FEMALE REPRODUCTIVE ORGANS
The ovaries are the main reproductive organs of a woman. The two ovaries, which are about the size and shape of almonds, produce female hormones (oestrogens and progesterone) and eggs (ova). All the other female reproductive organs are there to transport, nurture and otherwise meet the needs of the egg or developing fetus. The ovaries are held in place by various ligaments which anchor them to the uterus and the pelvis. The ovary contains ovarian follicles, in which eggs develop.
The fallopian tubes are about 10 cm long and begin as funnel-shaped passages next to the ovary. They have a number of finger-like projections known as fimbriae on the end near the ovary. When an egg is released by the ovary it is caught by one of the fimbriae and transported along the fallopian tube to the uterus. The egg is moved along the fallopian tube by the wafting action of cilia (hairy projections on the surfaces of cells at the entrance of the fallopian tube) and the contractions made by the tube.
The uterus is a hollow cavity about the size of a pear (in women who have never been pregnant) that exists to house a developing fertilised egg. The main part of the uterus (which sits in the pelvic cavity) is called the body of the uterus, while the rounded region above the entrance of the fallopian tubes is the fundus and its narrow outlet, which protrudes into the vagina, is the cervix.
The thick wall of the uterus is composed of 3 layers.
It is the inner layer of the uterus. If an egg has been fertilised it will burrow into the endometrium, where it will stay for the rest of its growth. The uterus will expand during a pregnancy to make room for the growing fetus. A part of the wall of the fertilised egg, which has burrowed into the endometrium, develops into the placenta. If an egg has not been fertilised, the endometrial lining is shed at the end of each menstrual cycle.
It is the large middle layer of the uterus, which is made up of interlocking groups of muscle. It plays an important role during the birth of a baby, contracting rhythmically to move the baby out of the body via the birth canal (vagina).
The vagina is a fibromuscular tube that extends from the cervix to the vestibule of the vulva. The vagina receives the penis and semen during sexual intercourse and also provides a passageway for menstrual blood flow to leave the body.
WHAT FUNCTION IS PERFORMED BY THE OVARIES?
The ovaries are the main reproductive glands in a woman and are located in the pelvis region. The ovaries produce eggs (ova) and female hormones like estrogen. Each menstrual cycle represents the release of an egg from one ovary. The egg travels from the ovary through the fallopian tubes to the uterus.
Various female hormones control the development of female body characteristics like the breasts, body shape and body hair. Ovaries are the main source of female hormone and are important for women health. The hormones also regulate the menstrual cycle and pregnancy. Hormone estrogen also protects the bone. Therefore, a woman can develop osteoporosis (thinning of bone) later in life when her ovaries do not produce adequate estrogen.
The Ovulation Process
Ovaries produce female eggs in addition to the hormones.Once a follicle is mature, it ruptures and the developing egg is ejected from the ovary into the fallopian tubes. This is called ovulation. Ovulation occurs in the middle of the menstrual cycle and usually takes place every 28 days or so in a mature female. It takes place from either the right or left ovary at random.
When an egg is released by the ovary it is caught by one of the fimbriae (finger like projections o the fallopian tubes near the end towards the ovary) and transported along the fallopian tube to the uterus. The egg is moved along the fallopian tube by the wafting action of cilia (hairy projections on the surfaces of cells at the entrance of the fallopian tube) and the contractions made by the tube.
It takes the egg about 5 days to reach the uterus and it is on this journey down the fallopian tube that fertilization may occur if a sperm penetrates and fuses with the egg. The egg, however, is only usually viable for 24 hours after ovulation, so fertilization usually occurs in the top one-third of the fallopian tube.
WHAT IS A MENSTRUAL CYCLE IN A WOMAN?
The menstrual cycle is the correct term for the cycle (usually monthly) in which a woman’s body releases an egg, prepares itself for fertilization of the egg by sperm. An environment is then created in the womb in which the fertilized egg could implant and form a developing embryo (baby). If the egg is not fertilized, the lining of the womb is shed from the body in what are commonly known as a “woman’s periods”.
Girls start to have their periods (menstruate) around the age of 12, usually about 2 years after the breasts first start to develop, and will continue having periods until the menopause, which occurs, on average, at about the age of 51. The age of onset of menstruation and menopause may depend on various factors like diet, genetics etc.
The length of the menstrual cycle can vary from a short cycle of only 21 days to a long cycle of 40 days. The length of the cycle is calculated by counting the first day of bleeding as day 1 and then counting until the very last day before the next bleed (period). The length of the menstrual cycle is commonly described as 28 days, although this may be true for only one in 10 women.
The menstrual cycle is generally thought of in separate phases.
- The menses (bleeding or periods):
This period commonly lasts from day 1 to day 5 and may vary by a day in some women.
