INTRODUCTION

Menopause is the end of menstruation. The word menopause came from the Greek word mens meaning “monthly” and pausis meaning “cessation”. Menopause is a part of a women’s natural ageing process when her ovaries produce lower level of the estrogen and progesterone and when she no longer able to become pregnant.

Definition

Menopause means permanent cessation of menstruation at the end of reproductive life due to loss of ovarian follicular activity. Is the point of time when last and final menstruation occurs. The final menstrual period can only be determined when it is followed by amenorrhea for 1 year without other pathology.

Age of menopause

Age at which menopause occurs is genetically predetermined. The age of menopause is not related to age of menarche or at last pregnancy.

It is also not related to number of pregnancy, lactation, or use of oral pill, social economic condition, race, height or weight.

Cigarette smoking and sever malnutrition may cause early menopause. The age of menopause ranges between 45–55 years. Average being 50 years. Premature menopause is defined as the permanent cessation of menses occurring before 40 years of age.

PHASES OF MENOPAUSE

The phases of menopause are usually broken down into four categories:-

1. Pre-menopause: Is broadly defined as the entire woman’s life before menopause. During this phase a woman will have regular periods, can bear children and sex hormones like estrogen and progesterone retain a steady balance.

2. Peri menopause: A period of woman’s life characterized by the physiological changes associated with the end of reproduction capacity and terminating with the completion of menopause also called climacteric. Years prior to menopause encompassing the change from normal ovulatory cycles to cessation of menses. (irregular cycle, elev. FSH). Perimenopause can begin 8–10 years to menopause. The drop in estrogen increases with experiencing many symptoms. There is a possibility of getting pregnant if still experience the menstrual cycle.

3. Menopausal phase
It is the end of menstruation. The age of menopause ranges between 45–55 years, average being 50 years. Menopause refers to a specific, and that is your last period. Once you have gone through a period of 12 consecutive months without experiencing menstrual cycle the ovaries stop releasing eggs.

4. Post-menopausal
It is defined formally as the time after which a women has experienced 12 consecutive month of amenorrhea without period.
Early – first five years after the final menstrual period- complete dampening of ovarian function and accelerated bone loss.
Late – five years after the final menstrual period and ends with death.

Types of menopause

The type of menopause depends on the cause and or timing of the end of menstruation

• Natural menopause

• Premature or early menopause

• Surgical or induced menopause

ETIOLOGICAL FACTORS

Menopause occurs when the ovaries are totally depleted of eggs and no amount of stimulation from the regulating hormones can force them to work.

1. Natural decline of reproductive hormones
2. Hysterectomy
3. Chemotherapy and radiation
4. Primary ovarian insufficiency
5. Bilateral oophorectomy

Menopausal symptoms

• Vasomotor symptoms
• Urogenital symptoms
• Musculoskeletal changes
• Cardiovascular disease
• Psychological changes
• Skin and hair sexual reproductive changes.

PHYSIOLOGICAL CHANGES

The lack of estrogen and progesterone causes many changes in women’s physiology that affect their health and well-being. The symptoms of menopause due to changes in the metabolism of the body.

Increased cholesterol level in the blood: Hyperlipidemia or an increase in the level of cholesterol and lipids in the blood is common. This leads to gradual rise in the risk of heart disease and stroke after menopause.

1. Skeletal system
   Calcium loss from the bone is increased in the first five years after the onset of menopause, resulting in a loss of bone density hence osteoporosis. The calcium moves out of the bones, leaving them weak and liable to fracture at the smallest stress.
2. Digestive system
   Motor activity of the entire digestive tract is diminished after menopause. The intestine tend to be sluggish resulting in constipation.
3. Urinary system:
   As the estrogen level decreases after menopause, the tissue lining the urethra and the bladder become drier, thinner and less elastic. This can lead to increased frequency of passing urine as well as an increased tendency to develop UTI.

CHANGES IN THE REPRODUCTIVE ORGANS

Uterus: The uterus becomes smaller and fibrotic due to atrophy of the muscles after the menopause and the ratio between the body and the cervix reverts to the ratio of 1:1.

Cervix: Becomes smaller and appears to flush with vagina. In older women the cervix may be impossible to identify separately from vagina. Cervical secretion decreases in amount and later disappear completely.

