Menopause: A Guide for Every Woman
Assessment of the risks versus the benefits of HRT has become a challenging task for the physicians. Controversial issues have surrounded the status of HRT for postmenopausal women lately. Several randomized controlled trials present contradicting evidence and have raised questions about the short-term risks of long-term benefits of HRT. The association of HRT with cancer, stroke, cognition, cardiovascular disease, venous thromboembolism, osteoporosis, gallbladder disease is under scrutiny. The latest controversial results of randomized controlled trials in recent years have posed newer challenges for the physicians in prescribing HRT for postmenopausal women.
Controversial issues have surrounded the area of HRT for postmenopausal women in the past years. Many recent evidence-based studies have highlighted that HRT use led to a decreased risk of atherosclerosis, osteoporosis fractures, along with no significantly increased risk of breast cancer. However, in the past several years, evidence-based medicine has brought forward the results of several randomized double-blind placebo-controlled trials, especially the results of WHI study,[ 26 ] which have radically affected routine prescribing of HRT in clinics.
The randomized controlled trials present contradicting evidence and has raised questions about the short-term risks of long-term benefits of HRT. Some of the risks are mentioned below: An increase in the risk of venous thromboembolism was reported in both WHI and HERS, with the highest risk in the 1 st year of use. Contradictory results have been reported in various studies for effects of HRT on the incidence of stoke. WHI study exhibited an increased risk whereas some other studies reported a protective effect.
Estrogen is implicated in tumorogenesis in experimental animals. A direct carcinogenic action of HRT on ovarian cells to induce proliferation of ovarian cells has been confirmed. Amongst evidence-based studies, HERS study had shown no decrease in colorectal cancer risk in women which was contradicted by the results of WHI suggesting a decrease risk of colorectal cancer by estrogen. The average age of menopause in India is Therefore, Indian women are likely to spend almost All women over 65 years have been found to suffer from osteopenia or osteoporosis Indian Menopause Society, A study[ 96 ] found that Indian women are now attaining menopause as early as at the age of It also puts them at a higher risk of being affected with osteoporosis, heart diseases, diabetes, hypertension, and breast cancer, says the study conducted by Bangalore's Institute for Social and Economic Change.
The report, which was presented in Parliament, has said that in India 3. The study said that there are a higher number of illiterate women who are in premature menopause as against those who are educated. There is a wide variation in the frequency with which women from different ethnic groups and different socioeconomic and educational backgrounds report the occurrence of symptoms associated with menopause. The variables that affect the socioeconomic status are different in the urban and rural population.
Genitourinary symptoms like incontinence, frequency, urgency, difficulty in voiding etc. The study showed that perimenopausal women showed greater symptoms when compared to menopausal women. Another study[ 99 ] also showed that menopausal symptoms peak at the perimenopausal period, followed by a decline in symptoms during the postmenopausal period. In contrast to the Srilankan study,[ ] an Indian study showed that vasomotor symptoms were more prevalent in the perimenopausal group, while musculoskeletal symptoms were common in the postmenopausal age group.
One study[ ] showed that women of low socioeconomic status had a greater prevalence of biological and psychological symptoms. Another study[ ] demonstrated that women of the lower socioeconomic group have more severe menopausal symptoms and poorer subjective adaptation to daily life than women of the higher socioeconomic class. This is in contrast to the Indian study, which showed a greater prevalence of musculoskeletal and psychological symptoms in the middle socioeconomic group, while vasomotor symptoms were found to be more prevalent in the lower socioeconomic group.
The difference found in the study could be due to sociocultural factors that are known to modify the experience of menopause and midlife. A study[ ] observed low to moderate level of anxiety, depression, social dysfunction and somatic symptoms as well as psycho-social stress in middle-aged women working as school teacher. It was noted that level of these factors was comparatively higher in postmenopause group than during menopause group. However, as far as these psychological factors are concerned this study could not find statistically significant difference between the groups.
