Premenopause is a period in a woman’s life from the moment of the first signs of menopause to the last independent menstruation. A decrease in the level of estrogens leads to the appearance of a variety of symptoms, the severity of which is individual. The first signs are hot flashes, sweating, changes in the emotional background. In premenopause, changes affect the cardiovascular and nervous system, the urogenital tract, affect metabolism. Treatment is designed to reduce the severity of symptoms of approaching menopause with the help of hormone replacement therapy.
ICD 10
N95.8 N95.9
Meaning
The last menstruation, which marks the beginning of menopause, is observed on average at the age of 50. Symptoms of premenopause, or early menopausal syndrome, appear several years before the last menstruation. An increase in life expectancy has led to the fact that pronounced signs of fading ovarian functioning are observed in 60% of women. Of these, in half of the cases, this process is severe, in a third the symptoms are moderate. The mild course of premenopause is observed in healthy women without chronic diseases, and in the presence of psychosomatic disorders, it acquires a severe protracted course.
Causes of premenopause
The extinction of ovarian function is a physiological process, the symptoms of which are observed already at the age of 45 years. They are associated with a lack of estrogens and the reaction of target organs that have receptors for sex hormones. Throughout the reproductive age, the female body functions in a cyclical mode of hormone secretion. When they are deficient, mechanisms leading to aging and metabolic disorders are triggered.
The first to react to estrogen deficiency are the genitals and mammary glands, the nervous system, later – the urinary system, connective tissue, blood vessels. Severe premenopause occurs against the background of the following conditions:
- Premenstrual syndrome. In women with pathological manifestations of premenstrual syndrome, there is an imbalance in the work of the hypothalamic-pituitary system. If this condition was not corrected at the reproductive age, it passes into pathological premenopause.
- Diseases of the endocrine system. Against the background of existing thyroid diseases, hot flashes, tachycardia, nervousness are more pronounced. This is due to the fact that during premenopause, TSH secretion is stimulated in the evening.
- Metabolic syndrome. Patients with metabolic syndrome have disorders in the neuroendocrine system that trigger a complex chain of severe manifestations of premenopause.
- Gynecological diseases. Inflammatory processes in the pelvis, dishormonal diseases – fibroids, endometriosis – make the transition from the reproductive period to premenopause and menopause more difficult. Also, these pathologies can progress against the background of hormonal changes.
Pathogenesis
Three types of estrogens are synthesized in the ovaries of women of reproductive age – estrone, 17-β-estradiol and estriol. Estradiol has the greatest biological activity. But 5 years before the cessation of menstruation, a gradual decrease in its production begins. The pituitary gland reacts to this with additional secretion of follicle-stimulating hormone (FSH). By the time of menopause, its blood level increases 13 times, and the concentration of estradiol tends to zero. The main hormone of menopause becomes estrone. But it does not give the same effect as estradiol.
The targets for estrogens are the reproductive organs, mammary glands, bladder and urethra. Dystrophic processes are observed in them. The connective tissue, musculoskeletal system, skin and hair react to the lack of estriol, which leads to the omission of the pelvic organs, the appearance of gray hair and wrinkles, and in the late period – to the development of osteoporosis. Hormone deficiency affects the state of the intestine, adipose and nervous tissue.
The autonomic nervous system participates in the development of premenopausal symptoms. In women, the production of norepinephrine and dopamine involved in thermoregulation is disrupted. This leads to periodic vasodilation of the upper body, the appearance of a feeling of heat and sweating. LH and TSH are also involved in this process. The daily secretion of thyroid-stimulating hormone is preserved and does not lead to a change in the release of thyroid hormones. But there is a paroxysmal increase in the release of TSH in the evening and at night. Therefore, hot flashes often begin at this time, women develop insomnia.
Classification
On average, premenopause begins to manifest itself from the age of 45, and the last monthly period comes about 50 years. But sometimes the time frame shifts due to the suppression of ovarian function, so the symptoms of premenopause begin to bother earlier. According to the time of onset , the following forms of menopause are distinguished:
- Early. Menstruation stops before the age of 45. The symptoms of premenopause in this case begin to bother already at 40 years old or earlier.
- Premature. The last menstrual periods occur before the age of 40, and the menopausal syndrome manifests itself already at 35. Pathology develops with premature depletion of the ovaries.