During this phase, if fertilization of the egg has not happened, the lining of the womb or uterus, which is called the endometrium, comes away from the uterus wall and the blood and tissues pass out via the vagina. Most women bleed for between 3 and 5 days. The lining of the endometrium will end up about 1 mm thick at the end of the period. As well as the loss of the endometrial tissue, about 35 to 50 ml of blood is lost from the broken endometrial blood vessels in a typical period. This blood does not usually clot unless bleeding is very heavy.
- The follicular phase
This phase is so-named because it is when the follicles in the ovary grow and form an egg. About 3 to 30 follicles grow between days 8 and 10. Each follicle contains an egg, but by days 10 to 14 one follicle has overtaken the rest and has reached the correct stage of maturity.
During days 6 to 14, the lining of the uterus is repaired and, as can be seen on the diagram, builds up to be thicker. This is why this phase is also known as the proliferative phase. This is stimulated by estrogen secreted from the ovaries. The lining of the uterus will now be about 3 mm thick and is also more velvety again.
A surge of luteinising hormone occurs roughly just before day 14 in a 28-day cycle. This surge stimulates the mature follicle in one of the ovaries to release its egg (ovulation) 16 to 32 hours later. The other follicles over-ripen and break down. Estrogen also peaks during this surge. Some women can feel a pain on one side of the abdomen around the time the egg is released. This is known as “middle pain”.
An egg is released from the right or left ovary at random and takes about 5 days to travel down the fallopian tube to the uterus.
The luteal or secretory phase
This phase follows ovulation and lasts from about day 15 to day 28. After the follicle ruptures as it releases its egg, it closes and forms a corpus luteum. The corpus luteum secretes more and more progesterone, which acts on glands in the endometrium and causes them to make a secretion. The purpose of this secretion is to feed the embryo for a few days until a placenta has formed. Even if the egg is not fertilized and pregnancy has not happened, the secretion is still produced.
The progesterone secreted by the corpus luteum causes the temperature of the body to rise slightly until the start of the next period. This rise in temperature can be plotted on a graph and gives an indication of when ovulation has occurred.
If the woman has not become pregnant the corpus luteum lasts about 14 days and then starts to break down. This is when progesterone production rapidly drops and the estrogen level decreases. This lack of hormones causes blood vessels in the endometrium to go into spasm and they cut off the blood supply to the top layers of the endometrium. Without oxygen and nutrients from the blood, the endometrial cells begin to die, tissue breaks down and there is bleeding from the damaged blood vessels and so this is how the new menstrual cycle begins on about day 28.
WHAT CAUSES ABSENCE OF PERIODS IN A WOMAN?
Absence of periods in a woman or amenorrhea is classified amenorrhea into primary or secondary amenorrhea.
This is a stage when the periods have never started even till at least 16 years of age.
In this stage you normally have periods but they have stopped for some reason for 6 months or more.
Amenorrhea may be due to either of these stages in a woman’s life:
- before a girl reaches puberty;
- during pregnancy;
- during breast feeding after giving birth to a child;
- after menopause.
Absence of periods or amenorrhea may be attributed to any of the following reasons:
- Glandular malfunction
Malfunction of the thyroid gland or pituitary gland or hypothalamus (part of the brain that helps regulate the menstrual cycle);
- problems with the ovaries;
- anatomical problems with the uterus, cervix or vagina;
- strenuous exercise;
- the absence of puberty;
- depression and some other forms of mental illness;
- low body weight;
- some medications, including the oral contraceptive pill (it can take 3-6 months to start periods again after stopping the pill);
- chronic illness; or
- hormonal imbalances such as polycystic ovarian disease.
WHAT CAUSES PAINFUL PRERIODS IN SOME WOMEN?
During painful periods or dysmenorrhea, the pain and discomfort is usually most severe for the first day or so of the menstrual periods. Dysmenorrhea tends to peak quite soon after puberty, so if your periods are getting increasingly painful as you get older, see your doctor.
The symptoms of dysmenorrhea usually do not last for more than one to 2 days). These symptoms may be some or all of the following:
- Pain in the lower abdomen;
- Nausea and vomiting;
- Constipation or diarrhea.
The cause of the pain and discomfort is prostaglandins a natural substance found in many body tissues. Prostaglandins stimulate contractions of the muscles of the uterus during menstrual period. These contractions of the uterus compress the blood vessels to the uterus, temporarily cutting off the blood supply and depriving the tissues of blood, which triggers pain.
Dysmenorrhea is typically classified into primary or secondary dysmenorrhea:
- Primary dysmenorrhea
It may affect more than half of all women, and occurs with no known underlying cause. The pain in primary dysmenorrhea occurs from the contractions of the uterus, caused by prostaglandins.
- Secondary dysmenorrhea
Secondary dysmenorrhea is caused by an underlying gynecological problem or condition which could be:
- Inflammation of the fallopian tubes.
