September 21, 2006

The word ‘menopause’ comes from the Greek mens, meaning monthly, and pausis, meaning cessation. Menopause is the end of fertility — resulting from the ovaries slowing down production of two hormones, estrogen and progesterone. The former is responsible for the development and maintenance of the female organs and the latter prepares the body for pregnancy

Sometimes referred to as ‘the change of life’, menopause is one of women’s many important natural-life stages. For some, it is a challenging period of difficult physical and emotional changes. For others, it’s a time of personal growth and renewal. And, for many, it’s both at the same time.

The word ‘menopause’ comes from the Greek mens, meaning monthly, and pausis, meaning cessation. Menopause is the end of fertility — resulting from the ovaries slowing down production of two sex hormones, estrogen and progesterone. The former is responsible for the development and maintenance of the female sex organs, and the latter prepares the body for pregnancy.

Unlike a woman’s first menstruation, which starts on a single day, the changes leading up to menopause happen over several years. A woman can say she has begun her menopause when she has not had a period for a full year.

The terms often used to discuss menopause include ‘pre-menopause’ (all the reproductive years leading to menopause), ‘peri-menopause’ (when the symptoms of approaching menopause commence) as well as the first years immediately after menopause, and post menopause (all the time beyond menopause).

There are many possible signs of menopause and each woman feels them differently. The clearest sign of the start of menopause are irregular periods (when periods come closer together or further apart), and when blood flow becomes lighter or heavier. Other signs may include: weight gain, hot flashes, insomnia, night sweats, vaginal dryness, joint pain, fatigue, short-term memory problems, bowel upset, dry eyes, itchy skin, mood swings and urinary tract infections.

According to senior gynaecologist Dr Sadiqua N. Jafarey single women, whether unmarried or divorced, don’t have a ‘different menopause.’ They go through the same symptoms as their married counterparts. The important factor here is involvement in work, whether outside or inside home, which helps women ignore menopausal symptoms.

Research has shown that women’s experience of menopause can be related to many things, including genetics, diet, lifestyle and social and cultural attitudes toward older women. The average age for menopause in the West is 50, while in our part of the world, it is said that menopause occurs between late 40s and early 50s.

According to a study conducted some years ago by the Department of Obstetrics and Gynaecology, Shaikh Zayed Postgraduate Medical Institute, Lahore and PMRC Research Centre Fatima Jinnah Medical College Lahore, to determine the age pattern and symptoms of menopause among rural women of Lahore, it was found that majority of the women reached menopause at 50. In 66 per cent cases the onset was sudden; among those who had a gradual transition, the duration of climacteric ranged from two to 30 months, the symptoms associated with menopause were lethargy (65 per cent), forgetfulness (57 per cent), urinary symptoms (56 per cent), agitation (50 per cent) and depression and insomnia (38 per cent). The data was collected from a random sample of 130 women selected out of 1337 women who had reached natural menopause.

Another study conducted at the Civil Hospital, Karachi by Professor Nusrat H. Khan shows that women belonging to low socio-economic strata of society suffered more from vasomotor (hot flashes, night sweats, and palpitation), psychological and urinary symptoms and complained more of joint pains as compared to women who were of higher socio-economic group. The average age for menopause was 47.

“The research showed that educated women had better strategies to cope with menopause. Women by and large welcome this change in life in our society. Most of the women do have symptoms while reaching menopause, but their intensity and duration vary. For some they are of low intensity and last for two to three years, but for others they can be very disturbing and last for many years.

For instance, some women don’t have periods for two to three months, and when they do come they are terrible. Majority of women come to us after consulting doctors for heart and urinary problems,” says Professor Nusrat H. Khan of CHK.

Doctors say that continuous clotting and heavy periods should be investigated. It is possible that the woman might have cancer in the uterus. If so, then her uterus has to be taken out (there can be many other reasons for removal of the uterus). For women reaching menopause it is suggested that their ovaries should also be removed to prevent chances of ovarian cancer in the future. But, for those in the younger age group ovaries are not taken out. In both cases, women experience early menopause, in cases where uterus and ovaries are removed the onslaught is sudden.

Premature Ovarian Failure (POF) is also a form of premature menopause. It can result from cancer treatment and damage to ovaries during surgery. In this condition periods stop before the age of 40 and the woman experiences menopausal symptoms. Most importantly, when a hormone test (a test of follicle stimulating hormone, or FSH, and estradiol, the main circulating estrogen) is taken, the test will show the patient at post-menopausal levels.

“Ovarian failure among young girls, which is a rare phenomenon in the West, is quite common here. Every week I examine one patient with ovarian failure. Girls visit clinics after marriage when they are unable to conceive and after the tests, come to know that they have POF. No scientific study has been conducted here to determine the reasons for this ovarian failure. However, one can say that they might be related to environmental pollution, consumption of poor diet, contaminated water and exposure to radiation. X-ray machines should be used with proper protection,” says Dr Shaheen Zafar of Liaquat National Hospital.

