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Menopause in Women and Men:  Solutions to the Disquiet of Middle Age

Feelings of internal heat or perception of hot belly are not the only symptoms of menopause. As we shall see later, the distress caused by the change in reproductive function during middle age is huge and can be disabling.     Women suffer needlessly when they don’t realise the changes that is going on in them. When a person is well informed biologically, the burden of the changes will be less.  There is no doubt that menopause causes a lot of unease but a lot of women sufferers do not often realise the cause of their symptoms and very frequently blame the feelings on something else even to the point of accusing others of persecution. So far, I have directed my attention in this article towards women. However, evidence, albeit not generally accepted yet, is gradually emerging to say that men also suffer from “menopause”. Thus, in the coming weeks, I will be dealing with menopause primarily in women but with some degree of devotion to “menopause” in men at latter stages. To date both in medical circles and in public minds, the term menopause is generally applicable to women. With this in mind, let us now get on with the task of dealing with preliminaries of menopause in women: First, the definitions. These definitions , taken in part from International Menopause Society, will guide us in our way when we begin to have our discussions under menopause. Natural Menopause: This is simply the term that is used to indicate that a woman has ceased to have her menstrual periods and her ovaries are no longer functioning to produce hormones to support her so as to be able to reproduce and bear children naturally. To qualify as having reached menopause, a woman’s menstrual period must have stopped for at least for the last 12 consecutive calendar months. Pre-menopause: This term means, anytime before the arrival of menopause. Very often it means anytime from the adolescence to end of reproductive age. Peri-menopause: This means the few years before menopause and up to one year after the last menstrual period. Climacteric simply means transition from the period of being able to reproduce to that time when the woman is no longer being able to reproduce. It’s the change over time. Post-Menopause: this is the term that doctors use to indicate the time that comes after menopause. Premature Ovarian Failure (POF): This term is reserved for the event that occurred in a woman who is under 40 years old whose ovaries have failed to continue to function. This failure to function may be as a result of natural occurrence or due to disease states that is inherited from own parents. A lot of the reasons for POF are due to genetic diseases.  It may also be due to a situation when the ovaries are surgically removed. In some other occasions, it may be due to conditions whereby the woman is treated for cancer. Such treatment may be an exposure of the ovaries to chemotherapy or radiotherapy. Surprisingly, POF may occur as a consequence of cigarette smoking.  Premature ovarian failure may also be due to common infections such as tuberculosis of the reproductive tract.  In some cases, the failure of ovaries to continue working may be as a result of no specific or identifiable conditions. Induced menopause: Menopause can be natural or brought upon the individual by artificial means. When menopause is not natural, then it’s induced.  Such unnatural occurrence of menopause is called Induced menopause. This induction can be due to administration of medications such as chemotherapy for treatment of cancer or exposure to radiotherapy because of the need to bring a cancer under control.  Induced menopause may also be as a result of surgical operations during hysterectomy (removal of womb with or without removal of ovaries) carried out by medical doctors. Now that we have taken care of the necessary definitions that relate to menopause, we can begin the proper task of elaborating on the very distressing matter of menopause. We shall begin this by looking at the causes of menopause and what the sufferers feels (symptoms) as well as the signs. We shall also address the investigations. Remember that we had earlier defined natural menopause simply as the term that is used to indicate that a woman has ceased to have her menstrual periods and her ovaries are no longer functioning to produce hormones to support her so as to be able to reproduce and bear children naturally. To qualify as having reached menopause, a woman’s menstrual period must have stopped for at least for the last 12 consecutive calendar months. We also saw earlier menopause may not be natural or it may be induced. Whatever the cause, to qualify as being in menopause:  a woman’s period “must have stopped for at least for the last 12 consecutive calendar months” backed up relevant laboratory investigations.  I will encourage the reader to go back to Part 1 of this series so as to get familiarize with the necessary and guiding definitions. Causes of Menopause:  The first thing to realise in all these discussions is that, aging process is inevitable.  However, natural menopause occurs on the average, in a woman in the age range of 45-52 but most commonly around 48-52years. At this age range, the ovaries may stop to respond to the instructions or stimulations from the brain. By not responding, there will be no ovulation. As a matter of fact, after ovulation which occurs at about the mid cycle in a woman who has a 28-day cycle, pregnancy is suppose to result. It’s the failure of pregnancy to result that leads to menstrual period. This event is repeated every month. Therefore, when the ovary fails to respond to the said instructions as I said above, there will be no menstrual period. This lack of response is essentially due to aging process and the woman’s timed biological clock. Anything outside the above natural menopause could either be a pre-mature ovarian (POF) resulting in early premature menopause or menopause that is induced.  POF may be due to no specific cause which scientists are yet to discover. POF may result from a genetic defect in the individual which the woman may have inherited from her parents.  