According to the authors, one of the reasons of low and similar scoring between the groups may be due to the fact that these women were not psychological cases. In a study[ ] on 32 postmenopausal and 32 premenopausal patients aged between 40 and 55 years to investigate the anxiety and depression in postmenopausal women, the beck depression scale showed highly significant difference whereas, State-Trait Anxiety Inventory I and II showed no statistically significant difference and, therefore, concluded that depression rate is significantly higher in menopausal women.
This study concluded that changes occurring in women during 40—60 years of age require proper attention. Working women preferably may require more care due to dual role responsibility. It may become slightly difficult to manage all activities with the same efficiency as before. That may cause feeling of guilt, irritation, stress etc. Physical relaxation, emotional support, and essential care are needed for healthy living.
Certain modifications in life-style and some programmed interventions can provide the enhancement of positive, healthy habits, reduce stress and can add quality to their life. A study[ ] which analyzed a sample consisting of menopausal, premenopausal and postmenopausal women in the age range of 35—50 years using a two-stage screening procedure for identifying and screening psychiatric morbidity General Health Questionnaire and Standard Psychiatric Interview, found highest psychiatric co-morbidity in the menopausal group, in terms of age maximum number of cases with psychiatric co-morbidity were from 41 to 45 years.
Menopausal women suffered more symptoms of menopause as well as psychiatric symptoms as compared to premenopausal women. Both set of symptoms was found to be less in the postmenopause group also. The most common reported symptoms in the group were depression, depressive thoughts, anxiety, and excessive concern about bodily functions. Supporting the findings of the earlier study[ ] the predominant symptom in menopausal women was depression.
Another study,[ ] including a sample of 30 married women in the age range of 39—52 years from middle socioeconomic group noted, mean age of menopause was This study was on the perception of women towards physiological problems faced at menopause. It was revealed from this study that women who were undergoing menopause were suffering from more difficulties during the perimenopausal phase than the menopausal phase, this in turn can affect the mental health of women and thus may increase psychosocial problems in their life.
It was also found that women complained more of backache, loss of sight, pain in joints and fatigue during the menopausal phase than the perimenopausal phase. The women in the perimenopausal phase perceived more physiological difficulties irregular periods with the heavy menstrual flow as compared to the menopausal women.
It has been difficult to distinguish between symptoms that result from loss of ovarian function and those from the aging process or from the socio-environmental stresses of midlife years. Symptoms which result from loss of ovarian function should resolve by hormone replacement, but it has not been found so. Further research is required in this direction. Symptoms have variable onset in relation to menopause. Some women experience symptoms earlier during perimenopause while some experience them at a later time. When should treatment start is also prophylaxis or management an issue for debate.
Although HRT remains the first-line treatment for hot flushes, the WHI findings have drawn attention to nonhormonal treatments of hot flushes and other menopausal symptoms. Growing evidence to support the efficacy of serotonergic antidepressants and other psychoactive medications in the treatment for hot flushes suggests that nonhormonal interventions will prove important alternatives to HRT. As further evidence of the benefits of psychoactive medications for menopausal symptoms is established, the choice between using hormonal and nonhormonal therapies for the management of menopausal symptoms will continue to evolve.
Source of Support: Nil. Conflict of Interest: None declared. National Center for Biotechnology Information , U. Journal List Indian J Psychiatry v. Indian J Psychiatry. Pronob K. Dalal and Manu Agarwal. Author information Copyright and License information Disclaimer. Address for correspondence: Dr. E-mail: moc. This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3. This article has been cited by other articles in PMC. Abstract Menopause is one of the most significant events in a woman's life and brings in a number of physiological changes that affect the life of a woman permanently.
Keywords: Hot flushes, menopausal depression, postmenopausal syndrome.
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Treatment Systemic estrogen therapy is the most effective treatment available for vasomotor symptoms and the associated sleep disturbance. Hormonal changes Depression seems to be significantly linked to times of hormonal change in women. Life stressors Societal roles and expectations may contribute to the heightened rate of depression in women. Such stressors include the following:[ 33 , 40 ] Lack of social support Unemployment Surgical menopause Poor overall health status.