- Fibroids (Growth in the uterus)
The use of intra-uterine devices for contraception has also been associated with dysmenorrhea and heavy bleeding.
WHY DO SOME WOMEN EXPERIENCE VERY HEAVY PERIODS?
In some women periods are long and heavy- this condition id called menorrhagia. Women with menorrhagia may lose up to 80 ml or more of blood as compared to around 30 to 40 ml lost in a typically normal period. This condition specifies periods that are:
- Prolonged (lasting for more than 9 days). And/or
- Excessive bleeding involving flooding or clots.
The underlying causes for menorrhagia may be:
- Hormonal imbalances;
- A bleeding disorder;
- Polyps (small growths on the cervical or uterine wall);
- Polycystic ovarian syndrome;
- Thyroid disease;
- Liver or kidney disease;
- Intra-uterine devices (IUDs),
Dysmenorrhea or menorrhagia can both be treated and a physician must be consulted for making a proper diagnosis and treatment.
WHAT IS MENOPAUSE?
After attaining a certain age the regularity of menstrual periods changes. The age is different for each individual. The menopausal transition starts with varying time gaps in each menstrual cycle and ends with the final menstrual period. One may not get a regular period for 2-3 months duration or more before the next one. Menopause implies that the ovaries have stopped their function
Menopause is absence of menstrual periods for 12 months. Various terms are used to describe this important period in the life of a woman.
Perimenopause means “around the time of menopause.” It is different for each woman. All factors that initiate and influence this transition period are not yet known. It is not officially a medical term, but is sometimes used to explain certain aspects of the menopause transition in lay terms.
Post-menopause is the entire period of time that comes after the last menstrual cycle.
AT WHAT AGE DOES A WOMAN TYPICALLY REACH MENOPAUSE?
The average age of menopause is 51 years old. But there is no way to predict when an individual woman will enter menopause. The age at which a woman starts having menstrual periods is also not related to the age of menopause onset. Most women reach menopause between the ages of 45 and 55, but menopause may occur as earlier as the 30s or 40s or may not occur until a woman reaches her 60s. As a rough “rule of thumb,” women tend to undergo menopause at an age similar to that of their mothers.
Perimenopause, often accompanied by irregularities in the menstrual cycle along with the typical symptoms of early menopause, can begin up to 10 years prior to the last menstrual period.
WHY IS THE TIMING OF MENOPAUSE DIFFERENT IN WOMEN?
Many factors influence the timing of menopause in a woman. These could range from genetic to certain medical and surgical conditions. Some of these conditions are:
- Surgical removal of the ovaries
Since menstrual periods result from the action of the ovaries, there surgical removal (oophorectomy) in an ovulating woman will result in an immediate menopause. It is also called surgical menopause. In such cases there is no perimenopause, and after surgery, a woman will generally experience the signs and symptoms of menopause. In cases of surgical menopause, women may experience severe symptoms of menopause because of their abrupt appearance.
- Surgical removal of the uterus
Hysterectomy or surgical removal of the uterus is generally carried out with the removal of ovaries also. In cases when a woman has not reached the menopause stage and the uterus only is removed, the ovaries are still capable of producing hormones. The normal production of hormones would continue in such women till their normal time of menopause, without their menstruating. At that age the woman will experience the other symptoms of menopause though her menstruation had stopped with the removal of the uterus. She would experience hot flushes and mood swings at this stage when the ovaries stop producing the hormones. The ovarian failure may, however, get preponed and may be as early as 1 to 2 years after removal of the uterus. Under such a situation she may not experience menopausal symptoms.
- Chemotherapy and radiation therapy
A woman undergoing treatment for cancer may experience menopause before the normal age of menopause. This will depend on the type and location of the cancer and its treatment. The symptoms of menopause may appear during the treatment itself or a few months after the treatment.
- Premature ovarian failure
This is a condition when a woman experience menopause before attaining the age of 40 years. It may be due to genetic causes or auto-immune diseases and occurs in about 1 in a hundred women.
WHAT ARE THE SYMPTOMS OF MENOPAUSE?
The symptoms of menopause are different for each woman and it is a highly individualistic experience. There may be total lack of symptoms in some women while others may suffer from multiple physical and psychological symptoms. The extent and severity of symptoms vary significantly in women. The symptoms of perimenopause and menopause are as discussed below.
1. PHYSICAL SYMPTOMS- Onset of menopause is characteristic of appearance of some apparent physical changes a woman experience. Some of these are:
- Irregular vaginal bleeding
Perimenopause phase starts with irregular vaginal bleeding in most women. Some women have lesser problems while others may have excessive and unpredictable bleeding. The menstrual cycle may gat reduced or lengthened- the gap between one period to the other may increase or decrease before finally stopping. There is no set normal pattern and the changes for different women. Most will menstruate after a gap of several months and the final transition to menopause may be different for each woman. The time and extent of irregularity may be different in each case.
