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Try out PMC Labs and tell us what you think. Learn More. Menopause is one of the most ificant events in a woman's life and brings in a of physiological changes that affect the life of a woman permanently. There have been a lot of speculations about the symptoms that appear before, during and after the onset of menopause. These symptoms constitute the postmenopausal syndrome; they are impairing to a great extent to the woman and management of these symptoms has become an important field of research lately.

This chapter attempts to understand these symptoms, the underlying pathophysiology and the management options available. Menopause is the permanent cessation of menstruation resulting in the loss of ovarian follicle development. Factors that are toxic to the ovary often result in an earlier age of menopause; for example, women who smoke experience an earlier menopause,[ 3 ] etc. Women who have had surgery on their ovaries, or have had a hysterectomy, despite retention of their ovaries, may also experience early menopause. Premature ovarian failure is defined as Mature woman hot night before the age of 40 years.

It may be idiopathic or associated with toxic exposure, chromosomal abnormality, or autoimmune disorder. Although menopause is associated with changes in the hypothalamic and pituitary hormones that regulate the menstrual cycle, menopause is not a central event, but rather a primary ovarian failure. At the level of the ovary, there is a depletion of ovarian follicles. The ovary, therefore, is no longer able to respond to the pituitary hormones, that is, follicle-stimulating hormone FSH and luteinizing hormone LHand ovarian estrogen and progesterone production cease.

Androgen production from the ovary continues beyond the menopausal transition because of sparing of the stromal compartment. Menopausal women continue to have low levels of circulating estrogens, principally from peripheral aromatization of ovarian and adrenal androgens.

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Adipose tissue is a major site of aromatization, so obesity affects many of the sequelae of menopause. The ovarian-hypothalamic-pituitary axis remains intact during the menopausal transition; thus, FSH levels rise in response to ovarian failure and the absence of negative feedback from the ovary.

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Atresia of the follicular apparatus, in particular the granulosa cells, in reduced production of estrogen and inhibin, resulting in reduced inhibin levels and elevated FSH levels, a cardinal of menopause. Some of these symptoms may emerge 4 years before menses ceases. The menopausal transition is characterized by variable cycle lengths and missed menses, whereas the postmenopausal period is marked by amenorrhea. The menopausal transition begins with variability in menstrual cycle length accompanied by rising FSH levels and ends with the final menstrual period.

Menopause is defined retrospectively as the time of the final menstrual period, followed by 12 months of amenorrhea. Post-menopause describes the period following the final menses. The ovary is a women's only source of oocytes, her primary source of estrogen and progesterone, and a major source of androgens.

Menopause in infertility secondary to oocyte depletion. Ovarian cessation of progesterone production appears to have no clinical consequences except for the increased risk of endometrial proliferation, hyperplasia, and cancer associated with continued endogenous estrogen production or administration of unopposed estrogen therapy in menopausal women. The major consequences of menopause are related primarily to estrogen deficiency.

It is very difficult to distinguish the consequences of estrogen deficiency from those of aging, as aging and menopause are inextricably linked. Principal health concerns of menopausal women include vasomotor symptoms, urogenital atrophy, osteoporosis, cardiovascular disease, cancer, psychiatric symptoms, cognitive decline, and sexual problems.

However, it has been difficult to distinguish between symptoms that result from loss of ovarian function and those from the aging process or from the socio-environmental stresses of midlife years. Many symptoms are found related to postmenopausal syndrome: Hot flushes, irritability, mood swings, insomnia, dry vagina, difficulty concentrating, mental confusion, stress incontinence, urge incontinence, osteoporotic symptoms, depression, headache, vasomotor symptoms, insomnia etc.

They have been discussed below. Symptoms last for 1—2 years after menopause in most women, but may continue for up to Mature woman hot night years or longer in others. Hot flushes are the primary reason women seek care at menopause. Hot flushes not only disturb women at work and interrupt daily activities, but also disrupt sleep.

