The Menopause and Beyond

By Sivalingam Nalliah

DR. SIVALINGAM NALLIAH KMN, PMP, DPMP,
MBBS (MAL), MCGP, FRCOG, Master in Education, had his early education at the Tranquerah English School and Gajah Berang
English School before moving to the Malacca High School to complete his higher school certificate education. He obtained his basic medical degree from the University of Malaya graduating in 1974. He obtained his postgraduate degree in Obstetrics and Gynecology from The Royal College of Obstetricians and Gynaecologists (UK) in 1980. He worked in many parts of Malaysia before becoming Head of OBGYN services, Malaysia in 2001. He completed his civil service with the
Government of Malaysia before taking up an academic position with the International Medical University, Malaysia where he is Professor of Obstetrics and Gynecology. He has written and edited several books on Obstetrics and Gynecology. His interests are in undergraduate and postgraduate training in OBGYN and medical education. He was honoured with the title of DATO by the Sultan of Perak, Malaysia and was also awarded The DISTINGUISHED COMMUNITY SERVICE AWARD IN
EMERGENCY OBSTETRIC CARE by the Federation of Gynaecologists and Obstetricians (FIGO) in 2003.

• Language: English
• Publisher: Xlibris AU
• Release date: Aug 24, 2013
• ISBN: 9781483680149

Sivalingam Nalliah

DR. SIVALINGAM NALLIAH KMN, PMP, DPMP, MBBS (MAL), MCGP, FRCOG, Master in Education, had his early education at the Tranquerah English School and Gajah Berang English School before moving to the Malacca High School to complete his higher school certificate education. He obtained his basic medical degree from the University of Malaya graduating in 1974. He obtained his postgraduate degree in Obstetrics and Gynecology from The Royal College of Obstetricians and Gynaecologists (UK) in 1980. He worked in many parts of Malaysia before becoming Head of OBGYN services, Malaysia in 2001. He completed his civil service with the Government of Malaysia before taking up an academic position with the International Medical University, Malaysia where he is Professor of Obstetrics and Gynecology. He has written and edited several books on Obstetrics and Gynecology. His interests are in undergraduate and postgraduate training in OBGYN and medical education. He was honoured with the title of ‘DATO’ by the Sultan of Perak, Malaysia and was also awarded ‘The DISTINGUISHED COMMUNITY SERVICE AWARD IN EMERGENCY OBSTETRIC CARE’ by the Federation of Gynaecologists and Obstetricians (FIGO) in 2003.

Book preview

THE MENOPAUSE

AND BEYOND

Sivalingam Nalliah

MBBS, MCGP, MRCOG, FRCOG, FAMM M Ed

Professor of Obstetrics and Gynecology

International Medical University Malaysia

Copyright © 2013 by Sivalingam Nalliah.

The first edition of this book was published in 1996.

Library of Congress Control Number:   2013914102

ISBN:                        Hardcover                       978-1-4836-8013-2

                                  Softcover                         978-1-4836-8012-5

                                  Ebook                              978-1-4836-8014-9

All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the copyright owner.

Designations used by companies to distinguish their products are claimed as trademarks. All brand names and product names used in this book are trade names, service makes, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in the book. This publication is designed to provide accurate and authoritative information in regard to subject matter covered. It is sold in the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert advice is required, the services of a competent professional should be sought.

The author and publisher have taken every possible step to ensure the facts are up-to date at the time or printing. Misconception resulting from misunderstanding of the text and subsequent action and decisions will be the responsibility of the reader and not the author/publisher. Whilst advice and information are believed to be true and accurate at the time of writing, neither the author nor publishers can accept any legal responsibility or liability for errors or omissions that may be made. In particular every effort has been made to check drug dosages and names of drugs; however, it is still possible that errors have been missed. Furthermore dosage schedules are constantly revised and new side effects of drugs being recognised. A professional consultation is essential before taking medication. In view of on-going research, equipment development, changes in governmental regulations and rapid accumulation of information relating to biomedical sciences, the reader is urged to carefully review and evaluate the information provided herein. The author/publisher is not associated with any of the mentioned products or proprietary drugs and the appearance of any such commercial products are for illustration purposes and are not to promote any such products.

Rev. date: 08/16/2013

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Contents

Foreword

Acknowlegement

Preface

Introduction

Chapter 1       Hormones in menopause

Chapter 2       Menopause the world over

Chapter 3       The menopause and climacteric

Chapter 4       Psychological aspects of menopause

Chapter 5       The heart and blood vessels in ageing women

Chapter 6       Osteoporosis

Chapter 7       Calcium: myths and need for supplement

Chapter 8       Easing into the menopuase with excercises

Chapter 9       Nutrition in menopause

Chapter 10       Taking control of yourself through rest and relaxation

Chapter 11       Hormone therapies

Chapter 12       Hormone medical therapy

Chapter 13       Adherence to estrogen therapy

Chapter 14       Role of progesterone—the other female hormone

Chapter 15       The role of the male hormone in menopause

Chapter 16       The female breast in health and disease

Chapter 17       Cancer of the breast—the scare

Chapter 18       Cancer of the uterus—what you should know?