It is very important for a woman in the transitory phase to get regular gynecological check-ups to rule out any illness causing the irregular menstrual periods.
It is important for a woman to understand that the fertility or egg-producing capacity in woman in perimenopause is reduced but not finished yet and she may still become pregnant until she reaches final stage of menopause- absence of periods for 12 months.
- Hot flushes and sweating
This is a very common symptom among women during menopause. A hot flush is a feeling of warmth in the head and chest region and spreads to all over the body. These are followed by perspiration and usually last for 30 seconds to several minutes. The declining estrogen levels and resultant hormonal imbalance are likely to be the cause of hot flushes.
The exact cause, timing and duration of hot flushes is not known and about 40% of women in their forties experience these for sometime during menopause. These may appear before any other symptom of menopause has appeared and may last even up to 10 years in about 1 in 10 women. In most cases, about 80% women cease to experience hot flushes within 5 years. The frequency of these decreases over time but the exact duration of hot flushes is difficult to predict.
Usually they last for about 5 years and are sometimes also accompanied by night sweats (drenching sweats at night time). It results in night time awakening with difficulty in going to sleep again and a dtate of fatigue and unrefreshing sleep.
- Vaginal symptoms
The fall in estrogen levels and hormonal imbalance cause thinning, drying and reduced elasticity of the vaginal lining tissues. It also leads to vaginal inching, irritation, dryness and/ or pain during sexual intercourse. These changes may also cause vaginal infections.
- Urinary symptoms
Changes similar to the vaginal changes are also noticed in the lining of the urethra (the tube carrying urine from the bladder to discharge it outside). It also becomes thinner, drier and less elastic. This increases the risk of UTI (urinary tract infection), leakage of urine (urinary incontinence) and the urge / need to urinate more frequently. Incontinence may occur due to sudden urge to urinate, during straining when coughing, laughing or lifting heavy weights.
2. Psychological symptoms
During the perimenopause stage women experience a variety of cognitive (thinking) and emotional symptoms. It is not possible to identify which behavioral symptom is exactly caused by hormonal changes of menopause. Emotional and cognitive symptoms are very common and to exactly define the cause (menopause) is difficult. These symptoms could be:
- Fatigue / tiredness.
- Memory problems.
- Rapid mood swings.
The causes of these symptoms are difficult to exactly define but some of these could be:
- Hormonal changes.
- Night sweats and disturbed sleep.
- Other life changes during perimenopause or after menopause.
- Stressful life events related to marriage etc.
A woman during the perimenopause and post menopause period is under stress due to various factors. An understanding and supporting environment at home will help in reducing the severity of the experience.
3. Other physical changes
The menopause period stops the production of estrogen in the woman’s body. The male hormone, testosterone, is also produced in a woman in very small quantities and the predominant female hormone counter the effects of the male hormone in pre menopause life. The lack of female hormones and the male hormones may bring about certain changes in the physical appearance of a woman. These could be:
- Weight gain.
- Changed distribution of body fat with a shift of fat from thighs and hips to the waistline and abdominal area.
- Changes in skin texture- wrinkles and adult acne may develop.
- Some hair growth on the chin, upper lip, chest or abdomen.
- Heaviness in the voice in some cases.
Menopause is not a disease but a natural transition during the lifetime of a woman. Some of the symptoms of menopause are also caused by certain diseases and it is important to get a regular medical check up to identify the cause. Women differ in their symptoms. One woman may feel that insomnia she is facing is because of menopause while the other may associate joint aches with it. The same pattern of hot flushes in two different women can have a very different psychological impact. For one woman, they can disturb her daily functioning greatly, but for another, they may hardly be bothersome. In any case it is essential to provide emotional and physical support to a woman during this important phase of her life. It is difficult to exactly describe what to expect since medical science is yet to establish the real reason why declining hormone levels can cause these changes.
WHAT ARE HEALTH RISKS OF MENOPAUSE?
The changed hormonal structure in a woman after menopause renders her vulnerable to some health complications.
Osteoporosis is the thinning of the bones and deterioration of the quality and quantity of the bone structure. The loss of bone mineral density starts around 40 years of age and gets accelerated after menopause. The effects of age on the bones are accentuated by hormonal changes due to menopause. The effects of osteoporosis are felt only after suffering a fracture.
For other details check the details at page on Osteoporosis. It is important to adopt some lifestyle changes to avoid fractures due to osteoporosis. These are:
- Regular medical check ups to monitor the health condition.
- No smoking.
- Reduced alcohol consumption.
- Regular exercise.
- Balanced diet.
- Taking vitamin supplements like Calcium and vitamin D.
Before the perimenopause and menopause stage a woman compared to a man is at a lesser risk for cardiovascular disease and stroke. After the onset of this period in her life the risk goes up for her.