Other stressors that tend to correspond with perimenopause and that are postulated to relate to depression include the following: Onset of illness in self or others Care of aging parents Changes in employment. Psychological or social conditions Numerous psychological and social theories have been proffered to explain why women may become depressed during perimenopause.
Some of these are related to the following factors: Change in the childbearing role Loss of fertility, which may be associated with a loss of an essential meaning of life Empty nest syndrome The societal value of youth in societies where age is valued, women tend to report having fewer symptoms at the menopause transition. Pre-existing tendency to develop depression A personal or family history of major depression, postpartum depression, or premenstrual dysphoric disorder seem to be a major risk factor for depression in the perimenopausal period. Treatment For major depression, standard antidepressants are first-line treatments.
Bipolar disorder Exacerbation of mood symptoms during menopause has been noted in women with the pre-existing bipolar disorder. Panic disorder Panic disorder is common during perimenopause. Sherwin B. Menopause: Myths and realities. Psychological aspects of women's health care. Arlington: American Psychiatric Publishing; Spinelli MG. Depression and hormone therapy. Clin Obstet Gynecol. Cigarette smoking and the age at menopause. Ann Hum Biol. The effect of hysterectomy on the age at ovarian failure: Identification of a subgroup of women with premature loss of ovarian function and literature review.
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Everything I needed to know about the menopause No One Told Me - Evidently Cochrane
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Effects of risedronate treatment on vertebral and nonvertebral fractures in women with postmenopausal osteoporosis: A randomized controlled trial. Reduction of vertebral fracture risk in postmenopausal women with osteoporosis treated with raloxifene: Results from a 3-year randomized clinical trial. Soares CN. In: Meeting Program and Abstracts. Psychopharmacology and Reproductive Transitions Symposium. Hormones and menopausal status as predictors of depression in women in transition to menopause. Arch Gen Psychiatry.
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Kirsty Wark: 'Let's talk about the menopause'
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Three out of four women who seek help for symptoms don’t receive it
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Increased frequency of depressive episodes during the menopausal transition in women with bipolar disorder: Preliminary report. Burt VK, Rasgon N. Patience is vital in both the short and long term. Cutting her some slack when she seems sad or angry will go a long way. Offer to help. Getting help with the dishes or having the living room picked up when she gets home can help ease a hectic schedule. Do whatever you can to keep her from feeling overwhelmed. Approve of her. This is a perfect time to tell her that you admire her and why. Be honest in your praise.
Remember why you're together. In the heat of the moment, remind yourself why you have chosen to stay with her. In a calm moment, you might even want to share that with her. Help her get the sleep she needs. If you need a sleep study, get one and use a CPAP to decrease your snoring. It will help your heart too since sleep apnea can cause cardiac damage. Offer to sleep in the guest room on weeknights, so that she can get some real sleep and to turn off the television in the bedroom. If she wants to take a night class or join a book group, do what you can to make it easy for her.
Support her health. Getting started on an exercise plan is easier if you have company. Offer to take nightly walks with her or bike around a lake every weekend. It can become a healthy ritual that you both feel good about. If she is worried about weight gain , plan to cook healthful meals.
Talk about situations that stress your relationship and make a plan for dealing with them. If visiting your mother sends her over the edge, talk about the best way to manage these trips. The trick is in finding a balance of closeness, touch, and sexual activity. A foot rub or a shoulder massage can keep you connected. Vaginal changes during menopause may make sex uncomfortable or even painful. If she is experiencing pain with intercourse, encourage her to talk to her medical provider about treatments that might relieve the discomfort. These professionals can help you find the middle ground.
Not every woman will need heavy-duty support through menopause. Many will, at least, need a little boost from time to time. Women in menopause need patience, friendship and lots of laughter.
A Woman's Guide to Menopause and Perimenopause
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