POF may also be due to tuberculosis of her reproductive tract. In some cases, POF may be due to treatments that the woman may have received from the doctors. Such treatments are often directed at cancers and may be chemotherapy or radiotherapy. Cigarette smoking is another cause. In some individuals, autoimmune diseases may the cause whereby the body works against its own interest and body defences start to attack the body organs.  Individuals who have undergone a long time ovarian stimulation for in-vitro fertilization (IVF) to resolve infertility may also suffer premature ovarian failure and hence early menopause. Yet, there are other causes such as endometriosis whereby the menstrual flow instead of flowing outside the woman’s body through the vagina, flows inward back into the body. Outside these listed factors, surgical intervention to remove the womb or uterus may lead to early menopause. Obviously, outright removal of the ovaries without question results in menopause. How does perimenopausal and menopausal women present? What do they feel? Unfortunately in our African and indeed Nigerian cultures, some women especially if she suffers from infertility or she is under pressure not to appear as “old” may hide her symptoms and suffer in silence.  Such women may want to prove to her husband (and in polygamous homes prove to her contemporaries), that she is still in her fertile age and that she can bear still children.  Some women are in self-denial and may want to continue to have her menstrual periods as a false sign of continuing fertility. That said, about 80% of women undergoing perimenopause or menopause or climacteric suffer considerably. Sadly only about 10-20% of them world-wide including Nigeria may come forward. Some women make the assumption that, menopause is “part of a woman’s life” even if she is suffering greatly. The main symptom of fluctuating hormone in a woman is called hot flush which the main feeling of perimenopause and menopause. The hot flush, or flash, is well known as the classic menopausal symptom and affects 60–85% of menopausal women. Hot flushes and sweats constitute vasomotor symptoms and vary immensely in both their severity and duration; for many women, they occur occasionally and do not cause much distress, but for about 20% they can be severe and can cause significant interference with work, sleep and quality of life. Women are affected by vasomotor symptoms on average for about 2 years but, for about 10%, symptoms can continue for more than 15 years. Hot flushes usually last 3–5 minutes and are thought to be caused changes in the brain’s thermoregulator , according to Menopause Matters. In some women, with or without hot flushes, sleep could be impaired. She may become irritable—a “short fuse”, anxious and even depressed and lacking in concentration. In those with tendency but hidden vulnerability toward frank madness, serious mental illness may manifest as this age of menopause. The bones become weak and as a result, fractures of the hip and hands and back may occur in menopausal and post-menopausal women. As part of the symptoms or feelings that comes with perimenopause and menopause even up to postmenopause, the mouth may become dry and hot as well as painful. There may be colour changes in the mouth as it become pale. In some women, there could be changes in the manner of eating either too high or too low or general dislike for food. Of major concern to a lot of women is loss of their skin smoothness which becomes slack. Wrinkles appear. This is as a result of loss of the underlying fat underneath the skin. This loss may give the appearance of aging and loss of beauty. This is probably the reason that makes women to put in more efforts at this age to appear and maintain being beautiful and acceptable. Amongst other reasons, divorce and separation are common in menopausal and post-menopausal times. Still, menopause gives rise to a much more concerning symptoms. In the reproductive tract itself, vagina loses its elasticity and lubrication. As a result, difficulty with sex may emerge. These challenges with sex may drive a wedge between couples if not properly managed.  Further, the womb itself will shrink. At this time, any fibroid within the womb (uterus) may also correspondingly be reduced in size.  The womb lining may also dry up or be reduced in size. A note of warning and caution: Any woman, who had stopped having her period or be in post menopause but now having irregular vaginal bleeding, should as a matter of priority see her medical doctor for advice. The reason is that cancer of the womb lining (endometrium) may be the reason for the irregular vagina bleeding. That said, the ovaries also become smaller during menopause. Again, I must sound the note of caution here for two reasons here. The first is that, in spite of what I have written so far, break-through or occasional pregnancy may still occur. Women will need to take caution and not make a mistake believing that she is no longer menstruating and so not being fertile. Unwanted pregnancy can be heart-breaking.  The second point is that, though the ovaries had shrunken in size, and as the years go by, there remains a risk that the ovary may develop cysts and cancers. Post menopausal women should therefore be vigilant to irregular vaginal bleeding, abdominal swelling and unusual body appearances. Still on the symptoms of menopause and perimenopause and even post menopause, the bladder and urine passages may lose their strengths. Urging to go to toilet and loss of ability to control passing urine during stress such as coughing may now be a problem. The women simply wet her self. This may create considerable social problem for the woman and her family.  She may become an object of ridicule if the people around her fail to understand her difficulties. In some other circumstances, the womb may fall out (prolapsed) into outside world through the vagina as a result of the weakening of the supporting structures that hold the womb in place. In general, perimenopause due to variation of the hormone levels in the woman poses considerable changes. These difficulties may continue into menopause and climacteric times.  