Coronary heart disease rates in postmenopausal women are two to three times higher than in women of the same age who have not reached menopause. This increased risk for cardiovascular disease may be related to declining estrogen levels. The hormonal supplements provided to a woman after menopause should not be taken to reduce the chances of cardiovascular disease or stroke because of other medical conditions associated with hormone replacement therapy.
HOW CAN THE ONSET OF MENOPAUSE BE DETECTED?
There is no set test to clearly identify the menopause stage in a woman. The changes in hormonal levels keep fluctuating on day to day basis and can not be taken as a measure to identify the menopause stage in a woman. No blood test or other test can specifically provide information about the transition in to menopause state in a woman.
It can only be established by the woman herself by observing the lack of menstruation for 12 months around the general age of menopause.
IS SOME TREATMENT REQUIRED AND AVAILABLE FOR MENOPAUSE?
Menopause is a general phase in the life of a woman when her ovaries stop their normal function of producing the egg. As such there is no requirement for any treatment for menopause. Treatment may be necessary in cases when the symptoms resulting from menopause are severe. The treatment options for the symptoms are:
1. Hormone Replacement Therapy (HRT)
Hormones that are produced by the ovaries during their normal functioning are provided as oral supplements to make up the deficiency. These treatments include:
- Estrogen and Progesterone Therapy
It consists of estrogens or a combination of estrogens and progesterone (progestin). It is used to control the symptoms of menopause related to reduced estrogen levels. It is still the best and most effective way to deal with hot flushes and vaginal dryness caused by menopause. It is a very individual decision in which the doctor has to take in to account the inherent risks and benefits of this therapy to suit individual woman’s needs and case history.
This therapy has certain risks associated with it and those women who receive this therapy are at a higher risk for suffering any of the following:
- Heart attack.
- Breast cancer.
- Endometrial cancer (cancer of the lining of the uterus).
It is therefore recommended that the estrogen and progesterone therapy should be used for the shortest possible time at the smallest effective dose.
- Oral Contraceptive Pills
This is another form of hormone therapy generally recommended for women in perimenopause stage to control irregular vaginal bleeding. It is necessary to exclude any other cause of vaginal bleeding before prescribing this treatment.
During the menopausal transition period women generally tend to have unusual breakthrough bleeding while taking estrogen therapy. Same list of oral contraceptives that are used for women during the pre-menopausal stage are prescribed to women in the menopause transition stage to:
- Regulate menstrual periods.
- Relieve hot flushes.
- Provide contraception.
- Local Hormone Treatments
Treatment of vaginal estrogen deficiency is carried out by prescribing specific hormone treatments. These could be given orally or locally or in a combination of the two. The treatments could be:
- Vaginal Estrogen Ring.
- Vaginal Estrogen Cream.
- Vaginal Estrogen tablets.
- Oral Estrogen Tablets.
2. Other Drug Therapies
Symptoms of menopause are effectively treated by using some other drugs also. The treatment options could be:
- Antidepressant Drugs
Selective Serotonin Reuptake Inhibitors (SSRI’s) and related drugs are found to be effective in controlling hot flushes in about two third cases. Most of these drugs are known to reduce the severity of hot flushes in some women. The side effects of these drugs like decreased libido and sexual dysfunction require selective application.
- Other Medications
Some drugs used to treat seizures and blood pressure are also found to be effective in controlling hot flushes though these are not meant for treating this.These medications have side effects and it is imperative to discuss these with the patient before prescribing these drugs for treating hot flushes as such.
3. Alternative medical therapies
Some medicinal herbs and vitamins are also known to help in controlling the symptoms associated with menopause. Some of these are:
- Plant Estrogens
Plant-derived estrogens or phytoestrogens (isoflavones) have a chemical structure similar to the estrogens naturally produced by the human body. The strength of plant-derived estrogens is, however, much lower (1/1000 to 1/1,00,000) than that of natural estrogen. These estrogens are found in soybeans, chickpeas and lentils.
Plant estrogens are useful for women undergoing or after treatment of breast cancer who do not want to take HRT. Use of soy products helps relieve hot flushes and other symptoms of menopause. Some phytoestrogens can create anti-estrogenic properties and long-term use of these can cause overgrowth of the tissues lining the uterus (endometrial hyperplasia) an initial stage for cancer. The safety and potential risk of phytoestrogens needs to be established scientifically.
- Vitamin E Supplements
In some cases the use of vitamin E supplements may be helpful in relieving hot flushes and other symptoms of menopause. A dose more than 400 international units of vitamin E may not be safe and place the user under a higher risk of cardiovascular disease.
- Black Cohosh
It is a herbal preparation and its use is prevalent in Europe and US for controlling menopausal symptoms. It has relatively less side effects and its use is recommended for short periods of 6 months or so. Scientific evidence is required to support the effectiveness of black cohosh in treating the symptoms of menopause.
