Menopause is a natural and inevitable period of a woman’s life, not a disease. The absence of a menstrual period for at least 12 months, regardless of other reasons, is called menopause. Menopause is characterized by decreased ovarian function, decreased blood levels of estrogen and other hormones, and a permanent loss of fertility. During the transition years of menopause, women’s natural menstrual periods begin to lengthen to for more than 7 days. There are some changes in the female body. Hot flashes are one of the most important of these. Every woman experiences menopause differently. Some may have few or no complaints, while others may have very intense psychological and physical complaints. Here, the woman’s knowledge about menopause, her acceptance of menopause, cultural and genetic effects play an important role.
These are the transition years to the menopause. It covers a period of about 6 years before the last menstrual bleeding. These are the years when changes related to menopause begin in the female body. Irregular menstruation, hot flashes, vaginal dryness and emotional changes are common complaints of perimenopause. A woman can become pregnant during perimenopause, albeit with a low chance. For this reason, if pregnancy is not desired, it is necessary not to abandon birth control practices during this period.
What is natural menopause?
The spontaneous cessation of mentruation periods, regardless of any disease or medical practice, is called natural menopause. The natural menopause age is between 42-58. The average age of menopause in Western societies is 51. In our country, although there is not very precise data on this subject, we can say that it is between the ages of 47-50. About 10% of women go through menopause under the age of 40 and 0.1% under the age of 30. Genetics and smoking determine the natural age of menopause. Smoking women enter menopause 1.5-2 years earlier on average.
Every woman experiences menopause differently, but the common truth for all is that ‘menopause creates a unique opportunity to review women’s health and organize later life’.
Can menopause be created artificially?
Yes. It can occur as a result of various treatments or surgeries. Cancer chemotherapy (drug therapy) or radiation therapy to the lower abdomen causes significant damage to the ovaries. Menopause can occur after these treatments. In addition, surgical removal of two ovaries due to medical necessity also results in menopause. Here the complaints are much more severe than in natural menopause, because of the sudden decrease in blood hormone levels. The need for treatment of menopausal complaints in these women is much higher than in women who experience natural menopause. They should also be followed closely in terms of health problems such as vaginal dryness and osteoporosis that may occur in the later periods.
What is early menopause?
Whether it is naturally or artificially experienced, a woman’s menopause before age 40 is called premature menopause. Early menopause can be affected by genetic factors or medical treatments. Since ovarian functions are interrupted very early here, women will be deprived of the protective effects of the estrogen hormone in the body (heart diseases and osteoporosis) for many years. In addition, sudden and unexpected cessation of menstruation and loss of fertility will create very serious psychological trauma, especially for women who want to have children. This will be devastating for a woman who has an understanding that equates fertility with femininity and sexuality.
Sometimes so called early ovarian failure (premature ovarian failure) may develop due to excessive stress, excessive exercise, excessive weight loss or various medications. With the removal of these effects, menstruation may begin again. In this situation, which we call temporary menopause, the ovaries return to their normal functions and the woman can continue to have her menstruation until the natural menopause age.
What is the postmenopausal (after menopause) period?
The period in which a woman has lived since her last menstrual period is called the post-menopausal period. Medically, this period can be divided into two sub-periods. The first 5 years from the last menstrual period is called the early postmenopausal period, and the period from 5 years to the death is called the late postmenopausal period.
How to determine that a woman has reached menopause?
The first symptoms in women in their forties are menstrual irregularities and hot flashes. The absence of menstruation for 12 months is the diagnosis of menopause. Some hormones in the blood also help us here. If blood FSH levels are constantly above 30 mIU/mL, we can say that this woman has entered menopause. FSH levels fluctuate during perimenopause. One time FSH elevation in this period should not be mistakenly considered as menopause.
What are the risks and benefits that menopause brings to a woman’s life?
