Menopause – symptoms and treatment options

Menopause is the permanent cessation of menstruation. It can occur as early as age 40 or as late as nearly age 60s. The average age of menopause is usually about 49 to 51. It is normally diagnosed in females after 1 year of absent menstrual flow. Menopause does not occur suddenly. It is a slow transition and peri-menopause usually begins a few years before the last menstrual period. Menopause is only one event in the transition period involving changes in the female body between the mid or late 40’s, when the production of female hormones (estrogen and progesterone) begins to decline. Most of the signs and symptoms of menopause arise from this decrease in estrogen production even before periods stop altogether. Menopause occurring before age 40 is termed premature and may need medical evaluation for the cause. However, if menopause is delayed beyond the age of 55 (meaning a woman is still experiencing menstrual bleeding), there is an increased risk of breast, ovarian, and uterine cancer. This is due to the increased amount of time a woman’s body has been exposed to the estrogen. Therefore, regular mammograms and gynaecological review by specialist is important for women experiencing late-onset menopause.

Frequent symptoms and signs

  • Menstrual irregularity – the menstrual flow can be scanty, heavy and/or prolonged.
  • Hot flashes or flushes – sudden sensations of heat spreading from the waist or chest toward the neck, face and upper arms (symptoms are often referred to as vasomotor instability). Often associated with excessive sweating. It may occur frequently and last for few minutes. If they occur at night, they may disrupt your sleep. Hot flashes usually stop within one or two years but may persist for several years.
  • Headaches, dizziness, rapid or irregular heartbeat.
  • Sexual changes such vaginal itching and dryness, burning or discomfort during intercourse, (usually beginning a few years after menopause), reduced libido, or sex drive.
  • Urinary symptoms such as bladder irritability, discomfort, frequent urination and urinary tract infection may be more common.
  • Digestive issues such as constipation, diarrhea, bloating, heartburn.
  • Physical changes such as weight gain, thinning hair, dry skin, loss of breast fullness, reduced muscle mass, painful or stiff joints, increased hair growth on other areas of the body (such as the face, neck, chest), fatigue.
  • Psychological symptoms – such as mood changes, pronounced tension and anxiety, panic attack, sleeping difficulty, depression, difficulty concentrating, memory problems

Causes

  • This is a part of the normal aging process, when there is a decline in ovary function, resulting in decreased levels of the female hormones.
  • Surgical removal of both ovaries (surgical menopause).
  • Loss of ovarian function resulting from certain immunological diseases, infection, effects of radiotherapy or chemotherapy.
  • Genetic or chromosomal disorders

Risk factors

  • Smoking.
  • Hysterectomy.
  • Chemotherapy or radiotherapy.

Prevention

Menopause cannot be avoided and currently there is no preventive strategy to avoid or delay it.

Possible complications

  • Increased irritability and susceptibility to infection in the urinary tract.
  • Decreased skin elasticity and vaginal moisture.
  • Increased risk of hardening of the arteries, heart disease, stroke.
  • Osteoporosis.
  • Changes in feelings of self-worth and mental health issues.

Investigations

  • A blood test to confirm menopause is usually not necessary, unless when premature menopause is suspected.
  • Bone mineral density testing is recommended in older women or in those with a higher risk of osteoporosis.