Girls with ovarian failure cannot conceive and have to be given HRT for a longer period under the surveillance of a gynaecologist to improve quality of life and prevent fallouts of estrogen deficiency. The deficiencies of estrogen and progesterone are usually treated with Hormone Replacement Therapy (HRT) for which different hormone preparations are available. About the role of HRT, Dr Shereen Bhutta of Jinnah Postgraduate Medical Centre says, “Due to the marked increase in longevity, women now spend one third of their lives in the post-menopausal period.

It is estimated that one third of the total female population are in menopause. Therefore, they would have to cope with the post menopausal syndrome and face the long term consequences of estrogen deficiency. That is why there has been an interest in hormone replacement therapy in the recent years, both for symptomatic management of menopausal syndrome as well as prevention of long term complications of menopause like reducing the risk of bone fractures due to the thinning of bone called osteoporosis.”

Considering the side effects of HRT disclosed in some studies, most of the doctors support its short term use. It is also recommended that the patient taking HRT should be in regular contact with her healthcare provider and have regular breast examination.

Most women who are on hormone therapy are taking two hormones: a form of estrogen and a form of progesterone. Women who no longer have a uterus are usually only on estrogen. It’s generally better to gradually wean off hormones rather than stopping abruptly. Stopping suddenly is not dangerous, but one can be uncomfortable while the body adjusts to new lower natural hormone levels. It is best to work with the doctor who prescribes medication to create a plan that is best for individual needs.

Last but not least, awareness needs to be created that should aim not only at educating women about their body, but also making men develop empathy for their life partners during this crucial period. No doubt, the entire family can be adversely affected if the mother’s health needs are ignored. Understanding each other’s needs, making small changes in lifestyle and attitude can prove to be milestones in the general well being of a family.

Osteoporosis— a major concern

One of the major long term health concerns after menopause is osteoporosis. Known as a silent bone disease, osteoporosis isn’t something new. According to Dr Charles Chestnut, Director of the Osteoporosis Research Group at the University of Washington Medical Centre in Seattle, “There’s evidence of osteoporosis in the remains of Egyptian mummies. It’s been recognised as a condition which has been existing for a long time but no one really seemed to care about it.”

After the age of 35, and particularly after menopause, bone absorption gradually begins to outstrip bone formation, resulting in a slow loss of bone mass. If loss of bone mass continues long enough, osteoporosis is the result. Though loss of bone mass is an inherent part of the aging process, it tends to affect women more.

Our bone mass is less dense than men’s to begin with. After menopause due to lack of estrogen, there is a five to seven years period of accelerated bone loss, then the rate slows and returns to an age-related rate.

The world’s osteoporosis ‘time bomb’ is ticking with the projected global burden of osteoporotic hip fractures expected to exceed six million by 2050 with Asia suffering the most due to the projected large increase in its population, according to the World Health Organisation.

There are currently 14 million post-menopausal women in Pakistan. Just under half of all post-menopausal women, or the equivalent of six million women, face the risk of osteoporosis, says the Partnership Against Osteoporosis. It notes that until February 2002, less than half a million were diagnosed with the bone-eroding disease. Only one-third of those diagnosed were treated with osteoporosis specific therapies.

The drugs available in Pakistan to treat osteoporosis are costly and are out of reach of the common man. A lot of women get married at an early age and hence the process of bone formation stops before it can take off.

A study published by Professional Medical Publications in 2004 says that postmenopausal osteoporosis will become one of the leading gynaecological problems in Pakistan in the coming decades. The study suggests tools for early detection and subsequent management as well as education for prevention.

The contributory factors to osteoporosis include lack of exercise, low calcium diet, high use of soft drinks (calcium is the main ingredient utilised by the body to neutralise the acidic affects of soft drinks), multiple pregnancies, smoking, excessive alcohol and caffeine use, and being underweight. An important factor, which has been overlooked in the prevention of osteoporosis, is the consumption of milk and milk products. For over 50 years milk has been pitched as a wonder food whose calcium is the only protection against weak bones. Americans have one of the world’s highest calcium intakes, but still suffer from one of the world’s highest rates of osteoporosis. This is because milk products have about 10 times more calcium than magnesium. Lack of magnesium causes calcium to be pulled from the bones. This calcium is all too often deposited in soft tissue, where it can cause arthritis and arteriosclerosis.

Rates of osteoporosis are lowest in cultures where the ratio of calcium to magnesium is between two parts calcium to three parts magnesium, down to as much as three parts calcium to two parts magnesium. On the average, a vegan diet (no meat or milk) provides about 500 mg per day of both calcium and magnesium.

