By Dr. Dineshani Hettiarachchi Sirisena World Menopause Day was on 18 October 2019. This day is a worldwide awareness call for women who face health issues when approaching, during, and beyond menopause. To speak on the current trends in the management of this inevitable phase in a women’s life, we spoke to senior consultant obstetrician and gynaecologist and Menopause Society of Sri Lanka (MSSL) Past President Dr. Marlene Abeyewardene. Menopause is when your period stops permanently. This phase is also called “the change of life” and it doesn’t necessarily happen all at once as body transitions occur gradually over several years. Five facts about menopause

• The average age at which menopause occurs in women globally is 48-51 years
• Common symptoms include hot flushes and night sweats that can affect the quality of life for up to 25% of women.
• These symptoms are particularly hard to deal with at work as they can cause discomfort, tiredness, and embarrassment
• Women can also experience interrupted sleep patterns, mood swings, anxiety, irritability, weight gain, headaches, hair loss, overactive bladder, urinary incontinence, loss of libido, and vaginal dryness
• Menopause is a natural process that all women will go through
• The entire process may last between a period of 2-10 years

Stages of menopause Perimenopause Perimenopause means “around menopause”, and refers to the time during which your body makes the natural transition to menopause, marking the end of your reproductive years. It is often called the menopausal transition. Women start perimenopause at different ages. They may notice signs initially which may ultimately progress to menopause. These are menstrual irregularities that sometimes occur around the 40s. However, some women notice changes as early as their mid-30s. The level of oestrogen (the main female hormone) in the body rises and falls unevenly during perimenopause. The menstrual cycles may lengthen or shorten, and one may begin having ovulatory menstrual cycles, i.e. the ovary not releasing an egg (ovulate). One may also experience menopause-like symptoms such as hot flashes, sleep problems, and vaginal dryness. Treatment is available to help ease these symptoms. After 12 consecutive months without a menstrual period, you’ve officially reached menopause, and the perimenopause period is over. Menopause This is the point when a year has passed since a woman last had her menstrual period. At this stage, the ovaries have stopped releasing eggs and thus secreting most of their oestrogen. Postmenopause A woman is considered to be postmenopausal when she has not had her period for an entire year. Having your doctor measure your follicle stimulating hormone (FSH) level is important if one is near menopause. FSH is a hormone produced by the anterior pituitary gland (situated at the base of the brain). The FSH levels will dramatically rise as the ovaries begin to shutdown and these levels can be easily checked through a blood test. However, FSH levels can fluctuate during perimenopause, and the only way to know if one is definitely postmenopausal is when you have had no period for one year. During the immediate postmenopausal period, tiredness and lack of energy may continue but later in this period, one may regain one’s energy and feel better. However, menopause and postmenopause are associated with a higher risk of various health issues. This needs to be borne in mind and checked for by the doctor you see. Common symptoms

• Hot flashes affect approximately 50% of menopausal women
• Fatigue
• Memory lapses
• Mood swings commonly irritability and depression
• Night sweats
• Inability to sleep or Insomnia
• Loss of libido
• Vaginal dryness
• Recurrent urinary tract infection due to atrophic vaginitis and accompanying atrophic cystitis

When to see your doctor It is advisable for every woman over the age of 40 who experiences these symptoms to focus her mind on the fact that she might be approaching menopause. She should then see a doctor in order to seek medical advice. Dr. Abeyewardene stated menopause usually occurs in Sri Lankan women between the ages of 50-51, and women of this age group are prone to various medical issues. Medical issues related to menopause Women who have gone through menopause have very low oestrogen levels. Low levels of oestrogen and progesterone raise your risk for certain health problems. Other health problems may happen naturally as a consequence of aging. Common health problems in the years after menopause

