Menopause is a natural and inevitable period of a woman's life, it is not a disease. When a menstruating woman does not have a menstrual period for at least 12 months, regardless of other reasons, it is called menopause. In menopause, there is a decrease in ovarian function, a decrease in blood levels of estrogen and other hormones, and a permanent loss of fertility. During the transition years to menopause, a woman's natural menstrual periods begin to extend longer than 7 days. Some changes occur in the female body. Hot flashes are one of the most important of these. Every woman experiences menopause differently. While some have little or no complaints, others may have very intense psychological and physical complaints. Here, the woman's knowledge about menopause, her acceptance of menopause, and cultural and genetic influences play an important role.

Perimenopause

These are the transition years to menopause. It covers a period approximately 6 years before the last menstrual bleeding. These are the years when menopause-related changes begin in the female body. Irregular menstrual bleeding, hot flashes, vaginal dryness and emotional changes are common complaints of perimenopause. A woman can become pregnant during perimenopause, albeit with a low chance. Therefore, if pregnancy is not desired, birth control practices should not be abandoned during this period.

What is natural menopause?

The spontaneous cessation of menstruation, regardless of any disease or medical practice, is called natural menopause. The natural menopause age range is 42-58. The average age of menopause in Western societies is 51. Although there is no very precise data on this subject in our country, we can say that it is in the 47-50 age range. About 10% of women enter menopause under the age of 40, and 0,1% under the age of 30. The natural age of menopause is determined by genetics and smoking. Women who smoke enter menopause 1.5-2 years earlier on average.

Every woman experiences menopause differently, but what is common to all is that 'menopause creates a unique opportunity to review a woman's health and organize her later life'.

Can menopause be created artificially?

Yes. It may occur as a result of various treatments or surgeries. Cancer chemotherapies (drug treatments) or radiation treatments to the lower abdomen cause significant damage to the ovaries. Menopause may occur after these treatments. Additionally, surgical removal of both ovaries due to medical necessity also results in menopause. Here, the complaints are much more severe than in natural menopause. Because blood hormone levels have suddenly dropped. The need for treatment of menopausal complaints in these women is much higher than in women experiencing natural menopause. They should also be closely monitored for health problems such as vaginal dryness and osteoporosis that may occur in the future.

What is early menopause?

Whether it occurs naturally or artificially, when a woman reaches menopause before the age of 40, it is called early menopause. Genetic factors or medical treatments may affect early menopause. Since the ovarian functions are interrupted very early, the woman will be deprived of the protective effects of the estrogen hormone on the body (heart diseases and osteoporosis) for many years. In addition, sudden and unexpected cessation of menstruation and loss of fertility will cause serious psychological trauma, especially for women who want to have children. This would be devastating for a woman who equates fertility with femininity and sexuality.

Sometimes the condition called premature ovarian failure (premature ovarian failure) may develop due to excessive stress, excessive exercise, excessive weight loss or various medications. Once these effects disappear, 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 menstrual periods until the age of natural menopause.

What is the postmenopause period?

The period a woman lives 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 are called early postmenopause, and the period from 5 years until death is called late postmenopause.

How to determine if a woman has entered menopause?

The first symptoms in women in their forties are menstrual irregularities and hot flashes. Menopause is diagnosed when a woman does not have a menstrual period for 12 months. 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. During perimenopause, FSH levels fluctuate. A single FSH increase during this period should not be mistakenly considered as menopause.

What are the risks and benefits that menopause brings to women's life?

First, let's talk about the risks. If a woman has insufficient knowledge about menopause and thinks that stopping menstruation will cause significant deficiencies in her femininity and sexual life, she will experience menopausal complaints much more intensely. This perception will negatively affect the woman's sexual life and create a depressive emotional state. Due to the decrease in estrogen hormone, dryness will occur, especially in the vagina, and the osteoporosis process will accelerate. The woman will be deprived of the protective effects of 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, a woman who has generally taken care of her children until then will be able to be protected from many diseases and spend the rest of her life happier and more enjoyable.

