Postmenopause is the last stage of involutive changes in the female reproductive system, a physiological condition characterized by the cessation of menstrual function of the ovaries. Its manifestations include absolute infertility, persistent amenorrhea, thinning and dryness of the mucous membranes, skin and its appendages (hair, nails), weakening of sexual desire. The diagnosis is established on the basis of anamnesis, clinical examination, hormonal tests, ovarian ultrasonography. Treatment (mostly conservative) is necessary only in the presence of disorders associated with hormonal restructuring of the body, often accompanying menostasis.
Postmenopause is a genetically predetermined condition, the result of natural aging processes occurring in every woman. The postmenopausal period begins with the end of the last menstruation and continues until the complete extinction of ovarian function. The beginning of postmenopause usually occurs at the age of 50, and the end – at 69, then somatic involutive processes dominate. Menopause, which occurred at the age of 40-45, is considered early, premature before the age of 40, and late after 55. In 70-80% of patients, postmenopause is accompanied by various disorders. Pathologies are registered in urban women one and a half to two times more often than in rural women.
Causes of postmenopause
The cause of the onset of postmenopause is a state of hypoestrogenism, caused first by a significant decrease, and then by the complete cessation of hormonal function of the sex glands. This mechanism is based on age-related hormonal restructuring of the hypothalamic-pituitary system, a decrease in the sensitivity of target organs to sex hormones, which results in a violation of cyclic processes in the ovaries.
Postmenopausal pathology develops if age-related changes are not fully compensated by adaptive mechanisms. Common predisposing conditions for the development of pathological syndromes are sedentary lifestyle, bad habits (alcohol abuse, smoking), prolonged stress. There are specific risk factors for various disorders. Thus, menopausal metabolic syndrome develops more often in overweight women, and osteoporosis – in patients with reduced body weight. Psychoemotional disorders are often associated with a negative perception of menopause.
During the entire reproductive period, the target organs of the female body’s sex hormones are exposed to their cyclic effects. Such organs include exo- and endocrine glands (liver, mammary glands, hypothalamus, pituitary gland), genitourinary tract and colon, skin and its appendages, cardiovascular system, brain, musculoskeletal system. Postmenopausal estrogen deficiency leads to direct or indirect (through feedback mechanisms) effects on them, their organic and functional changes, which may result in a pathological course of menopause.
Directly hypoestrogenism causes dystrophy of the skin, epithelium, connective tissue, a decrease in bone density, hypercoagulation. A decrease in the synthesis of neurotransmitters (serotonin, catecholamines) by the brain provokes menopausal depression. The result of changes in the functions of the limbic system is a metabolic syndrome, long–term neurological complications – memory impairment, decreased vision, hearing, cognitive function.
In postmenopause, an early period is distinguished, which lasts for the first five to eight years, and a late one – up to ten years. There are natural menopause, which arose as a result of physiological age–related changes, and artificial, which occurred as a result of iatrogenic intervention – surgical removal of both ovaries, exposure to ionizing radiation and chemicals on the sex glands (after radiation or chemotherapy). The risks of the following pathological changes are associated with menopause:
- Neurological. 75% of women are registered at an early stage. Postmenopause is characterized by persistent vasomotor disorders – the so-called “hot flashes”. 10% of patients have depression. Psychoemotional disorders, more typical for perimenopause, are rarely observed at this stage.
- Urogenital. They affect 20-30% of women in early postmenopause. They are a consequence of atrophic changes in the tissues of the genitourinary tract, ligaments and pelvic muscles. On the part of the urinary system, atrophic cystourethritis is detected, on the part of the reproductive system – atrophic vaginitis.
- Musculoskeletal. They are most often expressed by bone resorption (osteoporosis), which is diagnosed in 50-60% of patients by the age of 60. The greatest loss of bone mass occurs in the early period, complications (fractures) may occur after 5-10 years. Other disorders are arthrosis, sarcopenia.
- Metabolic and endocrine. Disorders of late postmenopause include metabolic syndrome. On the part of the vessels, there is an increase in the vulnerability of vascular walls, the formation of cholesterol plaques, on the part of hemostasis – hypercoagulation. 20% of women develop hyperprolactinemia.
The main symptom of postmenopause is the complete absence of menstrual bleeding. The skin and mucous membranes thin out, become drier, and many age-related wrinkles appear. Hair, nails become brittle, their growth slows down. In most women, body weight increases with an even distribution of fat. Often there is a decrease in libido, minor signs of virilization – thickening and excessive growth of fluffy facial hair, coarsening of the voice. The mammary glands become flabby, the nipples flatten. These changes are the norm.
Postmenopausal disorders are characterized by a variety of signs. Vasomotor disorders are manifested by “hot flashes”, tachycardia or bradycardia and fainting, hyperhidrosis. The symptoms of metabolic syndrome include obesity, increased blood pressure (headache, “flies” in front of the eyes), osteoporosis – musculoskeletal pain, decreased growth, stooping. With urogenital disorders, dyspareunia, itching in the vulva, urination disorders are observed.
In postmenopause, there is a further progression of hyperplastic processes of the perimenopausal period. Possible malignancy of the affected tissues with the development of carcinomas, less often – sarcoma of the uterus, breast (in the latter case, the pathological process is aggravated by hyperprolactinemia). Atrophic changes in the epithelium are a source of precancerous and vulvar cancer. The risk of colorectal cancer increases. Untreated, increasing pathological changes in the muscles and ligaments of the pelvis entail omission of the genitourinary organs, accompanied by urinary incontinence of varying severity.