Let’s consider the risks first. If the woman’s knowledge about menopause is insufficient and she thinks that cessation of menstruation will cause significant deficiencies in her femininity and sexual life, she will experience menopausal complaints much more intensely. This kind of perception will negatively affect the sexual life of the woman and create a depressive emotional state. Due to the decrease in estrogen hormone, dryness will occur especially in the vagina, and the osteoclasis process will accelerate. The woman will be deprived of the protective effects of her estrogen against heart disease. Despite all these negativities, it is possible to turn the menopause period into an opportunity for women’s life. By knowing her own body, taking care of her health, and having annual screening checks done, the woman who has usually taken care of her children until then, will be able to protect herself from many diseases and spend the rest of her life more happily and enjoyably.
For this, first of all, it is necessary to change the perception of the ‘end of femininity’ by women during the menopause period. Women who receive adequate medical care can have a satisfactory sex life for many years after menopause. For this, first of all, atrophy that will develop in the vagina should be prevented. Women who have their annual smear and mammography checks can be easily treated if cervical and breast cancer is detected at a very early stage. Diseases such as diabetes and goiter can be diagnosed early with blood tests in annual controls. The woman, who is in constant contact with a gynecologist and obstetrician, will report any abnormal bleeding to her physician, and thus, uterine cancer that may develop can be diagnosed very early, and therefore the treatment can be carried out successfully.
Can menopause be prevented?
Menopause occurs as a result of the depletion of cell structures in the ovaries that produce hormones and ensure the menstrual cycle. Therefore, it is not possible to prevent the depletion of these cell structures. However, the most important factor that is known to affect the age of menopause is smoking. Menopause comes to the fore by an average of 1.5-2 years in smokers. The age of menopause in non-smokers will increase by 1.5-2 years. Apart from this, women continue to have regular menstruation as a result of hormonal treatments given due to menstrual irregularities and hot flashes during the transition years to menopause. But this does not mean that menopause is prevented. If the hormone drugs given are stopped and the FSH value in the blood is examined, it will be observed that it is above the menopausal values. Thanks to hormone treatments during the transition period to menopause, women will spend this important time of life more comfortably, and they will be protected from heart diseases, osteoporosis and vaginal dryness that causes pain during sexual intercourse.
What is the latest situation in menopause drugs?
In recent years, the variety of drugs that can be used for menopause has increased. We can examine them by dividing them into groups;
1- Oral estrogen pills:
There are pills containing pure estrogen that can be used orally in various doses (Premarin tab, Estrofem tab, etc.). The treatment hereto with the lowest possible estrogen dose should be planned. If the woman’s uterus has been removed (surgical menopause), pure estrogen pills should be used alone. If the uterus has not been removed, then progesterone-containing pills should be added for 12 days every month to reduce the side effects of estrogen on the uterus.
2- Estrogen preparations administered through the skin:
It reduces the general side effects that can occur by mouth. Patches (Estroderm, Climara, etc.) attached to the thigh or waist area once or twice a week provide ease of use. It can also be applied in the form of creams (EstroGel) that are absorbed through the skin. These creams should be applied every day. If the woman’s uterus has not been removed, progesterone hormone should be added to the treatment for 12 days a month.
3- Vaginally administered estrogen drugs:
Vaginal cream (Ovestin, Premarin vag. Cream) is applied to the vagina every day. It is mostly used for vaginal atrophy (dryness). Once a certain efficacy is achieved in the treatment, it will be sufficient to apply it once a week. The effectiveness of vaginal rings (Estring, Femring vag. ring) is 90 days. It secretes a certain amount of estrogen hormone into the vagina every day. It has ease of use. Vaginal tablets (Vagifem vag. tablet) are also administered once a day. Estrogen preparations in the form of monthly injections are not available in our country.
4- Combined hormone drugs containing estrogen and progesterone:
They are especially preferred for women who have gone through natural menopause and whose womb has not been removed. Oral Trisequens, Activelle, Anjeliq are examples of these drugs. Trisequens are used in the menopausal transition period, while others are preferred in the postmenopausal period. Activelle and Anjeliq are drugs with low hormone values. Estracombi and Climara Pro tapes can be given as examples of combination drugs in the form of adhesive patches. Estracombi adhesive patches are attached twice a week, and Climara Pro once a week.