To achieve this, women's perception of menopause as 'the end of womanhood' needs to be changed. Women who receive adequate medical care can lead a satisfactory sexual life for many years after menopause. For this, it is necessary to prevent atrophy that will develop in the vagina. Women who have annual smear and mammography checks, cervix and if breast cancer is caught very early, it can be easily treated. Diseases such as diabetes and goiter can be diagnosed early with blood tests at annual check-ups. A woman who is in constant contact with a gynecologist and obstetrician abnormal bleeding In this way, any uterine cancer that may develop can be diagnosed very early, and thus its 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. But the most important factor known to affect the age of menopause is smoking. In smokers, menopause occurs on average 1.5-2 years later. The age of menopause in non-smoking women will extend by 1,5-2 years. Apart from this, women continue to have regular menstrual periods as a result of hormone treatments given due to menstrual irregularities and hot flashes during the transition years to menopause. But this does not mean that menopause is prevented. Because when the hormone medications given are stopped and the FSH level in the blood is examined, it will be seen that it is above menopause levels. Thanks to hormone treatments during the transition to menopause, women will experience this important period of life more comfortably and will be protected from heart diseases, osteoporosis, and vaginal dryness that causes pain during sexual intercourse.

What is the latest situation in menopause medications?

In recent years, the variety of drugs that can be used for menopause has increased. If we 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.). Here, treatment should be planned with the lowest possible estrogen dose. If the woman has had her uterus 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 each month to reduce the side effects of estrogen on the uterus.

2- Estrogen preparations administered through the skin:

It reduces general side effects that may occur orally. Patches (Estroderm, Climara, etc.) applied 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 need to be applied every day. If the woman's uterus has not been removed, progesterone hormone should be added to the treatment for 12 days each month.

3- Estrogen drugs administered vaginally:

Vaginal cream (Ovestin, Premarin vag. Cream) is applied to the vagina every day. It is mostly used for vaginal atrophy (dryness). Once a certain effectiveness is achieved in the treatment, application once a week will be sufficient. The effectiveness of vaginal rings (Estring, Femring vag. ring) is up to 1 days. It secretes a certain amount of estrogen hormone into the vagina every day. It has ease of use. Vaginal tablets (Vagifem vag. tab) are also applied once every day. Monthly injection-shaped estrogen preparations are not available in our country.

4- Combined hormone drugs containing estrogen and progesterone:

They are especially preferred drugs in women who have entered natural menopause and whose uterus has not been removed. Trisequens, Activelle, Anjeliq taken orally are examples of these drugs. While Trisequens is used during the menopausal transition period, others are preferred during the postmenopause period. Activelle and Anjeliq are drugs with low hormone levels. Estracombi and Climara Pro patches can be given as examples of combined drugs in the form of adhesive patches. Estracombi fasters are applied twice a week and Climara Pro is applied once a week.

5- Medicines containing only Progesterone hormone:

In cases where estrogen administration is undesirable, medications containing only progesterone can be given. Provera tab, Progestan tab for oral use. are examples of these. Hormonal coils (Mirena) also secrete small amounts of progesterone hormone every day. There are also medications in the form of vaginal cream (Crinone gel). The absorption of progesterone this way is much higher than its absorption by mouth.

Does starting menstruation with treatments during the menopause transition really delay a woman's age at menopause?

No. Menstruation with medications given during the transition to menopause does not extend the woman's natural age of menopause. However, it will treat hot flashes and vaginal dryness that occur in women during this period, and will also reduce the risks of osteoporosis, heart diseases and colon cancer.

What are the most common complaints during the menopausal period? Should one go to a psychiatrist for these?

We can classify these complaints as hot flashes, sleep disorders, headache, changes in memory and concentration, depression and anxiety disorders. There is no need to consult a psychiatrist immediately for these discharges.

Hot flashes

Hot flushes are the most common complaint during menopause. It is thought to occur due to the interaction of temperature regulation centers in the brain with hormonal changes. However, it should be known that hot flashes will not only be due to menopause. Diseases such as thyroid, infection, cancer and medications such as tamoxifen (used for breast cancer) and raloxifene (used for osteoporosis) may also cause hot flashes. The severity of hot flashes varies from woman to woman. While in some cases it may appear as a vague complaint, in others it may cause severe distress in the woman's social life. It usually takes about 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:

• First of all, precautions such as avoiding hot environments, not using a hair dryer, staying away from hot drinks, alcohol, caffeine and cigarettes can be applied.
• Regular exercise reduces stress and ensures comfortable sleep.
• Working and especially bedrooms should be kept cool.