• Heart disease and high blood pressure – women have a lower risk of heart disease than men before the age of 55. Oestrogen helps women keep their blood vessels patent and it also maintains a healthy balance of good and bad cholesterol. Without oestrogen, cholesterol may start building up on vessel walls leading to coronary artery disease. By the age of 70, women have about the same risk of heart disease as men of the same age
• Diabetes mellitus – high blood sugar may lead to a plethora of complications such as ischemic heart disease, chronic kidney disease, and hyperlipidemias
• Hypothyroidism too is often associated with menopause and may lead to symptoms such as gaining weight, lack of libido, fatigue, and tiredness
• Stroke – one’s risk for stroke doubles every decade after the age of 55. The lower levels of oestrogen in your body may play a role in cholesterol build-up on vessel walls supplying blood to the brain which may cause this problem
• Osteoporosis – having less oestrogen after menopause causes loss of bone mass and bone density which puts one at a risk for osteoporosis. Osteoporosis is a condition that causes the bones to become brittle and weak as the lack of oestrogen causes an increase in the breakdown of bones without an associated new bone formation which normally occurs. A recent large study found that women who have severe hot flashes and night sweats during the years around menopause usually have more bone loss and are at higher risk for hip fractures than women who do not have severe symptoms
• Urinary incontinence – about half of postmenopausal women have trouble controlling their bladder. Lower oestrogen levels may weaken the urethra
• Oral issues – dry mouth and an increased risk for cavities are more common after menopause

All of the above problems need to be ruled out in patients in the perimenopause and menopausal periods of their life. Hence, visiting your doctor during this period is crucial for a healthy transition into the postmenopausal period. Malignancies are also common in postmenopausal women. The common malignancies that are encountered are uterine cancer, which could be endometrial or cervical cancer, ovarian cancer, and breast cancer. Irregular uterine bleeding during the perimenopausal period, which is 40-50 years, or in the postmenopausal period should be investigated by a doctor, preferably a specialist. Routine gynaecological and breast checkups are advised after the age of 35 in most developed countries. Checkups should include the below

• Breast lumps should be checked for by self-examination
• Mammogram for breast cancer screening is advised
• Two yearly pap smears
• Ultrasound scan of the uterus to check the thickness of its lining as well as visualise the ovaries
• After the menopause, routine visits to the doctor at least once a year for a general check up is necessary
• A DEXA (dual-energy X-ray absorptiometry) scan should be done to assess the degree of osteoporosis after the age of 45 years

Lifestyle modifications

• Avoid/minimise smoking and alcohol consumption
• Maintain healthy body weight through a balanced, low-sugar, and low-fat diet which should consist of reduced amounts of starchy food, more vegetables, and a moderate amount of proteins and healthy fats
• Avoid saturated fats which can increase cholesterol levels
• Regularly exercise for at least one hour per day, either by walking, going to the gym, or carrying out daily routine housework. This is also important in order to prevent sarcopenia or muscle wasting which occurs due to the lack of oestrogen during perimenopause and menopause. Hence strength training/resistance training exercises should be included in the workout
• Control any hypertension diabetes or hyper cholesterolaemia with medication if it’s indicated
• Altering one’s lifestyle by not breaking rest frequently may assist in preventing complications of hypertension, cardio vascular accidents, and coronary heart disease
• Hormone replacement therapy, which is using oestrogen alone or oestrogen progestin, has been used for many years. The Women’s Health Initiative (WHI) trial carried out in the UK showed that this treatment was effective in the management of moderate to severe menopausal symptoms in generally healthy women. Since the life expectancy of women in the present day is around 85 to 90 years, the management of patients with hormone replacement therapy helps them to lead active lives and carry out their normal functions without been inhibited by the symptoms of menopause. However, hormonal therapy still remains controversial and should be only taken if the benefit outweighs its complications and on the advice of a doctor.

About the writer The writer, Dr. Dineshani Hettiarachchi Sirisena, is a family physician with a special interest in rare genetic diseases and regenerative medicine currently working as a lecturer at the Department of Anatomy, Faculty of Medicine, University of Colombo, Sri Lanka.