Of crucial concern lies the fact that the larger African society and in particular Nigerian cultures may not fully understand the many problems that menopausal and peri-menopausal women go through. In rural cultures or even in cities, such women may be stigmatised or be called abusive names for lack of understanding of the events that is taking place in the woman. Investigations: Very often, the diagnosis of peri-menopause or menopause can be made by the doctor purely on history. Therefore, the woman should tell her story in full to her doctor.  Her husband, if married or partner can and should ideally accompany her to see the doctor. The man is probably going to be the target of the woman’s irritability that menopause had brought upon her and as such he is at vantage point to give an eye witness account and state his experience of the development. The reader should not be surprised that the tests to diagnose menopause is few and sometimes may nor even require a test. The doctor is well advised that the only test is follicle stimulating hormone (FSH) levels. With exception to where the clinical necessity so indicates, there is no need for ultrasound scan or unnecessary prodding or extensive and expensive investigations to make a diagnosis of menopause. Crucially, I wish to seriously encourage women that may be undergoing the symptoms and feelings that I have described here to consider seeing a doctor. There is really no sense in suffering in silence.   The main symptom of menopause in women is hot flushes (see earlier articles).  This symptom of hot flushes can be corrected with the hormone that is so deficient in women at their  mid-ages. Doctors, based upon clinical assessment may prescribe hormone replacement therapy (HRT) which comes in different formulations. Some can be taken by mouth as a daily pill similar to contraceptive pill. A note of warning is warranted here. HRT is not a contraception or anti-pregnancy pill. As earlier warned, women should still take precaution so as not to get pregnant.  Please note that this statement is not to be interpreted to mean that a woman’s fertility has returned with us of HRT. It’s not so. HRT can also be taken as a patch or vagina cream. While on HRT, women that have not had hysterectomy (removal of the womb),  may resume having regular menstrual periods. Again, this is not an indication that fertility has been restored.  The menstrual period is just the consequence of the way the HRT works. HRT may be continued for up to 5 years. HRT is not without own risk. Anyone with personal history of breast cancer, blood clotting, severe liver disease, undiagnosed vaginal bleeding and pregnancy should not take HRT. The HRT that I have described here is a combined hormones of estrogen and progesterone. For women who have had their womb removed, they may use a different form of HRT: estrogen alone. In all, because of the risks outlined, women intending on using HRT should consult their doctor for guidance before commencing usage. Vaginal dryness leading up to difficult sex may be relieved with either a lubricating cream such as K-Y jelly or estrogen cream. Urinary symptoms may also be relieved by HRT. Low sexual drive that is not helped by HRT may respond to male hormone testosterone. Risk of bone fractures which occurs in 1 person in 20 amongst Nigerian women undergoing menopause, can also benefit from HRT or a non-hormone treatment. However, good nutrition rich in vitamins, vitamin D and calcium, but cautiously taken, may reduce fractures. For individuals in whom HRT is not suitable, there are reasonable alternatives that may be used as a substitute. If mental health deteriorates during perimenopuase and menopause, attending doctors will take appropriate measures to address the problem. A cheaper form of treatment is for the woman to receive counselling and education of the changes that is taking place in her body. The key issue is not to deny ones suffering nor refusing to see a doctor for support. Distress and disquiet brought upon by perimenopause or menopause is not just a “woman’s thing” and neither should women suffer in silence!

“Menopause” in Men. Clearly, unlike women, men do not have menstrual periods. Therefore, the definition of male “menopause” is controversial and disputable. The claim of existence of male menopause is still at research stage. That said, there are some features that men in their mid-ages experience which gives rise to the suspicion that men may also be experiencing features that women suffer from. These features include: tiredness, weakness, depression and sexual problems such as loss of libido, erectile dysfunction: impotence or ejaculatory problems: collectively otherwise called mid-life crisis which may come with career changes.  Most crucially, it has been observed that in their mid-ages, men do have a low testosterone and like women, a boosting of their respective hormone levels may actually improve the symptoms that are outlined above.

It’s important to note that unlike in women who may experience inability of their ovaries to produce follicles and estrogen , men do not suffer from their testes stopping to produce sperms and testosterone.  Men may in fact continue to produce sperms well into their late eights though subtle changes occur in the testes around 45-50years of age in men. As outlined, men experiencing fatigue, depression, erectile dysfunction, low sex drive should seek medical help. Investigations in the laboratory may not yield much as the changes in men are not as dramatic as in women.  The doctor may nonetheless undertake a thorough examination to exclude any underlying faults. Treatment of male “menopause” while controversial is not without benefits: What I will call male HRT may also help. This HRT may essentially consist in giving a measure of testosterone. It should be noted that giving artificial testosterone carries its own risk and caution should be thoroughly exercised. In summary, women mainly experience menopause and I will urge those suffering from fluctuations in their hormone levels from the age of 40 in some and 45-52years in others should seek help and not be subdued by cultural considerations. Discomfort and disquiet should not be accepted. Similar advice is applicable to men.


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