menopause This is defined as the cessation of menstruation that occurs at the end of a woman's reproductive life. However, since menstrual periods can become very irregular towards the menopause, it is difficult to know which menstruation will actually be the last. Women around the age of 50 are usually considered to be past their menopause if menstruation has not occurred for a year. A variety of terms are associated with that of the menopause: pre-menopausal, peri-menopausal, post-menopausal. The ‘climacteric’ or more popularly ‘the change of life’ refer to the physical and psychological symptoms which occur in the peri-menopausal years. The menopause normally occurs between the ages of 45 and 55, although occasionally women may undergo a premature menopause much earlier in their reproductive lives. An ‘artificial menopause’ may be brought about by
hysterectomy. When only the
uterus is removed in a pre-menopausal woman, the cyclical changes continue in the
ovaries and the subsequent decline of ovarian hormone secretion takes its natural course. However, if the ovaries are removed at the same time, which is often advised in the late forties, the full menopausal condition is precipitated, and
hormone replacement therapy is likely to be required.
The natural menopause occurs because all the egg-containing follicles left in the ovary ultimately degenerate and so there are no follicles which, under the influence of gonadotrophins, will develop and begin secreting
oestrogen. Ovulation will not occur and there will be no formation of a corpus luteum to secrete
progesterone and oestrogen. Thus the body becomes deprived of the female
sex hormones normally produced by the ovaries. Since these have previously had a negative feedback effect on gonadotrophin secretion by the pituitary, this secretion increases dramatically. There remains only a limited source of female sex hormones after the menopause, by conversion of androgens secreted by the adrenal cortex. This does not compensate for the ‘oestrogen deficient’ state of the post-menopausal woman whose ovaries have ceased to function. If a woman lives to 90 she will spend nearly half of her life in an oestrogen-deficient state.
The loss of oestrogen secretions has several profound effects, not only physically but also psychologically. Some of these symptoms are limited to the peri-menopausal period when a woman is adjusting to the loss of her hormones. Others may become manifest at the menopause but can have serious consequences in the long term. Common symptoms associated with the peri-menopausal period are hot flushes and night sweats, vaginal dryness, and depressive episodes. There is evidence that oestrogens can affect dilatation of arterioles, and thus symptoms, like flushes, linked with altered control of blood flow during oestrogen withdrawal are not surprising. Loss of oestrogen also leads to the thinning of the vaginal walls and loss of vaginal secretions. This causes vaginal dryness, and sexual intercourse can become painful.
Psychological symptoms are often linked with the menopausal years, particularly in those women who have a history of depression. However, it is difficult to determine to what extent these are due to social changes (such as children leaving home, marriage becoming dull) and negative cultural influences (
ageing and loss of reproductive status and
sexuality). Nevertheless some women do suffer from tiredness, lack of concentration,
anxiety, tearfulness, and loss of interest in sex.
After the menopause there is an increased loss of bone mass (
osteoporosis). In both men and women peak bone mass is usually achieved between the ages of 30 and 40 years and thereafter there is a gradual age-related loss in both sexes. In women, after the withdrawal of oestrogens at the menopause this bone loss is accelerated for several years, thereafter continuing at a similar rate to men. The result is that the age at which bones become so brittle that they are likely to fracture without any major trauma is, on average, much earlier in women than men. Thus women are far more likely than men to suffer from fractures related to osteoporosis. Common fractures are those of the wrist, hip, and spine (vertebrae). Indeed, fractures of the vertebrae can occur without trauma, and the resulting compression can cause the loss of several inches in height. Hormone replacement therapy (HRT) can stop the acceleration of bone loss, but when the therapy is withdrawn the usual rate of bone loss will recur. There is, however, considerable individual variation in bone loss, which may well be affected by lifestyle: exercise, especially if it involves ‘impact’, has been shown to decrease the rate of bone loss.
The other major long-term adverse effect of the menopause is on the cardiovascular system. The loss of sex steroids changes metabolism so that there is an increase in the amount of fats in the blood. This can increase the risk of arteriosclerosis (narrowing of the arteries by fatty deposits), which can lead to coronary artery disease and stroke. Thus pre-menopausal women are to some extent protected against cardiovascular disease by their sex hormones, as are women taking HRT. After the menopause, or after withdrawal of HRT, their risk of developing cardiovascular disease becomes the same as that of men.
There is no doubt that the loss of female sex hormones, notably oestrogens, can have profound effects on physiological functions in women. There is also little doubt that cultural influences can affect the way in which women experience and cope with menopausal symptoms. Western women live in a society in which social influences on the menopause are largely negative and there is a tendency for women to feel that they are left with the choice of being ‘saved’ by HRT or becoming old, sexless, and useless members of society. In contrast, in cultures where menopausal women achieve status and social advantages the reported incidence of menopausal symptoms is often negligible or even absent. For example amongst the Rajput of Northern India, women who are past their menopause are no longer in purdah and are able to move freely within their community. This has a positive effect on their outlook. Similarly the New Zealand Mayans view their post-menopausal years as a relief from child-bearing, and thus the menopause is an attribute. Japanese women report a lower frequency of menopausal symptoms compared with American and Canadian women, and the same is true for the Navajo Indians.
But all is not gloom and doom, even in Western society. The increasing presence of women in responsible posts in political, business, and professional life, and the acceptance in general of their employment outside the home enhances the prospect of rewarding and indeed more energetic activity without the inconveniences of the menstrual cycle and of potential pregnancy; employment of mothers also enhances the scope of the traditional role of the grandmother in the extended family. Thus, while the menopause can be considered as the beginning of an oestrogen-deficient state which may become an increasing health problem as longevity increases, there are clearly large cultural influences which can affect the way women experience this change of life.
Saffron Whitehead
Bibliography
Greer, G. (1991). The change: women, ageing and the menopause. Fawcett Books, Greenwich, CT.
Mackenzie R. (1984). Menopause. Sheldon Press, SPCK, London.
See also
hormone replacement therapy;
hysterectomy;
ovaries;
sex hormones.