Studies show that vegans have stronger bones than meat and milk product eaters, especially after the age of 50. Vitamin D and K are also important in the prevention of osteoporosis. Along with that they also reduce stress; cortisol is a hormone produced when the body is under stress that causes calcium to be pulled from the bones. Studies suggest that a diet rich in soy can protect women against bone fractures. The Hormone Replacement Therapy is no longer the most effective and safest way to deal with osteoporosis as alternative medical treatments are available now. — F.I.

Coronary impact

Women become more prone to heart or coronary diseases after menopause due to the absence (in case of hysterectomy) or the reduction in levels of estrogen and progesterone. These two hormones, the female hormones, are most quintessential in protecting the heart from diseases, which is why women do not run high risks of heart disease until they experience menopause. The reduction, however, results in women developing a higher risk of heart disease.

”The rate of heart disease in women is lower than men before they experience menopause,” says Dr Bari, head of the Cardiac Surgery Department at Civil Hospital, Karachi and Associate Professor at Dow University of Health Sciences, “After its onset the ratio becomes 1:1.” It has been observed that symptoms of heart attacks in men and women vary. Men feel tightness in the chest, pain in the arm, or shortness of breath. Women, however, experience nausea, tremendous fatigue and dizziness. Besides hypertension or high cholesterol levels, obesity, smoking and diabetes are factors that lead to heart attacks.

Due to ignorance and a general apathy towards personal well-being, many women dismiss such risks until the disease takes a heavy toll. According to an estimate more women die of heart disease in the US than any other disease. “In Pakistan, 10 per cent of people below 40 years of age have coronary artery disease. Out of this 10 per cent, 1.5 per cent are female. In the age group above 40, the incidence rises to 25 per cent, out of which 12 per cent are female,” informs Dr Bari.

Hormone Replacement Therapy (HRT) was used by women in the pastover the years as it was claimed that it provided heart protection through relevant hormones, but some recent studies have shown that it can also contribute to heart risks. “It is very useful for women to take half an aspirin everyday after menopause, as it reduces the risk of heart disease,” says Dr Bari. “Women should start taking it at the onset of menopause and continue it all their life.”

To keep such risks at bay, lifestyles need to be altered as they play a vital role in reducing heart risks. “Exercise or walking at least half an hour everyday is crucial to health and also fighting heart risks,” Dr Bari emphasises. An hour of aerobic exercises almost three to five times a week also contributes to a healthy lifestyle. Besides, a balanced diet is the key to sustained well-being.

Though illiterate women living in the rural areas may not have the cognizance of menopause and conditions that may occur as a result of it, urban women have more facilities and information which makes them more equipped to deal with the issues of menopause. It is, however, very important to educate rural women of the risks. One way of disseminating information and knowledge of risks and issues of menopause is through the government’s Lady Health Worker Programme. The LHWs should be trained to enlighten women experiencing such problems and also updating them beforehand of the symptoms of menopause and how to deal with it once it occurs. — Sumera S. Naqvi

Effective vitamins and minerals

Some vitamins and minerals can help cope with menopausal symptoms. They include: Vitamin A (helps fight uncomfortable vaginal drying, increased risk of urinary tract and vaginal infections), Vitamin B (supports liver function, a definite plus if you are on HRT, prevents vaginal dryness, helps fight emotional symptoms that crop up during premature menopause), Vitamin C (has anti-stress properties, can help cut down hot flashes especially when taken in combination with citrus bioflavanoids that have a weak estrogenic affect on the body), Vitamin D, calcium and magnesium (help fight osteoporosis). These vitamins and minerals should be taken after consultation with a doctor who will also determine whether that source suits one’s bodily needs. — F.I.

Male menopause –– fact or fiction?

Male menopause (Andropause) is a recently discovered phenomenon. The term is used to describe a drop in male hormone levels after middle age leading to depression, anxiety and low libido. It has also been used to describe a mid-life crisis that happens to some men during their late 30s’ and early 40s’.

Experts have debated the issue for years whether male menopause actually exists or not because the condition, which though has similar symptoms as that of female menopause, is not associated with a sharp drop in hormones and the cessation of a bodily function such as in the case of female menopause when women’s periods stop. Those who dismiss the male menopause theory argue that since men’s testosterone levels fall gradually, their bodies should naturally adapt to lower levels over time.

The subject has remained outside the domain of public spotlight also because men who experience the characteristic decline in virility during middle age are reluctant or even unwilling to acknowledge the condition. In fact, in most cases this condition goes untreated.

According to the information collected from the Internet, even in healthy men, by the age of 55, the amount of testosterone secreted into the bloodstream is significantly lower than it was 10 years earlier. In fact, by the age of 80, most male hormone levels are decreased to pre-puberty levels.