5- Medicines containing only Progesterone hormone:
In cases where estrogen administration is undesirable, only progesterone-containing drugs can be given. Oral Provera tab, Progestan tab. are examples of these. Hormone spirals (Mirena) also secrete a small amount of progesterone every day. There are also drugs in the form of a vaginal cream (Crinone gel). Absorption of progesterone in this way is much higher than oral absorption.
Does menopause with treatments during the transition to menopause really delay a woman’s menopause age?
No. Menstruation with drugs given during the transition to menopause does not prolong the natural menopause age of the woman. However, it will treat hot flashes, vaginal dryness, and reduce the risks of osteoporosis, heart diseases, and colon cancer in women during this period.
What are the most common complaints in the menopausal period? Should I go to a psychiatrist for these?
We can classify these complaints as hot flashes, sleep disorders, headache, changes in memory and concentration, depression and distress disorders. It is not necessary to immediately consult a psychiatrist for these discharges.
Hot flashes in menopause are the most common complaint. It is thought to occur due to the interaction of the heat regulation centers in the brain with hormonal changes. But it should be known that hot flashes are not only related to menopause. Diseases such as thyroid, infection, cancer, and drugs such as tamoxifen (used in breast cancer) and raloxifene (used in osteoporosis) can also cause hot flashes. The severity of hot flashes varies from woman to woman. In some of them, it is in the form of vague complaints, while in others, it can put the social life of the woman into serious trouble. It usually takes 3-5 years. The severity of hot flashes decreases over time. There are treatment options for people with severe complaints.
First of all, lifestyle changes should be implemented.
- Primarily, measures such as avoiding hot environments, not using a hair dryer, avoiding hot drinks, alcohol, caffeine and smoking can be applied.
- Regular sports reduce stress and provide comfortable sleep.
- It should be ensured that the study and especially the bedrooms are cool.
Some herbal weak estrogenic drugs (phytoestrogens from soy) can reduce hot flashes by 30%. Women with severe complaints may be given hormone treatments, antidepressants, and some blood pressure medications.
Some women may experience sleep disturbances, especially during nighttime hot flashes. An adult at this age needs to sleep an average of 6-9 hours. Simple measures should be taken first in sleep disorders. These are approaches to avoiding heavy dinners, reducing light and noise, and lowering the bedroom temperature. Reducing alcohol, coffee and cigarette consumption will improve sleep quality. The bedroom should only be used for sleep and sexual activities. Other activities should be carried out in other areas of the house. Morning wake-up times, including weekends, should be regular, regardless of bedtime. If sleep disorders do not improve despite all these precautions, causes such as thyroid diseases, allergy, anemia, restless leg syndrome, depression and sleep apnea should be investigated. If the cause of insomnia is depression, the woman should consult a psychiatrist.
Central Nervous System Disorders
Headache, changes in memory and concentration, depression and distress disorders are common during menopause. Headache can occur for various reasons. Infection, dental problems, stress, allergies, emotional changes, environmental changes are some of them. Hormonal changes can also cause headaches. Women who complain of headache during menstrual periods and while using birth control pills are more likely to have headache during menopause. Headaches associated with hormones disappear with the complete cessation of menstruation. If there is a new onset and severe headache, if it is getting worse, if it is more severe than usual, if it wakes up from sleep, if it is accompanied by fever, medical help should be sought. If migraine occurs during hormone therapy, the hormone should be discontinued.
Memory and other mental capacities decrease with age. This process may accelerate with menopausal complaints. It is generally accepted that hormone treatments have positive effects in this process. The effect of estrogen on brain capacity is more pronounced, especially in women who have undergone surgical menopause. Emotional changes, depression and feelings of distress are common in the menopausal period. If a woman has premenstrual tension syndrome, if the menopausal transition period lasts for a long time, or symptoms such as hot flashes are very severe, the risk of depressive complaints increases. A woman should consult a psychiatrist for depressive complaints that do not improve with hormonal treatments.