Premenopausal symptoms
Early symptoms of approaching menopause occur against the background of a decrease in estrogen production. The reproductive organs, the autonomic and central nervous systems are the first to react to the lack of hormones. Therefore, menstrual cycle disorders, emotional problems and vascular reactions appear.
Menstrual cycle changes
The initial manifestations of a decrease in the work of the ovaries can be suspected in menstrual disorders. Menstruation becomes irregular, and anovulatory menstrual bleeding that occurs after a delay is often bothered. The cycle becomes shortened, or its duration changes every month, the volume and duration of bleeding may increase. Due to the unstable secretion of estrogens and progesterone, the failure of the cycle is accompanied by breast swelling, swelling, pain in the lower abdomen, in the lower back.
Vegetative disorders
Symptoms of vegetative disorders appear. In premenopause, the tides begin to bother. They are more pronounced in the autumn-spring period, which is due to the peculiarities of seasonal changes in the work of the hypothalamic-pituitary system. The tide begins with a feeling of heat on the scalp of the neck and shoulders, at the same time redness appears, a tactile increase in temperature is felt, sweating increases. Duration ‒ from a few seconds to a minute or more. The symptom is accompanied by a rapid heartbeat. Some women may develop hypotension or, conversely, increase blood pressure. After the tide, the head may ache.
Emotional and mental disorders
During premenopause, emotional disorders are expressed. The woman becomes irritable, aggressive. Nervous excitement is sometimes accompanied by an attack of suffocation, increased pressure. Emotional lability may appear, the mood changes several times in a short period of time. Everyday events, minor incidents cause frustration, tears, there is a tendency to depression. In severe cases and in the absence of support for loved ones, suicidal thoughts may bother.
Symptoms of premenopausal sleep disorders are expressed in the form of nocturnal insomnia. There are difficulties with falling asleep, sometimes they are combined with tides. Sleep becomes shallow, sensitive. After waking up ahead of time, it is not possible to fall asleep again. Pathological daytime drowsiness may occur when, after a quiet night and a full sleep, weakness worries, there is a desire to lie down.
Problems in the sexual sphere
Changes in the emotional sphere and reproductive system during premenopause lead to a decrease in libido. A woman is concerned about vaginal dryness, which is a consequence of estrogen deficiency. Lack of hormones leads to inhibition of microflora growth, reduction of lactic acid production, epithelial atrophy. The mucous membrane dries up, becomes vulnerable. Sex is accompanied by painful sensations, sometimes after sexual intercourse there are cracks in the vulva and vagina. The rest of the time, itching may bother, which is a consequence of atrophic processes.
Complications
Against the background of hormonal changes in women, the risk of hyperplastic processes increases. After 40 years, endometrial hyperplasia is often diagnosed, the growth of uterine fibroids accelerates. They are characterized by bleeding, which leads to severe anemia. The risk of oncopathology increases, and tumors of the endometrium, breast or cervix grow rapidly. Women who do not visit a doctor risk finding out about the disease at an advanced stage. A decrease in the work of the ovaries does not mean a complete absence of ovulation, sometimes the egg matures, so there is a risk of an unplanned pregnancy.
Diagnostics
Examination for premenopausal symptoms is necessary to determine the general condition of a woman, the presence of concomitant diseases that may be a contraindication for hormonal treatment. The primary examination is performed by an obstetrician-gynecologist. It is also indicated to consult an endocrinologist, in case of pathology of the heart or vascular system – a cardiologist. In premenopause , the following studies are needed:
- Gynecological examination. It allows you to determine the state of the reproductive organs, assess the severity of atrophic processes, identify the presence of fibroids, changes in the cervix, in the mammary glands. A cytological examination of a smear from the cervical canal is mandatory in order to notice background or precancerous processes in time.
- Physical examination. It includes the measurement of body weight, height, blood pressure, waist circumference and the thickness of the skin fold at the navel. These data are necessary to determine the body mass index and assess the risks of various heart and vascular diseases.
- Mammography. It is carried out in women from 40 years and older once a year, with suspicious results, an ultrasound of the breast is supplemented. In premenopause, mammography is necessary for early detection of symptoms of breast cancer, which is the most common female cancer.