Chapter 19       Cancer of the ovary—the difficult tumor

Chapter 20       abnormal Bleeding from the uterus and pre-cancer of the uterus

Chapter 21       The dry vagina

Chapter 22       Prolapse of the uterus and urine incontinence

Chapter 23       Hysterectomy—surgical removal of the uterus

Chapter 24       Aging and mental health

Bibliography

FOREWORD

‘MENOPAUSE and BEYOND’ is written for women who reach menopause. The author has been careful in having included several chapters dealing with various aspects of life after menopause. Emphasis is given to exercise, diet and relaxation apart from dealing in depth with effects of female hormones on the body.

The lay public has been exposed to the social media and to the medical fraternity to various views regarding the role of estrogen, progesterone and testosterone at menopause and beyond. There are differing levels of acceptance to advice and adherence to treatment in indicated cases.

Dr. Sivalingam has presented the facts surrounding the use of estrogen hormone therapy as he sees best without bias and discusses the overall impact in terms of benefits and risks.

Although this book is written for women in the menopausal years, it would also prove to be useful source of information for nurses and doctors who care for women as they grow older.

Tan Sri Dato (Dr) Abu Bakar Suleiman

Former Director General of Health

Ministry if Health

Malaysia.

ACKNOWLEGEMENT

I wish to express my gratitude to my wife Sivamani Rasiah and my two children Navin Anand and Vanitha Nandini who have supported and encouraged me to revise the original edition of this book which was written in 1996. An old teacher of mine, the late Professor N. Chandrasekaran needs mention as he volunteered to review the manuscript and gave me useful suggestions for improvement before his untimely demise.

I am indeed happy that there are excellent people at the International Medical University who have assisted me in getting some of the illustrations used in this book in time. To this end I must thank Aida Lina and Siti Aeysha. Apart from putting down in words my own experiences in managing women in the menopause for over 30 years, I went through several references for input and information. Many of the facts are drawn from the results of research done and published in medical journals and social media. I wish to thank all authors whose work I have quoted for sharing their research findings for the betterment of women’s health and well being. There are too many for me to name them but I have indicated the sources I have used in both the Bibliography and in the text where relevant. Resources are often useful for readers to obtain up-to-date information regarding aging and management of menopause. I have included some of these where relevant.

I wish to thank open domains for the use of images of equipment and instruments that have been included in the text to make reading easier. I must particularly mention the following sources for some of the figures used in the book. They are of importance in attempting to explain difficult text based on human disease and I believe such data would be used for the betterment of women’s health. The following sources are cited: Fig.6.4 (Snoots 3000), Fig.9.1 (Tufts’ University), Table 10.3 (EEG, Lagopoulos), Fig. 20.1 (medical expo), Fig. 22.1 (smith-medical), Fig. 22.2 (Win-health), and Fig.22.3 (patient.uk.com).

Dr. Sivalingam Nalliah

PREFACE

‘Menopause and Beyond’ is a comprehensive account of aspects of life beginning from the transition phase a woman is in between 40-50 years and post-menopausal age. Increasing longevity of life to beyond seventy years of age means that women will spend a third of their life span after menopause. Planning for this stage of life is necessary so as to enjoy a good quality of life. Tremendous progress has been made in understanding the menopause and manifest bodily changes that follows after cessation of menstruation. Knowledge of the effects of oestrogen decline on the genital tract and various other parts of the body has enabled health caregivers to prescribe hormones, provide information on nutrition and other interventions for health and wellbeing. Currently most women know the beneficial effects of oestrogen on bone metabolism and atrophic vagina and also are aware of the correct indications for its use.

This book on menopause became a reality after seeing an increase in women seeking care as they grow older. Women are now forthcoming with complaints related to dry vagina, hot flashes, night sweats and urinary symptoms. Treating these ailments and disturbances improves quality of life. The chapters in the book attempts to answer as many questions as possible that may go through the mind of the menopausal woman.

The author has tried not to be biased in his views in use of oestrogen therapy and has drawn on current thoughts about benefits and controversies surrounding medical hormone therapy. Some of the comments are based on views expressed by professional bodies and consensus statements. Women should be well equipped with accurate information to make their own decisions and choices in selecting treatment options. Cultural and social influences also affect the attitudes and views of such decisions.