The average age of natural menopause for women is in the range of 48-52. There is no definite age range defined as late menopause age. However, entering menopause after the age of 54-55 can be considered as late menopause.
Why do women age rapidly in menopause?
With the decrease in estrogen hormone production by the ovaries in menopause, age-related changes in the body accelerate. The most obvious of these are changes in the skin and connective tissue, changes in the skeletal system, and changes in the cardiovascular system. With aging, changes occur in the skin and connective tissue. The aging of the skin begins in the 30s. Aging, which is slow between the ages of 30-70, accelerates after the age of 70. In this process, the amount and structure of collagen, which forms the basis of the connective tissue, changes. The decrease and coarsening of collagen thins the skin, while the decrease in the amount of hyaluronic acid causes it to dry and wrinkle. Estrogens increase collagen synthesis in the skin. In addition, by accelerating the synthesis of hyaluronic acid, it provides moisture and vitality in the skin.
As can be understood from this information, the estrogen deficiency in menopause leads to the acceleration of negative changes in the connective tissue and skin. Estrogen hormone treatments given to women during menopause can significantly prevent or even reverse these negative changes. If we talk about the positive effects of estrogen on the skin; It increases the amount and quality of collagen, which gives strength and flexibility to the tissue, increases the thickness and vascularity of the skin, and corrects the structures responsible for the appearance and tension of the skin. Changes in the skeletal system during menopause are also important. Construction and destruction of bone tissue continues throughout life.
In advanced ages, bone resorption is seen because the destruction is more than the production. Osteoporosis (bone loss) is a disease that progresses with a decrease in bone tissue in the skeletal system and, accordingly, an increase in the risk of fracture in bones. There are two types of osteoporosis in women. Type I or menopausal osteoporosis occurs in the first 15-20 years after cessation of menstruation. With estrogen deficiency, the activity of cells that produce bone decreases, whereas the activities of cells that accelerate destruction increase. It is characterized by increased bone destruction, in which the balance of bone formation-resorption is impaired in favor of destruction. With the acceleration of bone resorption in the menopausal period, the structure of the female body changes, the bones weaken and the height becomes shorter. Type II osteoporosis begins around the age of 35 and lasts for life.
Why do heart attacks, cancer and osteoporosis increase after menopause?
Although cardiovascular diseases are less common in women, they are among the most common causes of death in both genders. Under the age of 50, cardiovascular diseases are more common in men than in women, while in the post-menopausal years (after 50 years), it begins to be seen at the same rate in both sexes. This is due to some protective effects of estrogen in women. Estrogen has important effects especially on blood fats in women. Although LDL-cholesterol (bad cholesterol) is found in lower proportions in women before menopause than in men, there is no difference between the two sexes after menopause.
In good cholesterol (HDL cholesterol), the situation is reversed. Although it is more common in premenopausal women than in men, it decreases slightly after menopause. Total cholesterol and harmful cholesterol (LDL) decrease with estrogen treatments given after menopause, while beneficial cholesterol (HDL) increases significantly. In addition, estrogen hormone has a positive effect on the functions of the vascular structure. The risk of heart attack increases in women who are deprived of the positive effects of estrogen hormone with menopause.
The increase in breast, uterus, ovarian and colon cancers in the postmenopausal years is completely related to the age of the woman. There is no protective effect of estrogen hormone on breast, uterine and ovarian cancers. However, it is known that estrogen therapy given after menopause somewhat reduces the occurrence of colon cancer in women. Osteoporosis (bone loss) increases rapidly after menopause. Menopausal osteoporosis, which we call type I osteoporosis, starts at the age of 50 and lasts for 15-20 years. Construction and destruction of bones continue throughout life. Estrogen hormone stimulates the cells that produce bone formation and suppresses the cells that cause destruction. With the decrease of estrogen hormone in menopause, the destruction process in bones accelerates and bone resorption increases. Menopause is an important period when a woman should have health screenings.
Cholesterol medications are contraindicated during menopause. Why? Which other drugs are inconvenient to use?