Treatment

  • Menopause is a normal process, not an illness. Most women can make an easy transition without difficulty.
  • Diagnosis is determined by patient’s age and symptoms. Laboratory tests (blood hormonal level assessment) are often not required for diagnosis.
  • Lifestyle changes may be necessary with the onset of menopause. Stay as healthy and happy as you can and live life to the fullest.
  • Psychotherapy or counseling may be required if emotional changes interfere with personal relationships or at work.
  • If you are sexually active, do continue to use birth-control measures until at least 12 months after your last menstrual period.
  • Reduce stress in your life as much as possible. Acupuncture, meditation, and relaxation techniques are all harmless ways to reduce the stress of menopause.
  • Herbal (or products termed as natural remedies) may be of help to some women, especially those with significant hot flushes. Discuss this with your health care provider.
  • Women who smoke may start menopause about two years earlier than nonsmokers. Also, smoking is linked to a decline in estrogen. If you smoke, talk to your health care provider about programs to help you quit.
  • See your doctor on a regular basis for health screening (Pap smear, mammogram, ultrasound scan and blood tests). Discuss the screening intervals with your doctor.
  • Activity – there is no restrictions. Active exercise is beneficial. Weight-bearing activities (such as walking) are helpful for bone strength. Swimming is also beneficial.
  • Diet – eat a well-balanced diet. Increase your calcium intake.
  • The menopausal transition is a trying time for the maintenance of weight. Many women gain weight during this period because their metabolism slows down. It is also related to aging, many lifestyle changes (e.g fewer activities), and other genetic factors. Therefore, you may need to reduce your calories (eat a healthy diet) and exercise more just to maintain your current weight.

Medications

  • Menopausal hormone therapy (MHT) is an option. Hormone treatment has benefits as well as risks. It must be considered on a patient-by-patient basis.
  • Medications to prevent and/or treat loss of bone density may be prescribed, depending on the bone mineral density assessment (BMI) and the risk factors for osteoporotic fractures.
  • Take calcium and vitamin D supplements every day. Discuss with your doctor regarding the types and the dosage required.
  • Antidepressants may be effective for treating hot flashes.
  • For vaginal dryness, moisturizers such as Replens may be effective. It comes in a pre-filled applicator and makes it easier to introduce the moisturizer into the vagina.

You should see your doctor immediately if you have:

Any unexplained vaginal bleeding, new or unexpected symptoms develop during the menopausal period. Drugs used in treatment may produce side effects and you should discuss these with your doctor.

 

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Loop Electrosurgical Excision Procedure (LEEP/LLETZ) for CIN

Loop electrosurgical excision procedure (LEEP), also known as large loop excision of the transformation zone (LLETZ), is a procedure for further diagnosis and treatment of cervical intraepithelial neoplasia (CIN). CIN lesion is an abnormal growth in the cervix. The CIN lesion is usually diagnosed during a routine Pap smear (or called Thin Prep) test. LEEP is a very safe way to remove abnormal tissue from the cervix that might otherwise progress to cancer. It minimizes the amount of tissue removed in order to preserve childbearing ability.

Reason for the procedure

• Presence of CIN lesions from the colposcopy evaluation and confirmed via cervical biopsy. Some types of CIN can progress to cervical cancer if not treated. This can be used as a treatment for CIN lesions.
• Unsatisfactory colposcopic evaluation whereby the whole transformation zone cannot be visualized or the cervix appeared abnormal and requires a bigger tissue specimen for a more accurate diagnosis to exclude cancer changes.

Read moreLoop Electrosurgical Excision Procedure (LEEP/LLETZ) for CIN

Endometrial biopsy (Endometrial sampling or curettage)

Endometrial biopsy is a procedure that involves the removal of tissues from the endometrium, which is the inner lining of the uterus.

Reason for the procedure

It is done to diagnose endometrial cancer or hyperplasia (with or without atypia). Endometrial hyperplasia is a potentially precancerous condition. This procedure is indicated in a woman with abnormal uterine bleeding. This includes bleeding between menstrual periods, excessive bleeding during a menstrual period, or bleeding after menopause. It is also done to exclude endometrial cancer in post-menopausal  women with abnormal endometrial finding on ultrasound scan of the uterus.

Read moreEndometrial biopsy (Endometrial sampling or curettage)

Vasectomy – Male contraception

Article contributed by Dr Peter Ng and Dr Beatrice Chua Yoong Ni

The aim of a vasectomy is to prevent sperm from reaching the semen by disconnecting the sperm duct. The resulting ejaculate is therefore sperm-free, eliminating the risk of pregnancy. Sort of like a cheap shark fin soup without the shark fins (sperms).