A variety of gynaecological and psychological disorders are seen in the older woman. Career change, retirement, relationship with family and bodily changes also impact on the woman’s attitude to life after the menopause. Coping with internal conflicts and external stresses after the menopausal are not directly related to either aging or hormonal deprivation but that which comes with changed circumstances in family and society. Cognitive-behaviour therapy and counselling are used to tackle such problems in improving health and adapting to life during this stage.

As one grows older one would also succumb to age related diseases like hypertension, diabetes and obesity. Woman would be consulting a number of experts for each of the ailment. Taking control of her body and life hence involves deriving sufficient knowledge of both wellness and illness so that the woman stays in the driving seat in deciding best treatment options or combination of treatments with advice from health carers. Attention to good nutrition, regular exercise and management of stressors are equally important.

Sivalingam Nalliah

INTRODUCTION

In many ways the menopause appears to be the ‘ragged’ inverse image of menarche i.e the first menstrual cycle a women experiences in her life. The young adolescent starts menstruating around 10-12 years of age. She sprouts into womanhood through the influence of the hormones especially oestrogen. The vital female hormone begins to increase in its production as the ovaries come ‘alive’ from the time the girl is about 10 years old, influencing several target organs especially the female genital organs and the breasts. By the time she reaches 12 years of age, this powerful hormone exhibits it effect in an overt manner on the skin and breasts. As breasts develop, other visible changes occur in the young girl. Armpit hair and pubic hair development are easy to note. The gradual evolution of the uterus and vagina to prepare for the reproductive phase of life is eventually exhibited with the onset of regular menstruation.

Two hormones, oestrogen and progesterone, work in synchrony to carry through the reproductive capabilities for the next three or so decades in their own peculiar waxing and waning patterns. As the patient enters the mid-forties, a gradual decline in oestrogen levels become evident as the ovaries age and become atrophic. Bodily changes are gradual in onset with a transition phase beginning well before the recognition of menopause (the last menstrual cycle). The terms ‘climacteric’ or ‘perimenopause’ is use to describe this transition phase. Ovaries become functional in menarche but the opposite occurs in the perimenopausal period when the ovaries become senescent and exhaust themselves of ‘eggs’. They ‘shrivel’ and stop producing adequate amounts of the female hormones, especially oestrogen.

Do we call the phase of life after menopause the end of the reproductive life or the beginning of a new phase of estrogen deficiency? Should we categorize the phase of life after the menopause a clinical entity that requires treatment as it is well recognised that physical and biochemical changes occur with ageing and there are observable manifestations related to the menopause? The genital organs ‘flourished’ under the influence of female hormones at puberty and thereafter but after the menopause the uterus shrinks and becomes smaller, menstruation halts and the bones become brittle. Oestrogen appeared to protect the woman during the reproductive age from heart disease but this no longer remains true after menopause. The prevalence of coronary heart disease catches up with that of men, age for age. However, a great number of women especially from Asia traditionally accept the changes that come with menopause as natural events and can’t see what the fuss is about. Some find it disturbing in turning such a natural event into a disease that needs to be treated.

The phases of life in an adult woman

Table%201.1.jpg

Source: The Stages of Reproductive Aging Workshop (STRAW) staging system, Fertility and Sterility 76:874-878, 2001)

Advances in medicine led to a critical appraisal of hormones in the body and their relationship to functions. Endocrinologists and doctors interested in women’s health now consider the oestrogen deficient state after the menopause as a treatable disease state. Hormone therapy appears to be appropriate to overcome the clinical manifestations due to oestrogen deficiency as oestrogen has been shown to be effective treating hot flashes and vaginal dryness. It appears to be a wonder drug in establishing a state of wellbeing, while protecting against bone loss and even coronary heart disease. This purported Robert A. Wilson to pen a book Feminine Forever in an effort to explain the possibility of women to lead an extended state of youthfulness for decades after the menopause.

Health managers are concerned about the immense cost involved in hospitalization, surgery and aftercare of bone fractures in older women as a result of osteoporosis, a treatable disease through use of oestrogen! From the economic point of view treatment of osteoporosis could reduce the prevalence of osteoporosis related fractures.

The miseries of menopause appear to rapidly disappear with restoration of oestrogen levels in the blood. Several claims that oestrogen replacement would also protect menopausal women against mental deterioration, mood swings and Alzheimer’s disease was in vogue in the 1980s and 1990s but careful scientific evaluation suggests that this association is much more complicated to justify prescribing oestrogen. Positive effects on skin texture making it ‘plump and moist’ together with improvement of sexual function with application of oestrogen to the vagina have seen the increasing number of oestrogen preparations in the market.