Pronounced osteoporosis is characterized by spontaneous (at rest or with minimal load) fractures of the vertebrae, increased fragility of the bones of the extremities. Hypercoagulation dramatically increases the tendency to venous thrombosis, arterial thromboembolism. Against the background of postmenopausal metabolic syndrome, type 2 diabetes mellitus, hypertension, often develops. Cardiovascular complications include coronary heart disease, less often – myocardiodystrophy. Alzheimer’s disease may result from a violation of the trophic region of the hippocampus.
Diagnosis of artificial or timely natural postmenopause is carried out by a gynecologist, with a timely start usually does not cause difficulties. With early or premature (ovarian depletion syndrome) menopause, the use of laboratory and instrumental methods is required. The diagnosis is established primarily on the basis of anamnestic data in the absence of menstrual bleeding during the year. To confirm, the following studies are performed:
- Clinical examination. A general examination reveals signs of skin aging – dryness, flabbiness. During a gynecological examination, atrophy of the mucous membranes of the external genitals can be detected, a negative symptom of the “pupil”. The later phases of postmenopause are characterized by a decrease in the size of the uterus, flattening of the arches of the vagina.
- Hormonal analysis. The early stage of postmenopause is indicated by an increased level of FSH and LH (with a significant predominance of FSH) in the blood, a reduced concentration of estradiol. The ratio of estradiol to estrone is no more than one. At a late stage, the level of gonadotropins also decreases.
- Ultrasound examination. Transvaginal ultrasound reveals atrophy of ovarian structures, a decrease in their volume. At the initial stage of postmenopause, the presence of single small follicles is possible, later they are not detected. In the uterus, there is a thinning of the endometrium, sometimes an accumulation of fluid (serosometer), often resulting from occlusion of the cervical canal.
Differential diagnosis is not required, since postmenopause itself is not a pathological condition. To detect menopausal disorders, additional studies are prescribed: biochemical blood analysis with a lipid spectrum, densitometry, dynamic measurement of blood pressure. Before hormone therapy, a hemostasiogram, mammography, and ultrasound of the endometrium are performed.
Women who have a menopausal period without pronounced pathological changes do not need treatment. With the manifestations of menopausal syndrome, therapeutic measures should begin with perimenopause. At the first stage, psychological support is provided, a diet, a healthy lifestyle is recommended (a balanced work and rest regime, physical exercises, smoking cessation). Further, if the symptoms do not disappear, pharmacotherapy is connected. The treatment plan includes:
- Psychotherapy. The patient is clearly explained the essence of the changes taking place, focusing on the fact that postmenopause is not a pathology, but a normal physiological state. Methods of psychological influence are not aimed at increasing self-esteem, self-confidence. It is recommended to allocate more time for doing your favorite things.
- Diet therapy. The best source of protein in postmenopause is lean boiled meat, dairy products, fatty varieties of marine fish. The carbohydrate component provides a sufficient amount of fruits and vegetables, cereals (oatmeal, barley, buckwheat). Flour dishes, sweet desserts are sharply limited. Alcohol, strong tea, and coffee are subject to restriction or exclusion.
- Physiotherapy. The tonic and restorative effect is provided by physical education (yoga classes, long calm walking), hydrotherapy – bathing in reservoirs, showers and baths (coniferous, iodine-bromine), cold wipes. With vasomotor disorders, massage, electrophoresis of the collar zone is prescribed. For the treatment of dysuria, cystalgia, amplipulse therapy is used with the help of vaginal electrodes.
- Etiotropic pharmacotherapy. To normalize the state of the nervous system, herbal decoctions (valerian, motherwort), group B vitamins are used. Sympathomimetics or sympatholytics, cholinolytics, antihistamines are recommended for the correction of vasomotor disorders. Treatment of osteoporosis includes bisphosphonates, vitamin D, calcitonin. With hyperprolactinemia, dopaminomimetics are indicated.
- Pathogenetic treatment. Menopausal hormone therapy (MHT) is used for the prevention and correction of most postmenopausal disorders. Women in natural postmenopause are prescribed monophasic combined estrogen-progestogenic drugs for long-term treatment. In the case of early (natural or artificial) menopause, combined hormone therapy in a cyclic mode is more often used.
Hormone therapy involves the selection of individual doses of drugs. The most dangerous side effects of long-term treatment include breast cancer, uterine body, therefore, continuous monitoring of the condition of these organs and other targets of sex steroids is required. An alternative to estrogens is the synthetic steroid tibolone, which has a less pronounced side effect. With contraindications to MHT, phytoestrogens can be prescribed, but their effectiveness is poorly substantiated.
Surgical intervention is indicated only for the treatment of complications – urogenital, tumor. To reduce the severity of the symptoms of the urogenital syndrome, sling operations are performed, various pelvic floor reconstruction techniques are used. With tumors and precancerous postmenopausal organ-preserving treatment (ablative techniques, partial resection) is practically not used, preference is given to radical operations. In hyperplastic pathologies, endometrial neoplasia, as a rule, the ovaries are subject to removal even without histological signs of pathology.
Prognosis and prevention
With timely treatment of postmenopausal pathologies, the prognosis is usually favorable. MHT can eliminate or significantly reduce vegetative–vascular symptoms in 90-95% of women, manifestations of urogenital disorders – in 75%, reduce the risk of pathological fractures by 30%, colorectal cancer – by 37%. Estrogen-dependent carcinomas of the early menopausal period are easier to treat, have a more favorable outcome than hormone-independent ones that occur later.
The primary prevention of postmenopausal disorders includes the fight against physical inactivity and bad habits, maintaining a normal body weight. Before menopause, endocrine diseases, disorders of mineral metabolism, hyperplastic pathologies of the reproductive organs should be treated. Secondary prevention consists in the annual supervision of a gynecologist and other specialized specialists.