Vasectomy is the contraception of choice for 6%–8% of married couples worldwide. Vasectomy is a minor procedure that provides effective and permanent contraception. In fact, it is far more effective than many other methods of contraception, including female sterilization.

Prior to a vasectomy, it is important and both husband and wife be present together to be counseled by a specialist on the implications of the procedure. It is important that the completeness of family is ascertained and that both husband and wife had discussed beforehand and agreed that it is the husband who should undergo a vasectomy to attain permanent contraception.

Read moreVasectomy – Male contraception

Lower Urinary Tract Infection (Lower UTI, cystitis)

Infection of the lower urinary tract occurs when the inner lining of the bladder becomes infected and the urine is full of bacteria. In pregnancy, 5 – 10% of women have bacteria in their bladder and some will have no symptoms at all.

How common?

Up to 40 – 50% of women will have at least one attack in their lifetime and 25% will have recurrences.

Causes

  • Bacteria can reach the bladder from the genital and anal area, or through the bloodstream.
  • Injury to the urethra or the bladder.
  • Prolonged use of a urinary catheter to empty the bladder, such as during childbirth or surgery.

Risk factors

  • Sexual activity.
  • Infection in other parts of the genitourinary system.
  • Pregnancy.
  • Poor hygiene.
  • Menopause.
  • Diabetes mellitus.
  • Underlying abnormalities of the urinary tract, such as tumours, calculi (stones), and strictures.
  • Incomplete bladder emptying.
  • During or after major surgery

Read moreLower Urinary Tract Infection (Lower UTI, cystitis)

Contraception – Male condom

The main purpose of contraception (or birth control) is to prevent an unplanned pregnancy. You should know and understand the different types of methods available to you, the risks and benefits of each, and any possible side effects, so that both you and your partner can able to make an informed choice. Contraception can be broadly divided into:

  1. Temporary or permanent methods – permanent birth control is accomplished through sterilization (tying or removal of the fallopian tubes) or hysterectomy (removal of womb / uterus). The rest of the methods are classified as temporary or reversible.
  2. Short term or long-term methods – short term methods are condoms and oral pills. Long term methods are injectables, intrauterine device and hormonal implants.

Read moreContraception – Male condom

Colposcopy

This is a microscopic examination of the cervix, vagina, or vulva. It is used to diagnose potential abnormalities of these areas, which sometimes cannot be seen with the naked eyes. The colposcope can magnify the tissue by up to 30 times, thus making it clearer and much more accurate in terms of surface evaluation. Therefore, the biopsy of the abnormal areas performed with a colposcopic examination is more accurate than those done without the use of a colposcope.

Why do I need a colposcopy evaluation?

  • It is usually recommended if you have an abnormal Pap smear (Thin Prep) test or when pre-cancerous lesion is suspected in the vagina or labia area.

Read moreColposcopy

First visit to the gynaecologist – what you should know

Health screening as a person ages is especially important. It should be your top priority even if you are healthy. In women, this will include a visit to the gynaecologist’s clinic and will help in identifying if the woman has increased risks for developing a disease or already has the disease or condition that was not previously known about. Early identification of risks factors can help in counselling and instituting remedial or preventive measures to reduce that risk. This may in fact help to prevent the disease from occurring. Likewise, early detection of disease and starting treatment as soon as possible will results in a better outcome and lower the risks of complications. For example, many women with ovarian cancer do not have symptoms until it is too late. However, prompt diagnosis at an early stage of ovarian cancer will give excellent outcome with surgery alone and may not even need chemotherapy at all.
Many women feel nervous or even afraid to see the gynaecologist, especially if it is their first visit. Seeing a gynaecologist is just like seeing any other doctor in other specialities such as your dentist or general practitioner. They are there to help you and you should take this as an opportunity to seek their help in taking care of your health.

Read moreFirst visit to the gynaecologist – what you should know