Today’s Subject: Menopause

I was working doing a consultation with a patient the other  day, with the help of a translator. The patient was a woman, her husband had brought her to see me to discuss possible reasons as to why they had not been able to conceive. I went through a case history and eventually came to the conclusion this woman could be perimenopausal but needed blood tests to confirm this.
In India, particularly the villages where I work, these discussions are usually instigated by the men. My translator was fairly new to the job and I told him if he was uncomfortable discussing women’s health issues that I would find someone else, he assured me that he was capable and was very interested to learn as he has “a wife who may need this information one day”.
So I am in a room with my patient, and these two men (my translator and my patient’s husband). I say to the husband, have you thought of the possibility that your wife may be peri-menopausal.
The men exchange looks and start to become very uncomfortable, they start chattering away in the local dialect and I become annoyed. The stigma around women’s health here can be very frustrating at times and I was getting ready to give these men a lecture on how women deserve to be valued in society, that their health and wellbeing is just as important as the men’s, blah blah blah. My usual spiel when I get frustrated with the inequality and gender divide.
My translator, bless him, says in a very hushed voice “What is menopause?”.
My jaw drops, “What you you mean?” I say in Hindi.
The men look at each other again. “We don’t know what Menopause is, is she going to be ok?”. I lean back and laugh. I look at the wife and ask her is she knows what Menopause is. She shakes her head. I stop laughing.
I look from person to person, each just as confused at the other. Just as confused as me.
So I explained, in the most simple terms I could what Menopause was, what it meant, and the fact that it took absolutely no value away from status, that if anything it meant that this women was to be respected. There were all intrigued.
“No one has ever told us about this before” the husband explained. I told him that some male medical professionals (most are male) are either too embarrassed or do not know enough on the subject so avoid it all together.
Needless to say one of the projects we are now working on is related to women’s health and education.

In light of this, I started asking my western friends what they knew about Menopause and other than the usual “your periods stop and you can’t have babies” thing they couldn’t really answer. So naturally this go me thinking… and writing.

So here is a brief overview of Menopause and the hormone interactions.

Menopause is the opposite of menarche. The loss of follicles and ovum from the ovaries results in changes to the hypothalamic- pituitary- gonadal axis and in the gradual loss of progesterone, oestrogen and inhibin.
It is a natural change which signals the decrease in certain hormones or hormonal changes, which indications the end of fertility in a female’s life cycle.
The main sign that menopause has occurred is when menstrual bleeding has not been undertaken (amenorrhea) within the previous 12 months. Some females will experience this change as early as 45 years of age and as late as 55 years of age, but this can vary.
There are many hormonal changes which occur leading up to, during and the time preceding menopause. Menopause can be divided into four phases. Pre menopause, peri menopause, menopause, and post menopause.

Pre menopause is the period of time before menopause which usually occurs late 30’s to early 50’s. It can last years or months leading up to menopause and occurs while females are still experiencing regular menstruation. However menstrual bleeding can start to become unusually heavy or light, time between cycles can become irregular and the length of menstruation can become shorter or longer. Hormonal fluctuations are slight, but begin to occur and start to decline slightly during this phase.
This occurs when inhibin levels decreases and results in an increase of FSH, which begins to change the length of the female 28 day hormonal cycle, shortening the follicular phase, but not the luteal phase, and so peri menopause begins.

Peri menopause refers to the phase around the time of menopause and can start as early as 35 years of age but majority of females will experience peri menopause in their 40’s. This phase is when symptoms of menopause begin to occur such as hot flushes, night sweats, vaginal dryness, sleep issues, incontinence, as well as more serious issues such as osteoporosis and heart disease. Increases in body temperature occur with hormonal fluctuation particularly that of the oestrogen hormones.
Peri menopause in females causes the small antral follicles, which are recruited in each cycle, to diminish. DHEA which is a precursor for the oestrogen hormone, oestradiol, as well as testosterone begin to decease, and progesterone production begins to fall. This causes a shortening of the luteal phase in the female 28 day hormonal cycle further triggering irregularities. This can cause amenorrhoea as the rise in FSH and LH can imitate menopause but ovulation can still occur some months later and normal gonadotropin levels can resume.
As a result of insufficient inhibin and oestrogen the FSH levels start to rise and as a consequence FSH levels become too high. A down regulation of the FSH receptors happen and the secondary follicles no longer have FSH receptors, ceasing ovulation entirely.
Once ovulation ceases, LH starts to rise but GnRH stays the same.

Menopause itself occurs on the day the female menstruation flow finishes and the prospect of ovulation ceases to occur, permanently.
After final menstruation progesterone is no longer produced, as the corpus luteum is no longer relevant, however small levels of the oestrogen hormone oestradiol are still produced for a small time.

With the decline in oestradiol, the most circulating oestrogen in post-menopausal females become oestrone. Oestrone is converted from androstenedione. Prior to menopause there is a steady increase in adipose tissue deposits. With the decrease in ovarian production of androstenedione, there is a slight increase in peripheral conversion of androstenedione to oestrone from the adipose appendages (Copeland 1996). The levels of oestrone serum levels in the blood directly correlates to the amount of adipose tissue.

In the lead up to menopause the ovarian production of androstenedione falls, this causes a decrease in the rate of production of testosterone from the conversion of androstenedione. But the ovarian production of testosterone remains stable, hence why research suggest blood serum levels of testosterone decline with age, as opposed as a direct result of menopause (Rossouw et al 2002). Testosterone is a precursor for the production of oestradiol, with less androstenedione converted testosterone, oestradiol levels decline also, but remain steady post menopause.
Research on DHEA and DHEAS also suggests that these androgen hormones decline with age, and not as a result of menopause (Meldrum et al 1981). The decline in testosterone during menopause is small in spite of the decrease in androgen hormones, and shows that DHEA is regarded as a minor source of androstenedione and testosterone in menopausal females. Compared to the steep decline in oestrogen production the ovarian production of testosterone is maintained by the gonadotropins.

Post menopause is the subsequent 12 months after a female’s last menstruation and follows the point when female ovaries become inactive. This phase is delayed and should allow for 12 month due to the fact that menstruation can be erratic during this timeframe and it is necessary that the cycle has ceased completely to ensure that menopause is complete. Hormonal fluctuations still occur but begin to subside and stabilise and symptoms such as temperature fluctuations, hot flushes, night sweats, vaginal dryness and sleep disturbances start to stabilise. This is the time when females become infertile due to the absence of ovulation signalling the end of the fertility years.

Any female whom experiences menarche will experience menopause, unless some form of surgical intervention has taken place. It is a natural change which signals the decrease in certain hormones or hormonal changes, which indications the end of fertility in a female’s life cycle. This usually occurs between 45 and 55 years of age depending on the individual.
The main sign that menopause has occurred is when menstrual bleeding has not been undertaken within the previous 12 months. It is an extremely important phase in the female reproductive cycle and signals the end of the female reproductive years.


Aly Curd



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