During the menstrual years, the estrogen hormone in women makes a positive contribution to blood cholesterol levels. It lowers bad cholesterol (LDL) and raises good cholesterol (HDL). When this positive effect of estrogen disappears with menopause, bad cholesterol (LDL) rises and good cholesterol (HDL) decreases in women. As a result, while the rate of cardiovascular diseases is lower than men until the age of 50, this rate becomes equal after menopause. Of course, cholesterol-lowering drugs can be used in women at risk. The most important side effect of these drugs is on the liver.
Hormones used during menopause are also metabolized in the liver. Therefore, the risks on the liver may increase in women who use both cholesterol drugs and hormone drugs. For this reason, it is necessary to check liver enzymes frequently, monthly at first, in these patients. In patients with a known liver disease, these drugs should definitely not be used. Cholesterol drugs can be used easily in menopausal women who do not use hormone therapy and do not have a known liver disease. Apart from this, there is no drug group that is objectionable to use during menopause.
Is it right for gynecologists and obstetricians to prescribe osteoporosis drugs? What side effects do these drugs have?
Bone formation and destruction is a lifelong process. Type I osteoporosis in women begins at the age of 50 with menopause and lasts for 15-20 years. In other words, in this period, the rate of destruction exceeds the rate of construction. The most important factor in this is the lack of estrogen hormone. In these years, in addition to smear, mammography, and some blood tests, bone resorption scanning (osteodensimetry) is also requested for health screening purposes in women who apply to the Obstetrics and Gynecology Specialist. If osteoporosis is detected in these scans, treatment can be started after investigation of causes such as thyroid, parathyroid, chronic kidney failure, long-term use of corticosteroid drugs.
Estrogen is one of the most effective treatment methods in menopausal osteoporosis. Today, the most important benefits of estrogen hormone therapy are on menopausal hot flashes, vaginal dryness and osteoporosis, because the estrogen hormone increases bone formation and slows down the rate of destruction. Therefore, we prefer this treatment primarily in patients for whom estrogen use is not objectionable. In the follow-up, we also use other osteoporosis drugs in women for whom this treatment is not sufficient. These drugs can also be prescribed by Gynecologists and Obstetricians. There is nothing wrong with that. Osteoporosis drugs are used for a long time. Of course, some side effects may occur with long-term use. The most obvious known side effects are on the gastrointestinal system. It is inconvenient to use these drugs in women with gastrointestinal system diseases such as ulcers and gastritis.
MENOPAUSE AND SEXUAL LIFE
In menopause, does the woman no longer want sex?
There are two main factors that negatively affect the sexual life of menopausal women. The first factor is significant changes in the female body. As a result of these changes, some changes occur in the sexual life of menopausal women. These changes can be summarized as follows:
- Hormonal changes: With menopause, estrogen, progesterone and testosterone hormones secreted from the ovaries in women decrease. The hormone estrogen affects libido (sexual desire) indirectly, while the hormone testosterone directly affects it. Therefore, the decrease in these hormones will decrease sexual desire in women.
- Changes in the vulva and vagina: With menopause, tissue elasticity in this area decreases and dryness, which we call atrophy, begins. If it is not treated, there will be difficulties in sexual intercourse, pain and bleeding may occur during intercourse. For these reasons, the size of the vagina changes, shortens and narrows after a while in women who avoid sexual intercourse. Thus, sexual intercourse becomes more difficult. However, during this period, if the woman is adequately treated and does not lose her motivation for sexual intercourse, she can continue her sexual relationship for many years without experiencing any significant problems.
- Other body changes that affect sexual life: Some of these changes are weakening of the muscles and connective tissue, pelvic structures, reduction in size and tension in the breasts, drying due to connective tissue changes in the skin, thinning of the hair, and male pattern hair growth in some areas. These changes cause the woman to feel less sexually desirable.
