Menopause

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Menopause Overview:

Menopause marks the end of a females reproductive lifecycle. It is a normal event and therefore is not considered a disease. Diagnosis is made clinically after a 12 months of amenorrhea. The process is gradual, taking place over the course of 4-7 years.

The characteristic reduction in oestrogen is the cause for a range of symptoms associated with menopause, and increases several risk factors for other conditions like cardiovascular disease, osteoporosis, changes in immune stability, low libido, breast cancer, and metabolic conditions like diabetes.


Aetiology:

Menopause begins with perimenopause, which can last several years as ovarian function gradually decreases. It is diagnosed following a 12 month absence of menstruation. The average age of menopause is age 51 [2 ,11]. 

Beginning around age 38, the rate of follicle disappearance begins to accelerate. Over time, female gonad levels diminish to the point where it is unable to provide enough mature follicles to sustain menstrual cyclicity. 

FSH and LH are increased in menopause, while progesterone and estrogen are decreased. Surges in LH are thought to be the main cause in the pathophysiology of hot flashes, and subsequent diaphoresis and flushing of the face and neck [7, 8, 11].

With a drop in oestrogen, the protective action of the hormone is diminished, which can lead to confounding conditions like metabolic syndrome [3], hypotension, and osteoporosis. The loss of oestrogen also accounts for many of the other symptoms including fatigue, muscle and joint pain, vaginal dryness, lowered libido, maintenance insomnia, and headaches. In some instances these side effects can last several years in post menopausal women.

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Risk Factors With Menopause:

Menopause puts women at a greater risk of developing cardiovascular disease, metabolic syndrome and diabetes, breast cancer (especially if in conjunction with elevated testosterone) [6], and osteoporosis.


Symptoms:

Hot flashes

Insomnia

Lowered libido

Vaginal dryness/Discomfort

Amenorrhea

Occasional headaches

Muscle and joint pain

Breast Tenderness

Abnormal bleeding

Menstrual pain

Pelvic pain

Pelvic masses

Migraine Headaches

Anxiety

Exhaustion

Forgetfulness

Height Loss

Mood Swings

Depression

Urinary Tract Irritation

Urinary Incontinence

Heart Palpitations

+ Hot Flashes

Hopt flashes (AKA hot flushes) are the most characteristic trait of menopause and estrogen deficiency in general (75% of women will experience at least one). These vasomotor symptoms can involve night sweats and facial skin flushing as well.

They are defined as a recurrent transient sensation of heat, diaphoresis, chills, and may be accompanied by heart palpitations or anxiety.

It is thought to be the result of a thermoregulatory center (in the hypothalamus) dysregulation due to estrogen withdrawal. The result is temporary peripheral vasodilatation and increase in blood flow.

+ Urogenital Changes

Thinning of the cells lining the vulva, urethra, and vagina can lead to reduced epithelial secretions and dryness and pH changes which may then lead to symptoms of vaginosis. Recurrent urinary tract infections are far more common.

Additional changes to the urogenital system after a drop in estrogen levels includes dysuria, urinary incontinence, and increased urinary frequency.

 

Comorbidity:

  • Osteoporosis
  • Cardiovascular disease
  • Metabolic syndrome

Diagnostic Considerations:

Normal Hormone Ranges

Hormone Normal Range Typical Findings In Menopause
Beta Human Chorionic Gonadotrophin (HCG) xxx xxx
Follicle Stimulating Hormone (FSH) xxx High
Luteinizing Hormone (LH) xxx High
Estrogen xxx xxx
Estrone xxx Low
Testosterone xxx xxx
Anti-Mullerian Hormone xxx Very Low
  • Pelvic imaging (US, MRI, CT)
  • FBE, ferritin, coagulation
  • Genital cultures, DNA & viral probes
    • Chlamydia trachomatis
    • Neisseria gonorrhoeae
    • Human papilloma virus (HPV)
    • Herpes simplex virus (HSV)
  • Histology: (Pap) smear
  • Pelvic Endoscopy
  • Breast imaging
    • Mammography, ultrasound, MRI

Therapeutic Aims:

1. Assist The Adaptation To Lower Oestrogen Levels.

Reduce the effects of oestrogen withdrawal.

