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The hot flashes and mood swings are real

Menopause is a normal, physiologic change that every woman will have to go through if she lives long enough
Guardian Lifestyles Editor

Published: Aug 20, 2013

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Hot flashes, mood swings, irritability, decreased libido, vaginal dryness, the inability to bear children – symptoms that most women think of when they think of menopause or the change of life.

Menopause is a normal, physiologic change that every woman goes through if they live long enough, which extends from 12 months after their last period until death, and should not be viewed as a doom and gloom period according to a local gynecologist/obstetrician even though menopause signals the end of a woman’s reproductive cycle when the ovaries stop making estrogen resulting in the lining of the uterus becoming very thin.

Dr. Sharon Thompson says that even though a woman is in menopause until she dies, that the parts of the body that are affected when menopause starts is from head to toe. The changing hormones she said could result in hot flashes, mood swings, decreased libido or sex drive, sleep disturbances, cardiovascular disease, skin changes, night sweats, vaginal dryness, problems with sleep, being extra tired, extra irritable, problems with memory, vaginal and urinary tract changes as well as bone changes. The only symptom that would disappear with time she said would be the hot flashes. The average age of the onset of menopause is 51.

While menopause is a natural cycle of life for women, it can also be surgically induced by removal of a woman’s ovaries when hysterectomies are performed or an ovariectomy (removal of the ovaries) are done for cancer or benign reasons.

Speaking before a capacity audience at the most recent Doctors Hospital Distinguished Lecture Series, Dr. Thompson said that menopause symptoms are very real, that they can be debilitating and affect women’s interpersonal relationships. But she said there are treatments available to help women manage menopause symptoms. She said there is help and hope for women going through the change of life.

At average, she said perimenopause, the time leading up to menopause, could range from age 45 to 55. But that there are people who complain about hot flashes as early as their early 40s.

According to the gynecologist, a woman can spend one-third of her life in menopause, which she said could be in excess of 30 years. Declining estrogen levels can lead to irregular cycles (skipped menses) so some women will come in and they won’t see their period for about three months or so, and then when they do see it, it’s heavy prolonged bleeding.


The dreaded hot flash

During menopause, most women experience hot flashes, a sudden feeling of heat that spreads over a woman’s face and body and a woman may actually have flushing, or redness in the face and the woman breaks out in a sweat. The hot flash can vary in duration and timing of symptom.

It’s a symptom that Dr. Thompson says 75 percent of women experience, but that only about 25 percent of patients volunteer to their physicians. The incidence of hot flashes she said is also higher in black women.

Hot flashes may result in sleeplessness, restless sleep, or early morning awakenings. According to the doctor, the result of the lack of sleep can lead to irritability, mood swings, cognitive impairment and memory loss (a person is just not as quick as they used to be which she said could be an occupational hazard).

Vaginal dryness and vaginal atrophy are other symptoms that come along with menopause.

“Vaginal dryness results because there is a loss of estrogen that leads to the vaginal walls thinning and drying and can result in the patient having very debilitating symptoms – burning, itching and just an irritation. It makes the tissues more susceptible to infections, and it may lead to painful intercourse, and avoidance of the activity and hence a sexual dysfunction,” said the gynecologist.

The changes in the vagina can lead to the loss of collagen and fat in the vulva and the shrinkage of the hood that protects a female’s clitoral gland which can lead to it not being as sensitive or having pain. The doctor said the vulva tissue may also appear diminished, obliterated or even fused. She described it as a “vicious cycle”.

According to the doctor, vaginal atrophy leads to discomfort during intercourse, leading to loss of sexual activity, because if something is not pleasurable, is uncomfortable and hurts, a person will not be eager to engage in it.

The doctor said menopause could also affect the urinary tract that may become dry and irritated, as patients complain about frequent urination, and have increased bladder infections. She says they can also develop a benign condition called urethra caruncle that can be uncomfortable and can cause spotting (vaginal bleeding). Dr. Thompson says it’s a condition that can be easily treated.


Menopause and osteoporosis

Osteoporosis is when the bones become weak and fragile due to decreased estrogen. They are more prone to breaking in midlife, and that after menopause, breakdown is even more pronounced, especially the year right before menopause.

“As we’re progressing in our life, up to age 30 we’re actually building bone mass, after 30 it slowly starts to decline, and certainly right before menopause, it dramatically starts to decline,” said Dr. Thompson.

As a result, she said doctors do their best to help people build up bone reserves as osteoporotic fractures are more common than heart attack.

“Twenty percent of women die from a hip fracture within a one-year follow up; even if they fracture their hip and have hip replacement surgery, 50 percent of them never truly recover – those numbers are quite high, and it can mean that you don’t really want to live longer if you have a life where you’re bed-ridden or housebound; you’re not having any quality of life. Black women die more commonly from hip fractures than white women.”

