Menopause
Menopause is defined as the cessation of menses for 12 months. Most women generally enter menopause between the ages of 49 and 52. With the increasing life expectancy of women in the United States, it is expected that women spend approximately 40% of their lives in the post-menopause stage.
Disease Synthesis:
The menopausal transition occurs over several years as women experience changes in their menstrual cycle. The goal standard for determining the alterations in reproductive aging is the STRAW+10 (Stages of Reproductive Aging Workshop). There are three phases in this staging system which consists of reproductive, menopausal transition, and post-menopause.
Women are born with all their oocytes- a cell in the ovary and during the reproductive stage of women’s lives, the oocytes gradually diminish through a woman’s monthly cycle. These oocytes secrete a hormone called inhibin B which increases levels of another hormone FSH- follicle stimulating hormone. This increase in FSH leads to increased follicular recruitment and in return increased follicular loss. Once all the ovarian follicles are gone, the ovary is not able to respond to high levels of FSH, which leads to a fluctuation and uncommon levels of estrogen, which results in the loss of a normal reproductive cycle. The postmenopausal period is when there is an elevated concentration of FSH >30 mIU/mL and a low level of estradiol in the body.
Signs & Symptoms:
The common signs and symptoms of menopause include hot flashes and irregular of periods. Some women may also experience night sweats and sleep disruption. About 65% of women experience night sweats and hot flashes. Hot flashes are usually followed by sweating a chill then palpitations and anxiety. These flashes usually last less than 5 minutes, but sometimes they can last up to half an hour. Some important triggers to note are hot foods & beverages, stress, and warm environments. Although it is currently not fully understood what causes these symptoms, it is thought to be contributed to low estrogen levels which affect hormone levels in the hypothalamus, which is the part of the brain that regulates body temperature.
Once women reach menopause, they may suffer some postmenopausal symptoms including vaginal dryness, and vulvovaginal atrophy- decreased estrogen levels in the vaginal tissue leading to irritation, soreness, urinary frequency, painful sex, and urinary tract issues.
Contributing Factors & those at risk:
Some women may experience menopause early if they are smokers, have a lower body mass index, and have never given birth to a child. Some triggers for hot flashes include high-stress environments, hot temperatures, alcohol consumption, and a history of panic attacks.
Holistic Treatments:
For hot flashes, it may help to lower the room temperature, avoid drinking a hot drink and caffeine, avoid eating hot or spicy foods and keep a fan nearby. Smoking can also exacerbate hot flashes symptoms.
Treatments:
Estrogen therapy is the most effective treatment for menopausal hot flashes, and it improves vaginal symptoms. Estrogen can be prescribed in various dosage forms including oral (estrogen pills), transdermal as a patch (Estrogen patch and Combi patch), as a cream (Premarin), and as a vaginal ring insert (vaginal estrogen).
Some other non-hormonal treatments for hot flashes include paroxetine and fluoxetine as well as venlafaxine. Clonidine and gabapentin have also shown some improvements for women who experience hot flashes.
Adverse Effects of Treatments:
Some contraindications to hormone treatments include a history of breast or endometrial cancer, history of venous thromboembolism, coronary heart disease or stroke, uncontrolled high blood pressure, migraine headaches, gallbladder disease, and high cholesterol. Some side effects of hormone therapy include tender breasts, vaginal bleeding, mood swings, bloating, and nausea.
Vaginal dryness
Vaginal dryness is also referred to as vulvovaginal atrophy which is associated with a decreased level of estrogen in the vaginal tissue. Although this can occur at any point during a woman’s lifetime, it is more common in women who are postmenopausal.
Disease Synthesis:
Although vaginal dryness can occur at any point during a woman’s life, it is most common post-menopause. Other causes include lactation, several breast cancer treatments, and the use of certain medications. Most of the time this occurs due to an unbalanced and abnormal estrogen level in the body. The vaginal epithelium is generally moist and thick with rugae before menopause, but with declining levels of estrogen after menopause, there are fewer cells that line the vagina which thins out the epithelium. As the cells around the vagina die during menopause, they release glycogen which is hydrolyzed to glucose. The glucose is broken down into lactic acid which causes the pH to rise. With an increase in pH, there is an increased risk of overgrowth of bacteria. The bacteria can ultimately cause vaginal infections and inflammation. In addition, the elasticity of the vagina is limited, there is a decrease in vaginal blood flow and a decrease in vaginal lubrication after menopause when the estrogen levels are deceased.
Signs & Symptoms:
The initial symptom is usually a lack of lubrication during intercourse and if this becomes more common then it often leads to soreness and stinging pain in the vagina. Vaginal dryness symptoms include irritation, soreness, frequent need to urinate, and the urge to urinate. Sometimes there will also be vaginal discharge and painful sex. When a urinalysis is performed at the physician’s office, blood is commonly found in this. One issue with vaginal dryness is that women tend to not report this condition because they feel embarrassed or that it is not important enough to report. They are more likely to report vaginal discharge and urinary urgency. The diagnosis for this condition consists of 2 tests, a vaginal pH and a vaginal maturation index (VMI).
Contributing Factors & those at risk:
Women who are post-menopausal are the patients who are at the most risk for this condition.
Holistic Treatments:
Lubricants and moisturizers which are water-based can commonly help moisturize the vagina to help with the pain and soreness women experience. Vaginal moisturizers can be used long-term safely, but they must be used regularly in order to have an optimal effect. Lubricants are primarily used prior to and during sex for short-term use, meanwhile, moisturizers can be used at any time. The use of complementary and alternative medicine to treat vaginal dryness is lacking. One study showed supplementation with soy with no improvement or harm. Another study found that vitamin E and phytoestrogen applied locally as a gel improved some of the symptoms of vaginal dryness. The last study examined the use of vitamin D and its effects on vaginal dryness. Vaginal dryness was improved in patients who took vitamin D orally for at least one year.
Treatments:
Vaginal estrogen is an effective treatment for vaginal dryness in all forms including creams, rings, or tablets. Prescription vaginal estrogens are available as estradiol or conjugated estrogens. NAMS- the North American Menopause Society noted that it is generally unnecessary to prescribe a progestin in combination with a low dose vaginal estrogen to prevent endometrial hyperplasia or cancer. Systemic absorption of estrogen occurs but primarily in limited amounts. Although it is up to the patient and the physician to determine which is the best treatment regimen, estrogen creams tend to be very effective and the least costly. Some patients however prefer a tablet as it is less messy and easier to administer than a cream with an applicator.
Adverse Effects of Treatments:
Many surgical and chemotherapy treatments for breast cancer can increase the risk of vaginal dryness. If patients were prescribed very low dose estrogen to combat vaginal dryness, this would be a concern as some of the medication would be systematically absorbed. For patients with breast cancer or who have been treated for breast cancer, it is a good idea to avoid using hormone therapy.
References:
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- Donders GG, Mertens I, Bellen G, Pelckmans S. Self-elimination of risk factors for recurrent vaginal candidosis. Mycoses. 2011 Jan;54(1):39-45. doi: 10.1111/j.1439-0507.2009.01754.x. PMID: 19780979.
- InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. Vaginal yeast infection (thrush): Overview. 2019 Jun 19.Available from: https://www.ncbi.nlm.nih.gov/books/NBK543220/
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