The Management of Menopause
The Management of Menopause
September 2, 2024
Joy Stepinski, MSN, RN-BC
With the process of aging, women journey from their childbearing years to the stage of menopause. The cessation of menstrual periods marks this life transition, although perhaps more publicly discussed is the arrival of hot flashes. The health literature is filled with suggestions on combating the physiological effects women experience as they reach this milestone. Yet menopause is one stage of a woman’s life. Does it need to be managed? We will take an in-depth look at menopause and its effects on women’s health.
Menopause is a natural phenomenon, defined as “permanent termination of ovarian function and menses” [1, p.17]. While this change may seem like a distinct time, the decline of ovarian function begins when women are in their thirties. The number of follicles, which contain the unfertilized eggs, is reduced. Estrogen and progesterone decrease and women experience irregular menses in the time known as perimenopause (before menopause). Around age 50, only a few follicles remain.
Several physiological changes take place [2]. Certain organs (i.e., breast, uterus, ovaries) diminish their response to reproductive hormones. As a result, the ovaries atrophy. The tissues of the vulva lose their elasticity and the mucus membranes become thinner and drier. The vaginal mucosa undergoes similar changes, while the vaginal pH becomes more alkaline. The uterus shrinks to one-fourth of its premenstrual size.
One of the significant changes in menopause relates to the three types of estrogen. Estradiol starts decreasing two years before menopause and stabilizes about two years after. Estriol is mostly active during pregnancy when it increases 1,000 times [3]. Estrone is most abundant during menopause [1]. Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) normally stimulate the production of estrogen, progesterone, and some testosterone in women, important for reproduction. During menopause, these hormones increase, causing the body to shift estrogen production by decreasing estradiol and increasing estrone.
Health literature describes an abundance of symptoms related to the “diagnosis” of menopause. Some include joint and muscle aches, sleep disruption, depression, irritability, inability to concentrate, poor memory, and decreased libido. Yet even prestigious journals like The Lancet heed caution to the over-medicalization of this natural process [4]. In an editorial published earlier this year, the author describes that menopause is frequently considered a disease of “estrogen deficiency.” As a result, menopausal hormone therapy (MHT) is prescribed as a treatment without much discussion of the risks involved.
In the early part of the 20th century, reproductive hormones were identified. Premarin was one of the first hormone replacement therapies (HRT) developed by a Canadian pharmaceutical company called Ayerst, McKenna, and Harrison [5]. An estrogen complex was isolated from the urine of a pregnant mare in 1938, which led to the naming of the drug. Wyeth, the pharmaceutical company that merged with Ayerst, filed a trademark in 1943 and marketed the drug as Premarin. Indications include hot flashes, vaginal dryness, and osteoporosis prevention.
The widespread use of HRT has been of concern in recent history. In 2022, the United States Preventive Services Task Force (USPSTF) issued a final statement that hormone therapy should not be used for primary prevention of chronic conditions in postmenopausal women [6]. Although these drugs were recommended for women to prevent fractures, estrogen therapy (especially the kind found in oral conjugated equine estrogen) is associated with significant harm. Examples include gallbladder disease, stroke, and deep vein thrombosis [7]. Women taking estrogen-progestogen replacement had experienced the highest rate of breast cancer when beginning treatment within five years of menopause [8]. One study published by the Cochrane Database of Systematic Reviews stated that urinary incontinence worsened when women used systemic hormone replacement therapy of conjugated equine estrogen [9].
Interestingly, not every culture experiences menopausal symptoms. One cross-sectional study [10] researched 118 postmenopausal Mayan women in Yucatan, Mexico. The women denied feeling hot flashes or any other symptoms related to menopause, leading the author to conclude that environment, diet, and other factors may play a role. Another cross-sectional survey of Japanese women in 1983 – 1984 showed that the meaning of menopause is not the same as in Western cultures. “Culturally this has little significance, and distressing symptoms are not usually linked in the Japanese minds to the lack of menses” [11].
The Women’s Health Study, of more than 17,000 postmenopausal women, showed that sustained weight loss over one year decreased or eliminated hot flashes and night sweats. Those who decreased fat intake and consumed more vegetables, fruits, and whole grains also reduced symptoms [12]. A cross-sectional population-based study of 749 women ages 45 to 60 showed that menopausal symptoms were associated with obesity [13]. Hot flashes, joint and muscle pain, and urinary urgency increased with body mass index.
Soy is one type of food that may help to reduce hot flashes. Soy contains phytoestrogen, a kind of estrogen found in plants. Phytoestrogens bind weakly to estrogen receptors of the breast, uterus, and ovaries preventing these cells from being overstimulated by human estrogen. Therefore, soy and other phytoestrogen-containing foods (i.e., flax seed, garlic, dried dates, sunflower seeds) are protective. While American women tend to eat diets low in phytoestrogens, Asian women consume a range of 30 to 100 mg daily. These women are thought to experience 30% less hot flashes. In fact, one author reports that no words exist to describe hot flashes in Japanese because the symptom is rarely experienced [14].
In addition to diet and weight loss, exercise is another lifestyle factor that can reduce menopausal symptoms. One review of 23 studies between 2020 and 2022 concluded that women who engage in moderate-intensity exercise can reduce hot flashes [15]. Another study of 21 women found that cardiovascular exercise decreased hot flashes. This may be due to the effect that exercise has on thermoregulation [16].
Finally, mental health is another topic often tied to menopause. One author describes that menopause may elicit the reappearance of unresolved conflict from earlier in life [11]. With the end of fertility, women may experience and grieve the loss of the inability to bear children. Although this time may bring stressors related to role transitions, such as the illness or death of a parent, it does not increase depressive symptoms, anxiety, or major depressive disorder. This conclusion is based on cohort studies of more than 100 participants between the years 1990 to 2023 [17].
Returning to the initial question, does menopause need to be managed? Anthropologist Margaret Lock observed menopause had been of interest to the medical community for the past 100 years. Labeled a disease of estrogen deficiency, HRT was the prescribed treatment. Menopausal women were “seen as an anomaly, an unforeseen and unnatural result of cultural adaptations” [11]. Yet many women have lived to age 90 for at least 100,000 years. Women’s bodies were created to undergo this process. Her research with Japanese women led her to conclude that “menopause is not a disease, but a life-cycle transition to which powerful symbolic meanings, individual and social, are attached.” Menopause is more than a medical diagnosis that requires management.
Menopause is a natural part of life. Bodies need tender loving care. Eating whole foods with plenty of vegetables, fruits, and whole grains; exercising regularly; and reducing stress support health and the transition to menopause.
References
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