3. Non-Medical Therapies
Licorice, chaste berry, wild yam and dong Quai are some of the substances recommended for treating menopause symptoms. There is no medical evidence to support the claims for effectiveness of their curing power. Some of the alternative remedies available are:
- Non-pharmaceutical therapies
Breast cancer survivors and other women for whom oral or vaginal estrogens are not considered suitable can use OTC vaginal lubricants. These are, however, not as effective in relieving vaginal symptoms as oral or local estrogen.
- Lifestyle factors
Menopause symptoms are also known to be effectively controlled by affecting some lifestyle changes. The risk of cardiovascular disease and mental stress can be reduced by:
- Regular exercise for cardiovascular disease, osteoporosis and stress management and control.
- Proper and balanced diet.
- Stopping smoking.
- Reduced intake of alcohol.
- Menopause is defined as the absence of menstrual periods for 12 months. It is the time in a woman’s life when the function of the ovaries ceases. The ovary, or female gonad, is one of a pair of reproductive glands in women.
- The process of menopause does not occur overnight, but rather is a gradual process. This so-called perimenopausal transition period is a different experience for each woman.
- The average age of menopause onset is 51 years old, but menopause may occur as early as the 30s or as late as the 60s. There is no reliable lab test to predict when a woman will experience menopause.
- The age at which a woman starts having menstrual periods is not related to the age of menopause onset.
- Symptoms of menopause can include abnormal vaginal bleeding, hot flashes, vaginal and urinary symptoms, and mood changes.
- Complications that women may develop in the postmenopausal period include osteoporosis and heart disease.
- Treatments for menopause are directed toward alleviating the symptoms present in the particular woman affected.
WHAT ARE HOT FLASHES?
A hot flash is a feeling of warmth that spreads over the body, but is often most strongly felt in the head and neck regions and may be accompanied by perspiration or flushing. Hot flashes usually last from 30 seconds to several minutes. Although the exact cause of hot flashes is not fully understood, these are thought to be due to a combination of hormonal and biochemical fluctuations brought on by declining estrogen levels. Hot flashes are experienced by many women, but not by all women undergoing menopause.
Hot flashes occur in up to 40% of regularly menstruating women in their forties during the perimenopause stage before the menstrual changes characteristic of menopause even begin. In most cases (a About 80% of women) these last for about five years and sometimes (in about 10% of women), hot flashes can last up to as long as 10 years.
Hot flashes may be accompanied by night sweats (episodes of drenching sweats at nighttime) leading to awakening and difficulty falling asleep again. This causes un-refreshing sleep and a feeling of fatigue and tiredness during the day.
WHAT IS THE TREATMENT AVAILABLE FOR HOT FLASHES?
Hot flashes are treated by oral, trans-dermal (patch) or local use of estrogen. Hormone Therapy or Hormone Replacement Therapy consists of estrogens or its combination with progesterone. Because of the possibility of increased risk of cardiovascular disease, stroke and breast cancer or cancer of the uterus lining, the use of this therapy must be an individual’s well informed decision. The use of estrogens and or progesterone is recommended in minimal doses for the shortest possible time.
WHAT CAUSES RELUCTANCE ON THE PART OF PHYSICIANS TO RECOMMEND NON PRESCRIPTION ALTERNATIVE THERAPIES FOR TREATMENT OF MENOPAUSE SYMPTOMS?
Physicians are provided details of the composition and its effects as studied during the testing phase. This helps them assess the efficacy of a particular drug thus giving them confidence in prescribing a particular drug for the treatment of a disease. Non prescription alternative therapies are generally not recommended by doctors due to any of the following reasons:
- Testing before approval
Prescription products undergo stringent testing procedures before approval is accorded for their use. This is not so for alternative therapies.
- Quality control
These products are not subjected to testing to check their proof of safety and quality and quantity of the ingredients. The quality may vary from producer to producer or even from bottle to bottle from the same manufacturer.
- Scientific proof
There is generally no scientific proof about the effectiveness of these products and no studies have been conducted to assess the same.
- Number of products
There are a large number of these products available with the same or similar composition and it is difficult to assess the performance of each.
- Use of placebos
Studies conducted for these products are not carried out with the use of placebo since the same effect could probably have been achieved with a placebo (sugar pill).
- Supervised testing
Studies conducted are generally without supervision. Since the women participants were aware of the expected results, objective assessment would result.
- Long term studies
The duration of studies conducted has been rather short and long term effects have not been studied.
- Different criteria for study
Each study included different criteria for evaluation of the effectiveness of the product. Some studies evaluated the effect for hot flashes only while others studied the effects on other symptoms also.
It would thus be difficult for a doctor to recommend the use of non prescription alternative therapy products for relieving the symptoms of menopause.
WHAT IS HRT (HORMONE REPLACEMENT THERAPY) OR HT (HORMONE THERAPY)?
