High > 4.

Stages of Reproductive Aging Workshop (STRAW) has devised + 10 staging system [7]. Menopause is considered as 0 and 5 stages come before final menstrual cycle and 2 comes after. These criteria rely on pattern of menstrual cycle and FSH levels. Stage -3 is divided into − 3b/− 3a, where there are slight changes in menstrual cycle duration and flow with low to variable values of FSH. Menopausal transition stage − 2/− 1 where duration of menstrual cycle varies from more than 7 days to 60 days or more and FSH levels > 25 IU / L. Vasomotor symptoms may be experienced. Post menopause is divided into + 1a, + 1b, + 1c and + 2. Stage + 1a is year after final menstruation, + 1c stage where FSH > 40 IU /L with low estradiol levels. One year prior to + 1c is taken as + 1b. Later FSH levels stabilizes, and antral follicle count is low. Here, stage + 2 begins that continues till life.

Long-Term Complications

Cardiovascular disease and osteoporosis are long-term complications. Coronary heart disease rates are 2–3 times higher, hence healthy diet and exercise are advisable. For prevention of osteoporosis, avoidance of smoking, calcium–vit D supplementation, implementation of physical activity with non-hormonal therapies like bisphosphonates/denosumab is recommended. Teriparatide and romosozumab are used as second line of therapy.

Logistics in Menopause Transformation

Transition into menopause is an inevitable part of life. Menopause, though physiological, has associated morbidities with poor quality of life. Late age of retirement, attached stigma, negative universal impact on age–gender–status, with lack of knowledge are contributory factors. 1 in 5 will have severe symptoms that can affect home front and workplace. There is significant change in body during mid-life, thereby bringing about shift in metabolism, hormonal levels and overall health risks. Cognitive decline—forgetfulness, delayed verbal memory, reduced verbal processing speed, impaired verbal learning—scales number will not budge—no matter what one does—are the things that menopausal women experience. It is crucial time to reassess and adapt body changes. Most of the symptoms are under studied and treated. Most women do not get any treatment and often do not talk about it to their doctor. Why are these patients frequently ignored and why getting any treatment for the same is an afterthought? Managing menopausal symptoms require multidisciplinary team approach including mental health provider. There is need for workshops, online learning webinars, individually tailored program, forward thinking, strategies to stop memory loss, boost metabolism to loose extra weight, techniques to stop aging process—try to keep them young and empower them. Underlying mid-life crisis slows down metabolism and brings about decrease in muscle mass and increase in fat storage making weight management more challenging.

Today, women are more vocal and actively seeking support. Surveys have shown menopause being challenging time. There are not enough ways to balance it and women should not endure it alone. Supportive health care professional should be able to help them overcome symptoms during menopause transition. It is better to have supportive group with wealth of knowledge, discussions related to nutrition, inflammation, fitness, energy, fatigue, sleep, stress, mental health and more. Menopause management is understudied and there is not much of training happening. WHI [8] had caused big fear about MHT because average age factor in the study was 63 years which is not age of menopause hence only 4% used MHT. More analysis and studies have bailed out MHT and with better understanding of physiology–pathology has let the researchers have relook into usefulness of hormone therapy with its limitations. Provider should be able to select correct candidate for hormonal and non-hormone therapy.

Getting people talk about menopause is to create more inclusive, supportive environment and explore solutions. Celebs talk about it on media to encourage more women to be bold and express themselves. October 18 is being celebrated as ‘World Menopause Day,’ and International Menopause Society (IMS) with WHO has designated October as World Menopause Awareness Month. Movements like ‘Menopause Champions’ and ‘menopause moments’ are being introduced. There is shift in feeling from being tired, hot, and scared to hopeful, informed and normal. Targeted session for males has been introduced.

Conclusion

Menopausal women need to be counseled and individual therapy is advised. This gives an opportunity to carry out Risk assessment. Menopause is critical window of opportunity to reduce risk of CVD and maintaining skeletal–urogenital health. Importance of lifestyle counseling like cessation of smoking, healthy diet and physical activity is of importance. The main indication for MHT is relief of troublesome vasomotor symptoms. Least effective dose with minimum possible duration is advised. Only estrogen therapy is advisable for hysterectomised women, whereas progesterone needs to be added for those when uterus is present to prevent endometrial hyperplasia. Topical MHT is suitable for relief of GSM. Safety data does not support use of systemic HRT in breast cancer survivors. Adopting healthy lifestyle is cost-effective. Menopausal women should be provided with all possible therapies that are available and suitable to them for empowerment and better health.

Declarations

Conflict of interest

No conflict of interest.