There seem to be many influencing factors in male menopause and not all have been fully researched. Some known contributors to this condition are excessive alcohol consumption, smoking, hypertension, previous vasectomy, hernia operations, poor diet, lack of exercise, prescription and non-prescription medications, mumps, poor circulation, and severe physical or emotional stress.

Professor Abdul Jabbar, an endocrinologist working at the Aga Khan University Hospital, was interviewed on andropause. He also answered some questions concerning female menopause. Excerpts from the interview are as follows:

Is male menopause a myth or reality? When was the subject of male menopause reported in the medical journals?

Male menopause is a reality. It was first reported in 1944 in a key article by two American doctors, Carl Heller and Gordon Myers. They compared the symptoms with those of the female menopause, and did a blind controlled trial showing the effectiveness of testosterone treatment. Unfortunately, like many pioneering efforts, their initiative went unnoticed. Men were unwilling to accept that they could attain ‘menopause’ and such researches were often hurriedly brushed under the carpet. Men with genuine symptoms were told that this was just a mid-life crisis’ – like men with erectile dysfunction were told that ‘it’s all in the mind’.

Until recently, the entire subject of male menopause was steeped in confusion and controversy. While women were accused of going through middle-aged crises and menopause-related aberrations, their male counterparts got away with propagating the myth of the ‘ageless male’ and boasted of virility all the way to their graves. There is no doubt that a man’s sexuality changes with advancing age.

Is there something called a middle-age crisis? If so, how is it different from male menopause?

Mid-life crisis is essentially a problem of psycho-social adjustment. It does not necessarily have a bearing on a man’s sex life. It is thus not synonymous with the male menopause although there is frequently a superimposition of male menopausal factors in middle-aged men going through crises and this makes the picture hazy. Male menopause, on the other hand, is a distinct physiological phenomenon that is in many ways akin to, yet in some ways quite different from, the female menopause. The symptoms may vary from patient to patient, making accurate diagnosis a challenge.

What are the signs and symptoms of low testosterone level in men?

The signs and symptoms may include loss of libido, erectile dysfunction, depression, lethargy, osteoporosis, loss of muscle mass and strength, and some regression of secondary sexual characteristics, such as loss of area hair. Alterations in behaviour, such as inability to concentrate, diminished interest in activities, sleep disturbance, irritability and depressed mood may also be noted.

Is there a link between low testosterone level and diabetes?

Central obesity is recognised as a main risk factor for ischaemic (disease characterised by reduced blood supply to the heart. It is the most common cause of death in most western countries). Heart disease and type 2 diabetes and central obesity are rising rapidly in the developed world. Some work has suggested that there may be a link between increasing peripheral resistance to insulin, increased insulin levels, central obesity and lower androgen levels in men.

What do you usually suggest for mild and severe symptoms?

Short term HRT after assessment by an expert.

Does HRT in men increase risk of liver cancer, heart disease or prostate cancer?

The data that has been collected so far does not support this but we do not have long term results.

What are the tests that men and women need after 50?

If menopausal symptoms are present they should have a check-up for their male and female hormones.

Does sexual drive improve by taking HRT after surgical menopause?

Yes, but not in all patients.

Can a menopausal woman conceive?

Rare conceptions have been reported in menopausal women.

Is it true that women who are hyper-responsive to reproduction cycle and emotional events or to both bodily and/or emotional stress are disposed to be most vulnerable to experiencing a difficult menopause?

Usually yes. —F.I.

Lifestyle changes

Though many drugs offer effective options for treating menopausal symptoms, making certain lifestyle changes also makes a difference. The most powerful habit affecting health is cigarette smoking. In addition to increasing the risk of heart disease and osteoporosis, smoking brings on menopause three years earlier. Physical inactivity is another reason for many serious diseases.

Adequate exercise is the crucial ingredient missing in most women’s lives. Activities such as brisk walking, running and aerobics not only help the heart, but also the bones and muscles. Some women report fewer hot flashes when they exercise regularly. For the greatest benefit, every day one should do at least 30 minutes of moderate aerobic exercise – such as walking for two miles.

Diet is another lifestyle factor that can be considered ‘menopause treatment’. For instance, soy has gained special prominence in recent years as a rich source of an estrogen like substance found in plants and produces the same affect that human estrogen does and helps decrease menopausal symptoms.

Heart disease risk can be lowered for menopausal women by eating little or no cholesterol and fat, plus limiting salt and alcohol intake. Most adults should consume 1,000 mg per day of calcium and for postmenopausal women the limit is 1,500 mg per day. One should get at least 15 minutes of sun exposure daily to help the body form Vitamin D supply, a nutrient that assists in calcium absorption.

Controlling weight is also very important. Recent studies have found that for every two pounds of weight gained during menopause, the risk of high blood pressure increases by as much as five per cent. A positive attitude towards life also helps. — F.I.

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