What happens before female menopause sets in

MALAYSIA - Perimenopause is the time during which the ovaries start to fail, and ends 12 months after the last menstrual period, when menopause commences.

There are numerous stories and even myths about midlife.

For many, it is the prime of life. For others, there may be some dismay that the best life has to offer is over.

Nothing is further from the truth. What is true is that midlife is usually a busy time.

The children are older and some may be living on their own, giving a woman more time than she has ever had for years. Some women may have embarked on new activities.

The body also changes during midlife.

There are hormonal changes in the perimenopause, which is the period of time when the ovaries start to fail until the end of menstruation, and it ends 12 months after the last menstrual period, hailing the onset of menopause.

As these hormone changes usually occur gradually, it may not be obvious at first to the woman.

The perimenopause and menopause are natural events. Although the basic changes occur in all women, each woman feels and copes differently. No two women experience these changes in exactly the same way.

Menstrual changes

During the reproductive years, every woman usually has a distinctive menstrual pattern.

At the perimenopause, some women may just have one last period. However, most women experience changes or irregular periods over a period of time during the perimenopause.

This is due to the reduced frequency of the release of eggs (ovulation), leading to consequent irregular secretion of the ovarian hormones.

The initial changes may not be noticeable.

The menstrual cycle usually shortens, with periods occurring more frequently.

The duration of bleeding may vary, and the amount of blood flow may be light, heavy, or just spotting.

As the menopause approaches, it is not uncommon for there to be missed periods.

Some women may have no periods for several months, and then menstruate regularly again.

Sometimes, the bleeding may occur unexpectedly, even to the extent that it may lead to embarrassment.

Any pattern is possible, but the menstrual changes are recognisable.

Although irregular periods are normal and common during the perimenopause, it cannot be assumed that all changes are due to the body's hormonal changes.

Other conditions may cause abnormal uterine bleeding (AUB).

A doctor should be consulted if the periods last more than seven days, or two or more days than usual; the interval between the start of one period to the start of the next period is less than 21 days; there are heavy periods, clots or the flow is similar to that from an open water tap; there is bleeding, whether it is spotting or heavier flow, between periods; or there is bleeding after sexual intercourse.

The causes of AUB include hormone imbalance; miscarriage; contraceptive pills, depot contraceptives or intra-uterine contraceptive devices; fibroids; non-cancerous (benign) uterine polyps; cancers of the cervix, uterus or vagina; and conditions that affect blood clotting.

The doctor may perform one or more of the following procedures to establish the cause of any abnormal uterine bleeding:

> Ultrasound, which uses sound waves to create a picture of the pelvic organs.

> Endometrial biopsy, in which a small tissue sample of the uterine cavity is removed.

> Dilatation and curettage, in which the cervix is dilated and the uterine lining gently scraped to remove a small tissue sample of the uterine cavity.

> Hysteroscopy, in which a thin telescope-like instrument is inserted into the uterine cavity to look inside and remove a tissue sample.

Ultrasound and endometrial biopsy can be done in the clinic, whilst dilatation and curettage and hysteroscopy is done under sedation, whether local or general anaesthetic, as a day case. The tissue samples removed are sent to a pathologist who will carry out a microscopic examination.

The treatment of AUB depends on the cause. It includes operative hysteroscopy to remove polyps or fibroids in the uterine cavity; endometrial ablation, in which the lining of the uterine cavity is destroyed by heat or freezing (it cannot be used to treat fibroids unless the fibroids are also removed at the same time); laparoscopy, where growths like ovarian cysts and fibroids may be removed; myomectomy, in which fibroids are removed through an abdominal incision (laparotomy) several centimetres long or laparoscopically; or hysterectomy, in which the uterus is removed through a laparotomy or laparoscopically.

The ovaries may or may not be removed at the same time.

Post-menopausal bleeding

It is advisable to consult a doctor immediately should any bleeding occur 12 months after the last menstrual period.

Some women who are taking hormone therapy (HT) may have bleeding. Unless the bleeding is the typical pattern caused by hormone treatment, all post-menopausal bleeding requires investigation to rule out cancer of the genital tract.

The management of postmenopausal bleeding is similar to that of AUB.

Vasomotor changes

Some women experience hot flushes (also known as hot flashes). This is the most common symptom of the perimenopausal years. It is more common in Caucasians than Asians, and is believed to be due to sudden changes in the body's temperature regulation.

The brain, which mistakenly senses that one is too warm, initiates events to cool down. The blood vessels near the skin surface increase their diameter and blood flow, which produces the sudden feeling of heat.

It may or may not be accompanied by a red blushed appearance of the face and upper body. The woman may also start to sweat.

A hot flush occurs suddenly and may last a few seconds to several minutes or more. A few women may experience a cold chill after the flush.

Hot flushes usually have a consistent pattern. However, there is individual variation of the pattern. The flushes can occur several times a day, or a few times a month.

Some women will get hot flushes for a few months. Others have it for a few years. Some may escape it altogether. There is no way of knowing when they will stop.

Hot flushes can occur at any time. It may occur with increased sweating during sleep. The night sweats and hot flushes may interfere with sleep, although it may not wake the affected woman up.

Some hot flushes are tolerable while others are a nuisance, embarrassing or even debilitating to the extent that it interferes with daily life.

However, it must be remembered that hot flushes are not harmful.

Most women can identify certain factors that initiate their hot flushes - hot or spicy food, caffeine, alcohol, stress, cigarette smoke, tight clothes or external heat. Certain medicines, like tamoxifen for cancer chemotherapy and raloxifene for prevention and treatment of osteoporosis, can also trigger hot flushes.

Several measures can be taken to deal with the hot flushes and improve one's comfort, which can sometimes even eliminate them altogether. They include:

> Identifying the factor(s) that trigger the hot flush and avoid it if possible.

> Wearing thin layers of clothing made from natural fibres like cotton, and removing some pieces at the first sign of a hot flush to feel cooler.

> Keeping the office and/or home cool by using a fan or air conditioner.

> Sleeping in a cool room.

> Exercising regularly to reduce stress and promote better sleep. Some research indicates that women who exercise have fewer and less intense hot flushes.

> Reducing stress by a leisurely bath, meditation, massage or yoga.

> Taking slow and deep, abdominal breaths of about six to eight breaths a minute at the start of a hot flush may be helpful.

> Consulting a doctor and discussing the benefits and risks of prescription medicines like HT, oral contraceptives, progestogens, antihypertensives like methyldopa and clonidine, and antidepressants. Non-prescription treatments include vitamins B and E.

Reduced fertility

A woman's fertility declines from the late 30s due to ageing of the eggs in the ovaries. The risk of spontaneous miscarriage is also increased, so much so that by the age of 45, the rate is about 50%.

At the same time, the risk of congenital abnormality in the foetus increases with increasing maternal age.

Some perimenopausal women may still want to get pregnant. Although assisted reproduction technologies (ART) are available, they are expensive, and have some risks and low success rates. There is also an increased risk of pregnancy complications like maternal hypertension and diabetes, Caesarean section and stillbirth.

Despite reduced fertility, a woman is not free from an unplanned pregnancy until a year after the last menstrual period (when it can then be definite that menopause has been reached).

Even if there are other signs of the perimenopause like hot flushes, it does not mean that one cannot get pregnant. About 75% of pregnancies in women over the age of 40 are not planned.

If pregnancy is not desired, it is important that an appropriate, effective and safe contraceptive method be used. A pregnancy in the 40s will impact not only on the individual's health, but also on family and social life.

Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with. For further information, e-mail starhealth@thestar.com.my. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader's own medical care. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

SERVICES