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Treatment of vasomotor symptoms should improve these cognitive and mood symptoms if they are secondary to sleep disruption and resulting daytime fatigue. The incidence of thyroid disease increases as women age; therefore, thyroid function tests should be performed if vasomotor symptoms are atypical or resistant to therapy.

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The physiological mechanisms underlying hot flushes are incompletely understood. A central event, probably initiated in the hypothalamus, drives an increased core body temperature, metabolic rate, and skin temperature; this reaction in peripheral vasodilation and sweating in some women. The central event may be triggered by noradrenergic, serotoninergic, or dopaminergic activation.

Although an LH surge often occurs at the time of a hot flush, it is not causative because vasomotor symptoms also occur in women who have had their pituitary glands removed. Exactly what role estrogen plays in modulating these events is unknown. Vasomotor symptoms are a Mature woman hot night of estrogen withdrawal, not simply estrogen deficiency. Systemic estrogen therapy is the most effective treatment available for vasomotor symptoms and the associated sleep disturbance. Healthy women in the perimenopausal transition who are experiencing bothersome hot flushes but still menstruating may benefit from oral contraceptives.

Very-low-dose estrogen therapy also effectively treats hot flushes for many women. Low-dose oral esterified and conjugated estrogens 0. Progestin therapy must be given concurrently if a woman has not had a hysterectomy, although, with low-dose estrogen therapy, intermittent progestin treatment may be an option. When estrogen is contraindicated, other options are available. Progestin therapy alone is an option for some women.

Agents that decrease central noradrenergic tone, such as clonidine, relieve hot flushes.

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Potential side effects include orthostatic hypotension and drowsiness. Selective serotonin reuptake inhibitors SSRIs also are effective in relieving hot flushes. In a double-blind, randomized, placebo-controlled trial of paroxetine controlled release The actual hot flush frequency decreased by 3. The improvement in vasomotor symptoms was independent of any ificant change in mood or anxiety symptoms.

Both doses were effective, but the lower dose was better tolerated. The most common side effects were headache, nausea, and insomnia. Modulation of other central neurotransmitters with different antidepressants also may be effective, but have greater potential for adverse effects. The active treatment group experienced ificantly more side effects, including dry mouth, nausea, and anorexia.

Overweight women Mature woman hot night those who smoke have more severe vasomotor symptoms than women of normal weight and nonsmokers. These findings provide additional reasons to encourage women to lose weight and stop smoking. Urogenital atrophy in vaginal dryness and pruritus, dyspareunia, dysuria, and urinary urgency.

These common problems in menopausal women respond well to therapy. Systemic estrogen therapy is effective for the relief of vaginal dryness, dyspareunia, and urinary symptoms. Another option is a topical application. Because systemic absorption is low, endometrial stimulation is minimal. Low-doses of estrogen cream 0.

Women using vaginal estrogen therapy should be asked to report any vaginal bleeding, and this bleeding should be evaluated thoroughly. Typically, systemic progestin therapy is not prescribed to women using low-dose vaginal estrogen. Lubricants are a non-hormonal alternative for reducing discomfort with intercourse in the presence of urogenital atrophy.

Vaginal estrogen therapy appears to reduce urinary symptoms, such as frequency and urgency and has been shown to reduce the likelihood of recurrent urinary tract infections in postmenopausal women. Whereas the of some studies suggest improvement in incontinence with estrogen therapy, others show a worsening of symptoms.

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Musculoskeletal symptoms characterized by backache, fractures on minimal trauma, decreased height, and mobility are common due to osteoporosis. It is important to review a woman's risk factors for osteoporosis when making treatment decisions and to consider bone mineral density screening for high-risk women. Non-modifiable risk factors include age, Asian or Caucasian race, family history, small body frame, history of a prior fracture, early menopause, and prior oophorectomy.

Modifiable risk factors include decreased intake of calcium and Vitamin D, smoking, and a sedentary lifestyle. Medical conditions associated with an increased risk of osteoporosis include anovulation during the reproductive years e. Counseling women to alter modifiable risk factors are important for both the prevention and treatment of osteoporosis.

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