Various female hormones control the development of female body characteristics like the breasts, body shape and body hair. Ovaries are the main source of female hormones. These hormones are important for women health. The hormones also regulate the menstrual cycle and pregnancy. Hormone estrogen also protects the bone. Menopause stops the production of these hormones in a woman’s body and she can develop osteoporosis(thinning of bone) when her ovaries do not produce adequate estrogen.
HT or HRT is a general term used to refer to administration of estrogen alone or combined estrogen / progestin therapy. Estrogen alone is used for women who have undergone hysterectomy while the combination is used for women with the uterus intact. Estrogen alone can cause uterine (endometrial) cancer; progestin is administered for women with the uterus to eliminate this risk. This method or prescribing hormones is also called combined hormone therapy. All forms of hormone therapy are effective in suppressing the symptoms of hot flashes.
Usually a combination of estrogen and progesterone are prescribed in combination. To counteract the higher risk of uterine (endometrial) cancer due to long term use of estrogen progesterone is also prescribed. Estrogen is available as pills, tablets, patches, creams or vaginal preparations (vaginal rings, vaginal tablets or vaginal cream). The choice of estrogen recommended depends on the specific symptoms of the woman. Vaginal creams, vaginal tablets or vaginal rings are used for vaginal dryness and pills or patches are used to treat hot flashes. Estrogen pills are also used with vaginal applications for vaginal dryness. Progestin is available in both pill and patch form but is generally used as a pill.
HRT schedules are dependent on a woman’s symptoms and the treatment and schedules are individualized to suit the requirement. Some standard forms of HRT are:
- Oral therapy
Pills in small doses of estrogen and progesterone are administered together every day to avoid monthly vaginal bleeding. This is called Daily Continuous Therapy. It can cause irregular and unexpected vaginal bleeding sometimes in the initial stages of its use for a few months, especially in younger women entering menopause. In such cases Planned Cyclic Bleeding being better, progesterone is usually added to the estrogen for the first 12 days of the month.
- Trans-dermal Therapy
In this form patches are worn on the continuous basis and are changed / replaced with new patches once or twice a week. Patches with a combination of estrogen and progesterone are available for women with their uterus in place. Patches are as effective as oral therapy in controlling hot flashes.
- Local Application
Estrogen vaginal tablets and creams are prescribed as “maintenance Therapy” for a 2 weeks period every night. The use is later reduced to twice per week. The estrogen absorption in the body in this case is low and long term effects of vaginal tablets, creams or rings needs to be evaluated.
Vaginal estrogen rings are used for treating vaginal and urinary dryness and irritation caused by menopause. Estrogen absorption in to the body in this case is low but high dose rings are also available to treat hot flashes with vaginal distress symptoms. A vaginal ring is put in place for a period of 12 weeks after which it can be replaced by a physician or the woman herself.
IN WHAT CASES IS HRT PRESCRIBED?
Women suffering from hot flashes with sleep disturbance, caused by menopause, should consider HRT. Estrogen use on a short term basis (less than 5 years) is the most effective treatment for this and the accompanying risks are much lesser compared to the benefits.
Non-estrogen medication could be considered for women at risk of or diagnosed with osteoporosis.
Oral pills, skin patches, gel or vaginal forms of estrogen can be used for women suffering from vaginal dryness or irritation due to menopause.
Women experiencing only vaginal menopause symptoms without hot flashes should use a vaginal application of estrogen. Women with both hot flashes and vaginal symptoms can use either form. In such cases both oral and local therapies are used especially in cases where vaginal symptoms do not improve with oral application.
IN WHAT INSTANCES IS USE OF HRT NOT RECOMMENDED?
A woman with a personal medical history of breast or uterine cancer should not be administered HRT. Similarly, women with abnormal vaginal bleeding should have a medical check up before using HRT. Routine mammograms and breast examinations are necessary to detect breast cancer.
Women suffering from high blood pressure and under medication to control the same can use HRT. HRT does not have any significant effect on blood pressure.
Women affected by liver disease or migraine can use HRT in patch or vaginal form to avoid aggravation of these conditions.
Women with a past history of coronary artery disease may use HRT with proper evaluation and regular monitoring. HRT increases the risk of cardio vascular disease in women.
HRT is not recommended for women with history of deep vein thrombosis (blood clots in the veins).
IS IT NECESSARY TO UNDERGO REGULAR MEDICAL CHECK UPS WHILE USING HRT?
An annual medical evaluation is essential for all women receiving HRT. This is necessitated due to the increased risk of cancer (breast and uterine-endometrial) in women prescribed HRT. The breast examination by a doctor or a nurse is to check lumps or masses in the breasts that could be cancer. A mammogram may also be required.
The woman should discuss her bleeding pattern with the physician during or prior to the checkup to evaluate the same for being within the pattern for the prescribed specific type of hormone therapy.