- The study of the hormonal profile. The level of estradiol, LH and FSH and their index, prolactin, TSH are determined. Additionally, tests for testosterone, cortisol and other blood hormones may be required. A high FSH and an LH/FSH index of less than 1 means the onset of premenopause.
- Ultrasound of the pelvis. It is carried out on 5-7 days after menstruation. The condition of the endometrium and its thickness are evaluated. In premenopause, there may be a gradual thinning of the mucous membrane, there are no signs of maturation of follicles in the ovaries. If there are signs of endometrial hyperplasia, it is necessary to clarify the cellular composition using aspiration biopsy.
- Biochemical blood analysis. In order to assess the risk of developing cardiovascular pathologies and the absence of contraindications for the appointment of hormonal drugs, the lipid profile is investigated. Indications of the level of blood proteins, glucose, bilirubin, liver enzymes are important.
- Coagulogram. It is necessary to evaluate the blood clotting system. Hormonal drugs that are used in the treatment of menopausal syndrome, enhance clotting factors and can lead to thrombosis, especially with a predisposition to them.
Premenopausal symptoms are assessed by a special index using a single assessment scale. Depending on their severity and repetition during the day, the required number of points is set. After their calculation, the severity of the menopausal syndrome is determined. This serves as a criterion of indications for the initiation of substitution therapy.
Treatment
Treatment is aimed at reducing the severity of unpleasant symptoms of the coming menopause and preventing possible potential risks. The use of hormonal agents is pathogenetically justified, but in mild cases, non-specific treatment without medications is possible.
Non-drug methods
With a mild degree of severity of the menopausal syndrome, a woman is recommended to observe the daily routine. A 7-8-hour sleep is necessary for a full rest. Physical activity and restorative measures are important to increase the tone. Some help wiping with cold water, hardening procedures, contrast shower.
Nutrition correction is mandatory. With a tendency to increase blood pressure, the consumption of table salt is limited. It is recommended to reduce the amount of animal fats, preference is given to plant foods, cereals, fermented dairy products. Sweet, fatty foods, flour lead to weight gain and worsening of premenopausal symptoms, metabolic disorders. It is mandatory to give up smoking and alcohol consumption. With mild depressive disorders in premenopause, individual or group psychotherapy helps, the support of close people, relatives, spouse is important.
Conservative therapy
Hormone replacement therapy (HRT) is prescribed for moderate and severe premenopause, it begins at any age when the first signs of pathology appear. Drugs are selected individually in the absence of contraindications in the form of a tendency to thrombosis, diseases of the cardiovascular system. Hormonal drugs are prohibited if they are suspected of malignant tumors of the mammary glands or reproductive organs, uterine bleeding of unknown origin, acute liver pathologies. The following groups of drugs are used for HRT:
- Combined estrogen-progestogenic agents. In young women, monophasic or three-phase oral contraceptives are used, and after 50 years – preparations based on natural estrogens with the inclusion of a gestagenic component. Premenopausal women are prescribed estardiol valerate in combination with cyproterone acetate, levonorgestrel, nogestrel, medroxyprogesterone.
- Gestagens. Recommended for women with uterine fibroids, endometriosis and other contraindications to estrogen. Preparations of didrogesterone and micronized progesterone can be used orally cyclically from the 5th to the 25th day of the cycle. The intrauterine system with levonogrestrel, which is installed once for 5 years, is effective.
- Pure estrogens. They are used for the removal of the uterus, since there is no risk of proliferative processes that can turn into endometrial hyperplasia or cancer. Estradiol tablets, hormonal patch or gel for application to the skin are used.
- Phytohormones. With absolute contraindications to HRT or refusal of a woman, ready-made extracts of plants of circymphuga, melbrosia, raponticin, which contain phytoestrogens, are used. These include isoflavonoids, lignans, cumestans. They have an estrogen-like effect, but it manifests itself with prolonged use.
Prognosis and prevention
Premenopause, with timely access to a doctor and the use of HRT, proceeds more easily and with less pronounced symptoms that do not affect a woman’s daily activity and do not affect her lifestyle. Subsequently, this reduces the risk of developing urological disorders, heart disease and osteoporosis. Prevention of pathological premenopause consists in the timely treatment of somatic and gynecological diseases, a healthy lifestyle and quitting smoking. Women with premenstrual syndrome need to correct this condition as early as possible.