Not all menopausal women elect to go on this hormone. In fact, when the use of oestrogen was at its height in the 1990’s, less than 50% complied to long term therapy. The idea of being on a drug for several years does not appear acceptable to many. Attitudes to menopause vary between women and in different cultures. The spectre of cancer seems to halt prolonged oestrogen use. Are these risks real or imagined? Advocates of oestrogen therapy give conflicting views. ‘Benefits outweigh risks’ say many who are convinced that women will have a better quality of life with oestrogen.

The ultimate answer will lie on the wishes of the target population—menopausal women. Receptors on to which the oestrogen molecule docks in the body are found in over 300 different tissues. Current users of oestrogen and potential users should know about the wonders and risks of hormones prescribed in menopause. Where do the priorities lie? Is quality of life so badly affected that there is a need for oestrogen replacement? For instances, if hot flashes are incapacitating, there is a definite role for short term oestrogen therapy. In this context we are discussing a disease entity and not a phase of life. On the other hand, if the patient is a breast cancer survivor, alternatives to oestrogen may be preferred.

Counselling the menopausal woman on the various effects of menopause should be directed to bodily changes and the beneficial effects that oestrogen replacement has. Apart from focussing on oestrogen therapy directed counselling on avoiding obesity and attention to life style changes is essential. Smoking should cease and regular exercises are encouraged. Advice on nutrition, addressing stress factors and identifying depressive illness are Important for better health after the menopause.

Average Life Expectancy in Selected Countries

Source: The World: Life Expectancy (2013)

Chapter 1

HORMONES IN MENOPAUSE

In the 19th Century women rarely lived beyond the fifth decade of life. This scenario has changed rapidly. Current estimates indicate that women are living longer than men. In Malaysia the expected life span of women is 74.2 years. If the age of menopause is about 50 years of age, one can expect women to spend one third of their life span in the menopausal years.

The menopause is the eventual cessation of menstruation, an event that is clearly realized. The female child is born with about 400,000 follicles or potential eggs in the ovaries. However, not all will become functional. In fact only about 480 ‘eggs’ are eventually released during the lifetime of the women after puberty. The follicular stimulating hormone (FSH) produced and stored in the brain (hypothalamus and pituitary) plays an active role in maturation of these ‘eggs’ each month. In human females, usually only one ‘mature egg’ is eventually released (ovulation) each month under the influence of another hormone called the luteinizing hormone (LH), also produced and released by the pituitary and hypothalamus. The remaining follicles that do not get recruited through the ensuing complex biochemical processes in the ovary become the ‘corpus luteum’ which produces progesterone. If the ‘mature follicle’ released by the ovary is fertilized by a sperm (in the fallopian tube), the lining of the uterus needs to be ready to receive the fertilized egg after a few days. The preparation of the uterine lining (endometrium) is completed by the progesterone that is released by the corpus luteum.

Hence two major hormones operate synchronously during the menstrual cycle to enable the uterus to eventually receive and grow the fertilized ovum. The dominant hormone during the first half of the menstrual cycle is oestrogen. After ovulation, progesterone becomes dominant as described above. The endometrium hence grows thicker under the influence of oestrogen and progesterone. Should pregnancy fail to occur, the corpus luteum shrivels, rarely lasting not more than 14 days? At the end of this period, if pregnancy fails to occur, menstruation will result from sloughing off the endometrial lining completing a 28 day menstrual cycle. The whole cycle is repeated the following month with follicular stimulating hormone recruiting a new cohort of ‘follicles’ for maturation and eventual release of one mature follicle at ovulation under the influence of luteinizing hormone. As one can see there is such fine synchrony between hormones FSH and LH produced by the pituitary glands acting on the ovaries and oestrogen and progesterone produced by the ovaries influencing the endometrium of the uterus to facilitate ovulation, fertilization and eventual implantation of the embryo in the uterus.

The menstrual cycle begins after menarche and continues till the end of reproductive life when menopause sets in at about 50 years of age. As the ovaries are endowed with a ‘predetermined number of follicles ‘at birth, follicles become depleted with each menstrual cycle. This explains the eventual loss of function of the ovaries at the end of the reproductive cycle leading life with an oestrogen depleted state after menopause.

fig%201.1

Fig. 1.1 Female hormones and the menstrual cycle

THE MENOPAUSE

The ovaries clearly are invested with a fixed number of potential follicles from birth and this declines in number as a woman ages after menarche. Each menstrual cycle depicts that pregnancy has not occurred with ultimate loss of a huge number of follicles. Hence with advancement of age approaching the menopause very few potential follicles remain. By the time a woman attains 50 years almost all the follicles are gone and the ovary becomes much smaller in size (ATROPHY OF THE OVARIES). Not much oestrogen is produced by the atrophic ovaries and hence has little or no effect on the lining of the uterus (endometrium). This culminates in cessation of menstruation and onset of menopause.

MENOPAUASE is derived from two words-MENO referring to month and PAUSE referring to cessation.