Some plant-derived weakly estrogenic drugs (phytoestrogens derived from soy) can reduce hot flashes by 30%. Women with severe complaints may be given hormone treatments, antidepressant medications and some blood pressure medications.

Sleeping disorders

Some women may experience sleep disturbances, especially during nighttime hot flashes. An adult of this age needs to sleep approximately 6-9 hours on average. In case of sleep disorders, simple precautions should be taken first. These are approaches such as avoiding heavy dinners, reducing light and noise, and lowering the temperature of the bedroom. 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 performed in other areas of the house. Morning waking times, including weekends, should be regular, regardless of bedtime at night. If sleep disorders do not improve despite all these measures, causes such as thyroid diseases, allergy, anemia, restless legs 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

Headaches, changes in memory and concentration, depression and anxiety disorders are common during menopause. Headache can occur for various reasons. Infection, dental problems, stress, allergies, emotional changes and environmental changes are some of them. Hormonal changes can also cause headaches. Women who have headaches during menstrual periods and while using birth control pills are more likely to experience headaches during menopause. Headaches related to hormones go away when menstruation is completely stopped. If you have a new-onset and severe headache, if it gradually gets worse, if it is more severe than usual, if it wakes you 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 decline 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 menopause through surgery, which we call surgical menopause. Emotional changes, depression and feelings of distress are common during the menopausal period. before in women premenstrual tension syndrome If the menopausal transition period lasts for a long time or if symptoms such as hot flashes are very severe, the risk of depressive complaints increases. Women should consult a psychiatrist for depressive complaints that do not improve with hormone treatments.

LATE MENOPAUSE

The average age of natural menopause in women is between 48-52 years. There is no exact age defined as the age of late menopause. However, entering menopause after the age of 54-55 can be considered late menopause.

Why do women age rapidly during menopause?

As the estrogen hormone production of the ovaries decreases 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 advancing age, changes occur in the skin and connective tissue. Skin aging begins in the 30s. Aging, which progresses slowly between the ages of 30 and 70, accelerates after the age of 70. In this process, the amount and structure of collagen, which forms the basis of connective tissue, changes. The decrease and coarsening of collagen makes the skin thinner, while the decrease in the amount of hyaluronic acid causes it to dry and wrinkle. Estrogens increase collagen synthesis in the skin. It also accelerates the synthesis of hyaluronic acid and provides moisture and vitality to the skin.

As can be understood from this information, estrogen deficiency in menopause leads to acceleration of negative changes in 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 older ages, osteoporosis occurs because destruction is greater than construction. Osteoporosis (bone loss) is a disease that progresses with a decrease in bone tissue in the skeletal system and a corresponding increase in the risk of bone fractures. There are two types of osteoporosis in women. Type I or menopausal osteoporosis occurs within the first 15-20 years after the cessation of menstruation. With estrogen deficiency, the activity of cells that provide bone formation decreases, whereas the activity of cells that accelerate destruction increases. It is characterized by increased bone destruction, in which the balance of bone formation and destruction is disrupted in favor of destruction. With the acceleration of bone resorption in the menopausal period, the structure of the female body changes, bones weaken and height becomes shorter. Type II osteoporosis begins around age 35 and lasts throughout life.

Why are heart attacks, cancer and osteoporosis increasing after menopause?

Although cardiovascular diseases are less common in women, they are among the most common causes of death in both genders. While cardiovascular diseases are more common in men than in women under the age of 50, they begin to be seen at the same rate in both genders in the post-menopausal years (after the age of 50). This is due to some protective effects of estrogen in women. Estrogen has significant effects on blood lipids, especially in women. Although LDL-cholesterol (bad cholesterol) is lower in women than in men before menopause, there is no difference between the two genders after menopause.