Other routine check ups may also be carried out at this annual check up.
WHAT TREATMENT OPTIONS, OTHER THAN HRT, ARE AVAILABLE FOR TREATMENT OF MENOPAUSE SYMPTOMS?
HRT is by far the most effective form of treatment for symptoms of menopause. If a woman decides against HRT, other prescription non-hormonal medication options to reduce hot flashes are available. Water soluble jelly (not petroleum jelly) can be applied locally to reduce vaginal dryness.
Non hormonal prescription medicines may be given for osteoporosis sine these newer medicines are considered safe for preventing fractures.
WHAT ARE THE POTENTIAL RISKS OF HRT?
HRT has certain side effects on a woman’s health. These are divided in to two categories depending on the severity of the risks. The risks are minor side effects and major or serious side effects. It is not certain which effect is due to which component of the HRT and a physician generally will alternate the estrogen or progesterone component for a few weeks to assess the effect.
1. Minor Side effects
These are very common and are generally accepted as annoying rather than causing any major health risk. The symptoms of these could be:
- Nausea and vomiting.
- Breast pain.
Weight gain normally associated with HRT and menopause is not in any way connected to HRT and is more likely to be resulting from old age and reduced physical activity. Women prescribed HRT are as likely to gain weight during menopause as others not prescribed HRT.
2. Serious or major side effects
HRT has certain side effects which can cause a major health risk for a woman using HRT. The more serious health concerns for women undergoing hormone therapy (HT) are:
- Blood Clotting
Compared to others women prescribed HRT are at 2 to 3 times higher risk for formation of blood clots in the legs (deep vein thrombosis) and blood clots in the lungs (pulmonary embolus). In healthy women chances of these conditions occurring are rare and the actual risk is minimal. Women with a personal history of these clots are required to evaluate the risks further before starting HRT.
- Uterine cancer
Women having their uterus and using estrogen are at risk for endometrial cancer. Since progestin protects against endometrial cancer a combination of estrogen and progesterone is prescribed in such cases. Women who cannot be prescribed some form of progesterone due to any reason need to undergo an annual check-up of sample tissue from the uterus (endometrial biopsy) to check for cancer while she is taking estrogen.
- Breast cancer
HRT especially EPT causes a small increase in the risk for breast cancer as compared to women not taking HRT. The increased risk is to the tune of approximately 8 cases out of 10,000 women taking HRT. The risk increases with the duration of use and is especially increased with the use of HRT for 5 years or more.
- Cardio vascular disease
HRT is effective in lowering the LDL (bad cholesterol) and increasing HDL (good cholesterol). The risk of occurrence of cardiovascular disease, however, goes up in women using HRT. HRT does not prevent heart attacks. The risk of heart disease is equally raised in women having a past history of heart disease as compared to women who do not have it while they are using HRT.
- Abnormal vaginal bleeding
Women using HRT while in the postmenopausal stage are more likely to experience abnormal bleeding as compared to others. This excessive bleeding depends on the type of hormone therapy. Women having cyclic therapy are expected to have 5 monthly bleeding and bleeding is abnormal if it occurs when not expected or is excessively heavy or long in duration. Women using daily continuous therapy can have irregular bleeding up to about 6 months to 1 year. In these women, bleeding is abnormal if it lasts for more than 1 year. In cases of abnormal bleeding endometrial biopsy is carried out to rule out any other cause or uterine cancer. The HRT doses are adjusted to control/minimize abnormal bleeding.
Women using HRT are at a slightly higher risk for stroke as compared to others. The risk is about 8 cases out of 10,000 women taking HRT.
The possibility of a higher risk for women using HRT of breast cancer, stroke, endometrial cancer and cardiovascular disease may suggest to women with mild menopause symptoms to avoid HRT.
REPLACEMENT THERAPY (HRT) / HORMONE THERAPY (HT) – SUMMARY
- Hormone Replacement Therapy (HRT) or Hormone Therapy (HT) refers to either estrogen or combination estrogen /progesterone treatment.
- Estrogen therapy is the most highly effective prescription medication for treating menopause symptoms and is still safe and effective for many women when used for fewer than 5 years.
- Estrogen therapy reduces or eliminates several symptoms of menopause such as hot flashes, disturbed sleep resulting from hot flashes, and vaginal dryness.
- Other safe and effective non-hormonal medications exist to address a woman’s concerns regarding osteoporosis.
- The use of estrogen therapy, without progesterone (progestin), is associated with an increase in the risk of uterine cancer (endometrial cancer, cancer of the lining of the uterus).
- Treatment with progesterone along with estrogen substantially reduces the risk of uterine cancer (endometrial cancer) so that the risk of developing this cancer is equivalent to that of women not taking estrogen.
Users of oral hormone therapy (HT) for more than 5 years are at slightly increased risk of breast cancer risk, heart disease, and stroke than are nonusers