Ovaries: The ovaries become smaller and wrinkled in appearance. There is thinning of the cortex with increase in medullary components. There is abundances of stromal cells which have got secretory activity. The ovaries which produce little androgen during reproductive life begin to produce it in increasing amounts.

Vagina: Becomes narrower due to gradual loss of elasticity. The vaginal mucous membrane becomes thin and loses its rugosity after the menopause. Decreased secretion make vagina dry. Sexual intercourse become painful and difficult due to pain from the dry vagina.

Vulva or external genital organs: The fat in the labia majora and the Mons pubis decreases and pubic hair become scantier.

Breast: The breast fat is reabsorbed and the glands atrophy. The nipples decrease in size. In thin built women the breast become flat and shriveled while in heavy built women they remain flabby and pendulous.

CHANGES IN THE GENERAL APPEARANCE

Skin: The skin loses its elasticity and becomes thin and fine. This is due to the loss of elastin and collagen from the skin.

Weight: Weight increase is more likely to be the result of irregular food habit due to mood swing. There is more deposition of fat around hips, waist and buttocks.

Hair: Hair become dry and coarse after menopause. There may hair loss due to the decreasing level of estrogen.

Voice: Voice become deeper due to thickening of vocal cords.

CHANGES IN THE VASOMOTOR SYSTEM

Hot flashes: Hot flashes are incidents where the women in menopause gets a sudden feeling of warmth and flushing that starts in the face and quickly spread all over the neck and upper body. This `hot flashes’ can occur at any time of the day or night. They vary in number from 1 in every one hour to as one in every 15 mints. The hot flashes are often associated with profuse sweating.

Night sweat: Night sweat are closely related to hot flashes. Both usually occur simultaneously. Sweat can occur any time of the day or night, they are more common at night. The sweat can be severe enough to wake up the women from a sound sleep and may make it difficult for her to go back to sleep. The sudden waking up from sleep can cause palpitation and sometimes panic attacks.

PSYCHOLOGICAL CHANGES

The psychological changes are mainly manifested by frequent headache, irritability, fatigue, depression and insomnia. Although these are often said to be due to changes in the hormonal levels, they are more likely to be related to the loss of sleep due to night sweat. Diminished interest in sex may be due to emotional upset or may be secondary to painful intercourse due to a dry vagina.

SOCIAL CHANGES DURING MENOPAUSE

The feeling that a women holds about herself and her social relationship as well as the symptoms she experiences can be defined by the culture in which she live. Women vary in there subjective experiences of symptoms. Not all of the women’s perception of changes in the body are reflected in the mirror; some are derived from women’s perception of herself based on the account of other expectation vary and are adjusted to actual experience.

General signs and Symptoms of menopause

• Hot flashes and night sweats
• Heart palpitations
• Difficulty sleeping
• Mood swings
• Forgetfulness
• Urine leakage
• Joint stiffness
• Dyspareunia
• Reduced libido
• Vaginal infections
• Pruritus
• Leucorrhoea
• Increased anxiety
• Irritability
• Depression
• Dementia
• Osteoporosis

Complications of menopause

• Cardiovascular diseases
• Osteoporosis
• Mood changes
• Cognitive function
• Urinary incontinence
• Urinary tract infections
• Skin changes
• Weight gain.

TREATMENTS

NON-HORMONAL TREATMENT
There are variety of menopausal treatments both natural and medical that can alleviate the symptom of menopause:

• Dressing in light layers can alleviate hot flashes and night sweats; avoiding caffeine, alcohol and spicy foods can also minimize these symptoms.
• Menopause and weight gain tend to go together due to life style changes than to the hormonal changes. Reducing dietary fat intake and regular exercise help to combat weight gain during menopause.
• Menopause can lead to osteoporosis. Calcium, magnesium and vitamin D can help restore bone density, which naturally deteriorates after age 30 due to reduced estrogen level.
• Menopause decreases vaginal elasticity, leading to vaginal dryness. Vitamin E can help as can kegel exercises which help restore elasticity. Using water based lubricants during sexual intercourse also minimizes discomfort related to vaginal dryness.
• Menopause often lead to dry, itchy skin, and weak thin hair that breaks and that has lots of split ends. Poultry, dairy, red meat and whole grains can help restore hair and skin’s healthy appearance, as can vitamin E.

