The SEVEN Dwarves of Menopause

MEH-nuh-paws is defined as the time of women when the ovaries stop producing hormones and the menstrual period stops. Menopause is when one has missed 12 consecutive months without a menstrual cycle. The time before menopause can last eight to 10 years (perimenopause). The time after menopause (postmenopause) will last until the end of a woman’s life.

The transition is experienced by 1.5 million women each year and this often involves symptoms, including vasomotor symptoms, decreased libido, insomnia, vaginal dryness, joint pain and fatigue. 

The 4 core symptoms are vasomotor response, vaginal, insomnia and mood. Based on the population, epidemiologic studies of menopausal women have been conducted and are yielding reliable and consistent information about the incidence, prevalence, and severity of several menopausal symptoms. However, this is relatively new, and it is likely that there are subsets of women who are more or less vulnerable to particular symptoms or sets of symptoms.

Different meanings of menopause, according to age: 

• Premature menopause: In women below 40 years old
• Early menopause:  In women aged 50 years to 59 years old
• Late menopause: In women aged 60 years and over.
• Surgical menopause: Result of surgical removal of both ovaries
• Medical menopause: Result of permanent damage to both ovaries in women following either chemotherapy or radiotherapy. 

The mean age at menopause in the Malaysian women studied was 50.7 years. Analysis of the climacteric symptoms reported showed significant differences in the vasomotor and nervosity indices in the perimenopausal and postmenopausal groups. 80% of the women did not seek consultation about their climacteric symptoms. If one was done with the consultation, mostly about 84% of women will receive treatment, however 43% of them will not comply with the prescribed medication. Dyspareunia and urinary incontinence were evidently regarded as embarrassing complaints in all three major ethnicities (Malay, Chinese and Indian), among which 80% of the women did not seek medical advice. This is not surprising in view of the fact, 89% of the women have rated their health as good condition. 

Symptoms of menopause: 

• Hot flashes (a sudden feeling of warmth that spreads over the body).

• Night sweats and/or cold flashes
• Difficulty sleeping (insomnia)
• Vaginal dryness; discomfort during sex
• Urinary urgency (a pressing need to urinate more frequently).
• Emotional changes (irritability, mood swings, mild depression).
• Dry skin, dry eyes or dry mouth.

Symptoms of perimenopause:

• Breast tenderness.
• Periods that are heavier or lighter than usual.
• Worsening of premenstrual syndrome (PMS).
• Irregular periods
• Some people might also experience rapid heartbeat, headache, joint and muscle aches, changes in libido (sex drive), difficulty concentrating, memory lapses (often temporary), weight gain, and hair loss/thinning. 

Benefits of Hormone Therapy (HT)

1. Vasomotor symptoms, including hot flashes, sweating, feeling of weakness and irritability improve with HT.
2. Atrophic changes in the lower genital tract will definitely improve with HT. For example dyspareunia, dysuria, frequency of micturition and nocturia. 
3. Mood disorders, especially depression will improve. Decrease the time spent awake during sleep and increase the total time spent on rapid eye movement. 
4. Insomnia is an indication of HT.
5. Improves sexuality, for example by an increase in desire, arousal, activity, frequency and overall sexual satisfaction.
6. HT and calcium supplements increase bone marrow density and reduce bone turnover. Reduces the vertebral and hip and lower arm fractures. It also improves skin dryness, aging elasticity and thickness. 
7. Reduces the risk of colorectal cancer. However, this is not an indication of HT. 

Contraindications for Hormone Therapy (HT):

• History of breast cancer
• Venous thrombo-embolism
• Stroke
• Undiagnosed uterine bleeding and significant cardiovascular disease

Side effects of Hormone therapy:

Minor problems for taking estrogen therapy will be nausea, vomiting, dizziness and vaginal spotting while progesterone therapy will be bloated feeling, acne, hirsutism, mood swings and depression. 

Risk of Hormone therapy will be depending on the condition and duration of HT. 

• Coronary disease
  • Early menopause HT will decrease the risk, but in late menopause, the risk is increased. No relative risk if starts within 10 years of reaching menopause.

• Venous Thrombo-Embolism
  • Depending on whether to use combination therapy (Estrogen & Progesterone- EPT) or single therapy (Estrogen-ET). Higher risk in the first year (EPT), first 2 years (ET) and remain high for 5 years(EPT), high (ET). Risk is controlled by follow-up.

• Stroke
  • Recent studies revealed there is no increased risk of HT if used for less than 5 years in young postmenopausal women.

• Breast cancer
  • In WHI studies, a small increase in the risk of breast cancer was detected after 5 years of HRT usage (1 per 1000 women per year).

HOW, WHEN, WHO to start HRT?

1. Pre-treatment evaluation with full medical & surgical history, physical examination and investigations (Blood and urine workout, bone marrow density studies, mammogram, pap smear, ultrasound pelvis).
2. Ideally for ages between 50-60 years or within 10 years of menopause. Generally not recommended for ages after 60 years old.
3. For women with premature menopause, the HT should be started as early as possible with a lower dose of estrogen and progesterone.
4. The dose and regime of HT need to be individualized.
5. Route of medication either transdermal, cream or oral.
6. Follow up after 1 month, 3 months, 6 months and yearly. Routine blood test with hormonal test, cervical and pelvis screening (ultrasound and pap smear), mammogram 2-3 yearly and bone marrow density every 2-3 yearly.