The situation is the opposite for benign cholesterol (HDL cholesterol). Although it is more common in women than in men before menopause, it decreases slightly after menopause. With estrogen treatments given after menopause, total cholesterol and harmful cholesterol (LDL) decrease, whereas beneficial cholesterol (HDL) increases significantly. In addition, the estrogen hormone also has a positive effect on the functions of the internal vascular structure. The risk of heart attack increases in women who are deprived of the positive effects of the estrogen hormone after menopause.

The increase in breast, uterine, ovarian and colon cancer in the post-menopausal years is entirely related to the age of the woman. Estrogen hormone in breast, uterus ve ovarian cancers It has no protective effect on the skin. However, it is known that estrogen therapy given after menopause slightly reduces the occurrence of colon cancer in women. Osteoporosis (bone loss) increases rapidly after menopause. Menopausal osteoporosis, which we call Type I osteoporosis, begins in the 50s and lasts for 15-20 years. The construction and destruction of bones continues throughout life. Estrogen hormone stimulates the cells that build bones and suppresses the cells that destroy them. As the estrogen hormone decreases in menopause, the process of bone destruction accelerates and osteoporosis increases. Menopause is an important period when women should have health screenings.

Cholesterol medications are harmful during menopause. From where? What other drugs are dangerous to use?

During menstrual years, the estrogen hormone in women makes a positive contribution to blood cholesterol levels. It lowers bad cholesterol (LDL) and increases good cholesterol (HDL). When this positive effect of estrogen disappears with menopause, bad cholesterol (LDL) in women increases and good cholesterol (HDL) decreases. 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, risks to the liver may increase in women who use both cholesterol medications and hormone medications. For this reason, it is necessary to check liver enzymes frequently, initially monthly, in these patients. These drugs should never be used in patients with a known liver disease. Cholesterol medications can be easily used in menopausal women who do not use hormone therapy and do not have a known liver disease. Apart from this, there is no group of drugs that are harmful to use during menopause.

Is it right for Gynecologists and Obstetricians to prescribe osteoporosis medications? What side effects do these medications have?

The construction and destruction of bone is a lifelong process. Type I osteoporosis in women begins in the 50s with menopause and lasts for 15-20 years. In other words, during this period, the rate of destruction exceeds the speed of construction. The most important factor in this is the lack of estrogen hormone. In these years, women who apply to Gynecologists and Obstetricians are required to undergo smear, mammography and some blood tests as well as osteodensimetry for health screening purposes. If osteoporosis is detected in these scans, treatment can be started after investigating causes such as thyroid, parathyroidism, chronic renal failure, and long-term corticosteroid drug use.

One of the most effective treatment methods for menopausal osteoporosis is estrogen administration. Today, the most important known benefits of estrogen hormone therapy are on menopausal hot flashes, vaginal dryness and osteoporosis. Because 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 harmful. We also use other osteoporosis medications in women for whom this treatment is not sufficient during follow-up. These medications can also be prescribed by Gynecologists and Obstetricians. There is no harm in this. Osteoporosis medications are used long-term. Of course, some side effects may occur with long-term use. The most obvious known side effects are on the gastrointestinal system. It is unsafe to use these drugs in women with gastrointestinal system diseases such as ulcers and gastritis.

MENOPAUSE AND SEXUAL LIFE

Does a woman no longer want sex during menopause?

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:

1. Hormonal changes: With menopause, the hormones estrogen, progesterone and testosterone secreted from the ovaries in women decrease. Estrogen hormone affects libido (sexual desire) indirectly, while testosterone hormone affects it directly. Therefore, the decrease in these hormones will reduce sexual desire in women.
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2. Changes in the vulva and vagina: With menopause, tissue elasticity in this area decreases and dryness, which we call atrophy, begins. If left untreated, sexual intercourse may be difficult, pain and bleeding may occur during intercourse. For these reasons, in women who avoid sexual intercourse, after a while the size of the vagina changes, it becomes shorter and narrower. Thus, sexual intercourse becomes even more difficult. However, if the woman is adequately treated during this period and does not lose her motivation for sexual intercourse, she can continue her sexual intercourse for many years without experiencing any significant problems.
3. Other body changes that affect sexual life: Some of these changes include weakening of muscle and connective tissue and pelvic structures, decreased size and tension in the breasts, drying and thinning of the skin due to connective tissue changes, thinning of hair, and male-type hair growth in some areas. These changes make the woman feel less sexually desirable.
4. Changes in weight and fat distribution: Weight gain and fat storage in the waist area, which are generally observed after menopause, will negatively affect a woman's perception of her own sexuality. The second factor is the negative perception in society towards sexuality at older ages. In our society, there is generally a negative perception towards sexuality at older ages. If a woman is affected by this perception, her sexual desire will naturally decrease with the contribution of the difficulties she experiences in her sexual life. Lack of sexual desire, which is seen in 30-40% of women considering all age groups, increases after menopause. However, if a woman has accurate 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 security system pay for in vitro fertilization treatment after the age of 40? Medicine allows it, why don't the laws allow it?

Infertility is both a health problem and a social problem in our country. Especially in rural areas, couples begin to feel the pressure of their close circle to have children from the moment they get married. On average, about 15% of couples face infertility problems. Unfortunately, women pay the biggest price for couples experiencing infertility problems. Generally, women who do not have economic freedom may lose their marriages just for this reason. Therefore, 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. However, very strict restrictions have been placed here. While the success rate of an in vitro fertilization application is around 20-30% for women aged 35-40, this rate drops to 40% at the age of 10.

Additionally, pregnancies over the age of 40 are risky for both the mother and the baby. While diseases such as hypertension and gestational diabetes increase in the mother, the possibility of chromosomal anomalies in the baby also increases. Due to both the decrease in the chance of success and the risks for the mother and baby, the social security system, which has to use its resources correctly, does not cover in vitro fertilization treatments for women over 40.

How is it affected by men when a woman enters menopause?

As we get older, some problems will occur in the sexual life of both men and women.

These Ones;

1. Decreased sexual desire
2. decreased arousal
3. Decrease in orgasm
4. Difficulties in sexual intercourse
5. Erectile problems in men.

Problems in women are more evident than in men. Because women experience much faster changes during menopause. Women who receive medical help during this period can cope with problems more easily. Especially if a woman receives hormone therapy, it will reduce the changes that will occur in her body. Painful sexual intercourse due to vaginal dryness can be easily prevented with appropriate treatment. The relationship between the couple also helps overcome these problems. Couples who maintain their emotional ties to each other can show the harmony necessary to overcome the difficulties they face. A woman who receives understanding from her husband does not have negative perceptions about her own sexuality and does not restrict her sexual life as a vicious circle.

For example, the foreplay period can be extended due to low arousal in the woman. Erectile problems in men can be resolved with various orgasm methods. On the contrary, couples who do not have an emotional bond have a high chance of struggling 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 the man after a while. In couples who cannot empathize with each other's problems, solving sexual problems will be difficult.

How can we compare male andropause with female menopause?

Menopause is the permanent cessation of menstruation after a transition period of 5-6 years. Cessation of menstruation means that the hormone production of the ovaries decreases significantly and fertility is lost. Therefore, women experience very significant hormonal, physical and psychological changes during menopause. Although hormonal changes are the same in almost every woman, physical and psychological changes vary. A woman who suddenly loses her fertility may change her perceptions of her own sexuality. If we add to this the negative view of sexuality in older ages in society, a negative picture will emerge.

The period called andropause in men is different from that in women. In men, there is no such thing as a sudden loss of hormone production and reproductive ability. On average, hormone levels in men remain stable until the age of 50. Starting from these ages, it shows a slow decline over the years until the ages of 75-80. In other words, compared to women, men of the same age group experience milder changes over a longer period of time. For this reason, men do not experience the problems that women experience due to sudden hormone decreases. With advancing age, men may experience problems such as decreased sexual desire, decreased hair growth, weakness, weakness in muscle and connective tissue, sweating, irritability, erection problems, and difficulty concentrating. In these cases, if male hormone levels are below a certain level, then these complaints can be resolved by giving additional testosterone hormone.