HORMONE REPLACEMENT THERAPY

• Hormone Replacement Therapy (HRT) is indicated in menopausal women to overcome the short-term and long-term consequences of estrogen deficiency.
• HRT can be administered orally (in pill form), vaginally (as a cream), or transdermally (in patch form) because it replaces female hormones produced by the ovaries.
• Hormone replacement therapy minimize menopause symptoms. It can be used before, during and after menopause.

INDICATION OF HRT

Relief of menopausal symptoms
Prevention of osteoporosis
To maintain the quality of life in menopausal years.

Special group of women to whom HRT should be prescribed:

• Premature ovarian failure

• Gonadal dysgenesis

• Surgical or radiation menopause

TYPES OF HRT

Estrogen and progesterone:

1. The most common type of HRT involves both estrogen and progesterone.
2. It is designed specifically for women who have a uterus.
3. During this therapy, estrogen is given regularly while progesterone is added on a supplementary basis. These two hormones are given in combination in order to prevent the overgrowth of uterine lining. Estrogen alone may irritate this lining which could lead to endometrial cancer.

Estrogen only:

Estrogen therapy alone is usually given to women who have lost their uterus due to surgical menopause.

Because no uterus is present, the need for progesterone is not as great.

Progestin only:

Progestin-only therapy is not prescribed very often. Progestin does seem to provide excellent relief for women plagued with hot flashes.

AVAILABLE PREPARATIONS FOR HRT

• The principle hormone used in HRT is estrogen.
• This is ideal for a women who had her uterus removed already. But, a women with intact uterus, only estrogen therapy leads to endometrial hyperplasia and even endometrial carcinoma. Addition of progestin for last 12-14 days each month can prevent this problem.
• Commonly used estrogen are conjugated estrogen (0.625–1.25 mg/day).
• Progestin used are medroxyprogesterone (100–300 mg/day).
• Considering the risks, hormonal therapy should be used with the lowest effective dose and for a short period of time. Low dose of oral conjugated estrogen 0.3 mg daily is effective and has got minimal side effects.
• Oral estrogen regime: estrogen – conjugated equine estrogen 0.3 mg or 0.625 mg is given daily for woman who had hysterectomy.
• Estrogen and cyclic progestin: For a woman with uterus estrogen is given continuously for 25 days and progestin is added for last 12–14 days.
• Continuous estrogen and progestin therapy: Continued combined therapy can prevent endometrial hyperplasia.

HRT implants:

Are small pellets inserted under the skin periodically once in six months.

They are inserted subcutaneously over the anterior abdominal wall using local anaesthesia. 17β estradiol implants 25 mg, 50 mg or 100 mg are available and can be kept for 6 month.
Estrogen gel:

This is quite easy to use and it has to be applied daily onto the skin over the anterior abdominal wall or thigh.

Effective blood level of oestradiol (90–120 pg/ml) can be maintained. The gel works by releasing consistent dosage of estrogen into the blood stream.

Transdermal patches:

These are small plasters which can release hormones into the blood stream transdermally.

The patch contains 3.2 mg of 17β oestradiol releasing about 50 µg of oestradiol in 24 hrs. It should be applied below the waist line and changed twice a week.

Vaginal cream: Can be applied directly to the vagina by an applicator. Gives relief locally on the lining of the vagina. Conjugated equine vaginal estrogen cream 1.25 mg daily is very effective especially when

Progestin: Patient with history of breast carcinoma or endometrial carcinoma, progestin may be used.

It may be effective in suppressing hot flushes and it prevent osteoporosis. Medroxy progesterone acetate 2.5–5 mg/day can be used.

Tibolone: Is a steroid having weakly oestrogenic, progestogenic and androgenic properties.

It prevents osteoporosis, atrophic changes of vagina and hot flashes. It increases libido. A dose of 2.5 mg per day is given.

DURATION OF HRT
Generally, use of HRT for a short period of 3–5 years have been devised. Reduction of dosage should be done as soon as possible.

RISKS OF HRT

Endometrial cancer: When estrogen is given alone to a women with intact uterus, causes endometrial proliferation, hyperplasia and carcinoma.

Breast cancer: Combined estrogen and progestin replacement therapy increases the risk of breast cancer slightly.

Venous thromboembolic disease (VTE): It has been found to be increased with the use of combined oral estrogen and progestin.

Lipid metabolism: An increased incidence of gallbladder disease has been observed following ERT due to rise in cholesterol (in bile).
Dementia, Alzheimer disease are increased.