  • Phytoestrogens (Glycine max, Humulus lupulus)
  • Saponin containing herbs (Tribulus terestris, Chamaelirium luteum, Asparagus racemosa, Dioscorea spp., Alchemilla vulgaris)

2. Support The Adrenal Glands

Support increased burden to produce estrogens as a result of a loss in ovarian support.

  • Adrenal tonics (Rehmannia glutinosa)
  • Adaptogens (Withania somnifera, Panax ginseng, Eleutherococcus senticosus)

3. Support The Nervous System And Treat Any Insomnia Or Anxiety

...

  • Nervine relaxants (Avena sativa)
  • Anxiolytics (Passiflora incarnata, Hypericum perforatum)

4. Treat Hot Flushes Symptomatically

...

  • Salvia, Crataegus oxycanthus, Leonurus cardiaca, Vitex agnus castus
  • ...

5. Treat Infection (If Applicable)

...

  • ...

Differential Diagnosis:

Amenorrhea and FSH Levels

FSH Levels Mechanism Examples
FSH Low Neuroendocrine stress Female athelte triad, Prolactinoma
FSH Normal Comorbid endocrine disease PCOS, Hypothyroidism
FSH High Premature ovarian insufficiency/failure Menopause
 

Cautions:

The most important thing to rule out in any female reproductive system complaint is pregnancy. Beta HCG is the best test for ruling this out.


Herbs For Menopause:

  • black cohosh
  • red clover
  • Tribulus terrestris
  • helonias root
  • shatvari
  • ladies mantle (achemilla vulgaris)
  • dioscorea
  • panax ginseng
  • Angelica sinensis
  • leonurus cardiaca


Drugs Used For Menopause:

  • SERMs (naturopathic)
    • Soy –
    • Cimicifuga racemosa –
    • Humulus lupulus
  • Phytoestrogens (naturopathic)
  • Bioidentical hormones
  • Tibolone – Livial®

Related Conditions:


Author:

Justin Cooke

The Sunlight Experiment

Updated: October 2017


References:

  1. Campbell, S., & Whitehead, M. (1977). Oestrogen therapy and the menopausal syndrome. Clinics in obstetrics and gynaecology, 4(1), 31-47.

  2. Greendale, G. A., Lee, N. P., & Arriola, E. R. (1999). The menopause. The Lancet, 353(9152), 571-80. Retrieved from http://ezproxy.laureate.net.au/docview/199031753?accountid=176901

  3. Janssen, I., Powell, L. H., Crawford, S., Lasley, B., & Sutton-Tyrrell, K. (2008). Menopause and the metabolic syndrome: the Study of Women's Health Across the Nation. Archives of internal medicine, 168(14), 1568-1575.

  4. Matthews D. Diabetes. Oxford: OUP Oxford; 2008. Ipswich, MA. Accessed online October 18, 2017.

  5. Royal Collage of Patholgists of Australasia (2015). RCPA Manual

  6. Secreto, G., Recchione, C., Cavalleri, A., Miraglia, M., & Dati, V. (1983). Circulating levels of testosterone, 17 beta-oestradiol, luteinising hormone and prolactin in postmenopausal breast cancer patients. British journal of cancer, 47(2), 269.

  7. Stevenson, J. C., Crook, D., & Godsland, I. F. (1993). Influence of age and menopause on serum lipids and lipoproteins in healthy women. Atherosclerosis, 98(1), 83-90.

  8. Tataryn, I. V., Meldrum, D. R., Lu, K. H., Fruraar, A. M., & Judd, H. L. (1979). LH, FSH and skin temperature during the menopausal hot flas. The Journal of Clinical Endocrinology & Metabolism, 49(1), 152-154.

  9. Watkins, E. S. (2009). The estrogen elixir : a history of hormone replacement therapy in america. Retrieved from https://ebookcentral-proquest-com.ezproxy.laureate.net.au

  10. Weatherby, D., & Ferguson, S. (2002). Blood chemistry and CBC analysis (Vol. 4). Weatherby & Associates, LLC.

  11. Merck Manual (2016). Menopause. Retrieved October 20, 2017 from: http://www.merckmanuals.com/professional/gynecology-and-obstetrics/menopause/menopause