- Changes in weight and fat distribution: Weight gain and fat storage in the waist area, which are generally observed after menopause, will negatively affect the perception of women’s own sexuality. The second factor is the negative perception towards sexuality at advanced age in the society. In our society, there is generally a negative perception towards sexuality in old age. If the woman is affected by this perception, naturally, with the contribution of the difficulties she experiences in her sexual life, her sexual desire will decrease. When all age groups are considered in women, low sexual desire, which is seen at the rate of 30-40%, increases after menopause. However, if the woman has the right information about menopause and receives adequate medical treatment, she can easily cope with the problems in her sexual life and continue a satisfactory sexual life.
Why doesn’t the social insurance system pay for IVF treatment after the age of 40? Medicine allows it, why doesn’t the law allow it?
Infertility is both a health problem and a social problem in our country. Especially in rural areas, couples begin to feel child pressure from their close circles from the moment they get married. On average, 15% of couples experience infertility problems. Unfortunately, women pay the biggest price for couples with infertility problems. Often women who do not have economic freedom can lose their marriage just because of this. For this reason, the social security institution covers the treatment costs of the in vitro fertilization method, which is the last stage in the treatment of infertility, which is an important health and social problem for our country. But there are very definite restrictions set here. While the success rate in an IVF application is 35-40% in women aged 20-30, this rate drops to 10% at the age of 40.
In addition, 40-year-old pregnancies are risky for both mother and baby. While diseases such as hypertension and gestational diabetes increase in the mother, the probability of chromosomal anomaly increases in the baby. Due to the decrease in the chance of success and the risks for the mother and the baby, the social security system, which has to use its resources correctly, does not cover IVF treatments for women over 40.
How is a man affected when a woman goes through menopause?
As age progresses, there will be some problems in the sexual life of both women and men.
- Decreased sexual desire,
- Decreased arousal,
- Decrease in orgasm,
- Difficulties in sexual intercourse, and
- Erectile dysfunction in men.
Problems in women are more pronounced than in men, because women experience a much faster change in menopause. During this period, women who receive medical help can cope with problems more easily. In particular, the woman’s taking hormone therapy will reduce the changes that will develop in her body. Painful sexual intercourse due to vaginal dryness can be easily prevented with appropriate treatment. The relationship between the couple also helps to overcome these problems. Couples who maintain their emotional bond with each other can show the necessary harmony to overcome the difficulties they face. A woman who perceives understanding from her husband does not have negative perceptions about her own sexuality and does not restrict her sexual life in the form of a vicious circle.
For example, the period of foreplay can be extended for low arousal in women. Erectile dysfunction in men can be eliminated with various orgasm methods. On the contrary, couples who do not have emotional bonds have a high chance of faltering in the face of these problems. A woman who feels pain and burning during sexual intercourse will gradually try to avoid intercourse and keep the duration of intercourse short, which may cause sexual problems in men after a while. In couples who cannot empathize with each other’s problems, the solution of sexual problems will become more difficult.
How can we compare men’s andropause with women’s menopause?
Menopause is the permanent cessation of menses after a 5-6 year transition period. Cessation of menstruation also means a significant decrease in hormone production by the ovaries and loss of fertility. Therefore, very prominent hormonal, physical and mental changes are seen in women with the menopause period. Although hormonal changes are the same in almost every woman, physical and mental changes show differences. A woman who suddenly loses fertility may change her perception of her own sexuality. If we add to this the negative view of sexuality at advanced age in society, a negative picture will emerge.
The period called andropause in men is different from that in women. There is no such thing as a sudden loss of hormone production and reproductive ability in men. On average, up to the age of 50, the hormone levels in men are stable. From these ages, it shows a slow decline over the years, until the age of 75-80. In other words, men of the same age group experience milder changes over a longer period of time than women. For this reason, men do not experience the problems women do due to a sudden decrease in hormones. With advancing age, problems such as decrease in sexual desire, decrease in hair growth, loss of strength, weakness in muscle and connective tissue, sweating, irritability, erection problems, and difficulty in concentration can be observed in men. In these cases, if the male hormone levels are below a certain level, then these complaints can be eliminated by administering additional testosterone hormone.