DISADVANTAGES OF HRT

• Estrogen and progesterone over a long periods is known to stimulate cell division, and this seem to increase the risk for breast cancer by up to 9%.
• HRT also appears to increase your risk of heart disease by 24%.

Women taking HRT to reduce the risk of Alzheimer’s disease actually increased their risk by small percentage. In order to prevent increasing your risk of certain disease, it is suggested that you use HRT for not more than 5 years.

SURGICAL MENOPAUSE

1. Surgical menopause is a type of induced menopause in which both ovaries are surgically removed.
2. Surgical menopause can occur at any age before natural menopause occurs.
3. The symptoms of surgical menopause are generally more intense than when menopause occurs naturally. Induced menopause due to abrupt cutoff ovarian hormones, causes the sudden onset of hot flashes and other menopausal symptoms such as dry vagina and a decline in sex drive.
4. Hormonal therapy may be used to treat the symptoms of induced menopause. It stops or reduce the short-term changes of menopause such as hot flashes, disturbed sleep and vaginal dryness.

Nursing management of menopausal symptoms

Cool hot flashes:

• Dress in layers
• Have a glass of water or go somewhere cooler
• Try to pinpoint what triggers your hot flashes. For many women triggers may include hot beverages, caffeine, spicy foods, alcohol, stress, hot weather and even a warm room.

Decrease vaginal discomfort:

• Use over the counter, water based vaginal lubricants or moisturizers.
• Chose products that don’t contain glycerin, which can cause burning or irritation in women who are sensitive to that chemical.
• Staying sexually active also helps by increasing blood flow to the vagina.

Get enough sleep

• Avoid caffeine, which can make it hard to get to sleep
• Avoid drinking too much alcohol, which can interrupt sleep
•  

Practice relaxation techniques.

• Techniques such as deep breathing, paced breathing, guided imagery, massage and progressive muscle relaxation can help.

Eat a balanced diet

• Include a variety of fruits, vegetables and whole grains

Exercise regularly

• Get regular physical activities on most days to help protect against heart diseases, diabetes, osteoporosis and other conditions associated with aging.

Sexual and reproductive health and rights of the aging people

1. The world assembly on ageing urged governments to mainstream ageing throughout their policies and programs. It also stressed a human rights based approach, shifting away from viewing older people as being social burdens and/or mere welfare beneficiaries to being positive and active agents in society.
2. SDG3 suggests that states should ensure healthy lives and promote well-being for all at all ages. This goal offers an important opportunity to promote more age-inclusive health system and services and views older people quality of life as a health priority.

Challenges faced by older women

1. Ageing is one of the most significant global trends of the 21st century which presents new and complex challenges for health systems and has important implications for the sexual and reproductive health of older people.
2. The lifelong effects of sexuality and reproduction can affect all people in later life, but women may be more vulnerable due to their reproductive roles and gender inequality in society.
3. Stereotyping; physical intimacy is rarely acknowledged in most societies and is a taboo subject in some.
4. Older women and men continue to suffer exclusion and to face multiple challenges in accessing health care services.
5. Ageing women suffer from the lifelong effects of sexual bias and low social status.
6. Many older women disproportionately bear the emotional and economic burdens associated with their role as family caregivers as they are responsible for looking after ageing parents, older husbands, and orphaned or abandoned grandchildren.
7. Healthcare providers often have limited information about the physical, psychological and social problems of ageing.
8. Ageism; which is widespread within health systems and may create barriers that prevent older people from receiving adequate health care.
9. Older women may not understand their unique health risk or know that screening tests can detect health problems early and that treatments are available for many specific reproductive health concerns.
10. Physical and financial limitation may further limit their access to services.

Solutions

• Older women need representation at all levels in the decision-making process.
• Healthcare providers need training that enables them to treat immediate health problems, reduce risks of long term disease, and improve the quality of life of women as they age.
• Sexual reproductive programs which already serve women during their childbearing years, should extend their services for older women which may include counselling about menopause and its symptoms as well as elements of healthy lifestyle such as diet and exercise.
• Public campaigns can help overcome some of the challenges and also promote active healthy lifestyles.
• Outreach programs are also valuable supplement to clinic based services for older women.
• Community based activities, including support groups and volunteer health promoters.
• Education programs should aim to change providers attitude so that they value older clients.