Risk factors for osteoporosis include aging, a family history, too little exercise, if the person smokes, has a petite frame (weighing less than 125 pounds), certain ethnic groups (Caucasian and Asian women tend to be more prone to it), even though it affects everyone according to the doctor. She also said caffeine and alcohol are risk factors, and that if people if are on steroids for any reason, or if they’re on thyroid medicine that’s a risk factor. She said the eating of too much protein or salt is a risk factor as well as too little calcium.

At age 35, Dr. Thompson said most people have a nice linear spine standing tall, but that at age 55, their height decreases just a little bit with curvature of the spine and when they hit 65, about 25 percent of women over 65 have some element of osteoporosis.

“It’s very subtle, so sometimes you may just notice that you’re a little bit shorter, you may not even notice that you have a compression fracture, so it can be very subtle if you haven’t had a fall or significant pain.


Surgical menopause

According to Dr. Thompson, 50 to 60 percent of women between age 40 and 64 who have hysterectomy have had their ovaries removed, and that as a woman increases in age, most physicians electively remove ovaries. But she says post-menopausal ovaries studies are now showing that ovaries in older women are still working even though they’re excreting primarily androgenic hormones.

The gynecologist said when she graduated from residency approximately 12 years ago, the dictum used to be that if a woman was close to menopause that medical practitioners encouraged her to take her ovaries out to avoid the risk of developing ovarian cancer. That, she said, is now changing.

“When we talk to patients, we have to talk to them about what their lifetime risk of developing ovarian cancer is. Really if they’re a low-risk patient and don’t have a family history of it, or don’t have the BRCA gene positivity with breast cancer, their ovarian cancer risk is only 1.4 percent. The risk in a retained ovary, meaning we left that ovary behind and did a hysterectomy, the risk is only less than one percent. In high-risk populations, there is a benefit in risk reduction of ovarian cancer, especially in our young breast cancer patients, and if they have the BRCA 1 gene because their risk for ovarian cancer is 60 to 80 percent – numbers like that, I would counsel them to remove it,” she said.

And while natural menopause happens over years, Dr. Thompson said surgical menopause happens within a matter of hours after surgery. She said studies have shown that removal of ovaries before age 45, that female has almost a 50 percent chance of increase of dementia. And if you remove just one ovary, in a 30-year-old that risk also increases significantly. She also said there is an increased risk for Parkinson’s disease and an increased risk for cardiovascular disease if it’s not treated. There is an increase in all causes of death if you do ovariectomy in someone who is less than 45.


Help and hope

According to Dr. Thompson, women can breathe easy when it comes to hormone replacement therapy (HRT) after it had gotten a bad rap in recent years. She said people panicked in 2002 when a Women’s Health Initiative (WHI) study said that HRT would cause breast cancer and increase the patient’s risk for a cardiovascular event. But she said the parameters of the study needed to be taken into account — when it was started; what was the age group when the study started; how long they had them on it and what type of hormones they used. But she said since then a lot of changes have happened with the same data and that it’s not all bad.

“The benefits of HRT recently just came out this past year, [and] HRT remains the most effective treatment for the symptoms of perimenopause. It helps prevent the rapid bone loss seen in early menopause and prevents hip and spine fractures,” she said.

She said newly menopausal women would probably benefit more from HRT and have less risk than women in older categories. In the 50- to 59-year-olds with estrogen only, they had a decreased risk in breast cancer, decreased risk in coronary heart disease; they had minimal risk of stroke and minimum risk of thrombotic events like a clot. In the 60-69 age group, there was a decrease in the breast cancer risk, decrease in cardio-coronary heart disease, increase risk in stroke though and increase risk in clots; and in the 70-79 age group, there was an increased risk all-around.

Dr. Thompson said the key to HRT is when a woman starts the medications and how long she stays on them.

“The International Menopause Society actually came out with a consensus in April that says the benefits outweigh the risk with use before age 60, is indicated for the prevention of osteoporosis when started less than 60 years old. That the risk of breast cancer attributable to HRT is small, and the risk of custom-compounded bioidentical hormone therapy is not recommended.”

Short of using a fan to cool off, the doctor says there are other therapies available to treat menopause, but that HRT was the most effective with a 95 percent effectiveness and means that it is the gold standard.

Dr. Thompson says HRT is not recommended for breast cancer survivors.

Besides the many drug therapies available, doctors also tell women to limit their alcohol, dress in layers so that when they do get the hot flashes they can strip a little bit. And that if a patient comes to her and says she does not care what the studies show, that she does not want to take any risk of anything, she talks to them about vaginal moisturizers.

And for women that have atrophic vaginas that have actually shrunk in size, Dr. Thompson says they talk to them about using vaginal dilators.

“That old dictum ‘you don’t use it, you lose it’ is quite true in menopausal women. It does get quite smaller,” said Dr. Thompson.


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