The Definition of Menopause
Meno’ comes from the roots of ‘bleeding’ and ‘pause’ means stop, and the word menopause literally means stopping bleeding. As a clinical definition, it is defined as the woman’s inability to have menstruation for a year.
In the vast majority of women I have followed in my clinical practice, this period is quite alarming, and fewer women see menopause as a pleasing period. Again, a minority group of women perceives it as completely natural and remains not having comments. In fact, all three groups have their own lives and personality profiles, justified considering their family stories. Reasons for the satisfied minority who are tired of having menstruation is the possibility of avoiding anxiety of protection and decreasing the frequency of breast cancer. The reasons for the majority of the anxious group constitute the reasons for the discussion of menopause treatment, which we will talk about.
First of all, we have to believe wholeheartedly, this period is an important part of our life, and it is a naturally and long time period in which we live bringing some of the natural comforts of life.
Average Menopause Age
The average age of menopause is given as 47-48 in Turkey and the world and this period is extended as much as rare as can be seen from as early as age 54-55. The appearance of menopause before the age of 40 is also called early menopause.
Physiology of Egg Reserve
6-7 million egg cells are located in the ovaries of a baby girl in the womb and this number decreases to 2 million at birth. When the girl has the first menstruation, this number is around 700,000. This is also the number of eggs at the age when fertility begins. One egg becomes dominant in each menstrual cycle, cracks around 20-22 mm and is thrown into the abdominal cavity. Meanwhile, the tuba (Fallopian tube) covers the tiny egg cell and if the egg joins the sperm into the tube, the first step of pregnancy is taken. If this process does not occur, the woman will have menstruation approximately 14 days after ovulation. During the formation of one dominant egg, many egg cells are eliminated in the race and are known to disappear. The reduction of the ovarian reserve naturally at the age of 35-40 or unnaturally at an early age reduces fertility and makes it impossible during the menopause.
This long period between the age of sexual maturity and old age has been gradually prolonged with the increase in life expectancy all over the world and the risks of menopause period have been more discussed with their lifestyle and treatments.
Complaints in the Menopause Period
It is appropriate to divide the complaints into two as a period. Increasing or decreasing the frequency of menstruation in the early period of menopausal complaints called premenopausal period, decreasing the amount of menstrual, sometimes interrupting suddenly are the problems of menstrual order. Basically, the complaint that disturbs the woman socially and psychologically is the intense flushing and sweating in the upper chest, head and neck region. Especially in women with an active working life, flushing and sweating should be perceived as a serious social problem. These symptoms will disappear in most women after 3-5 years. However, it is known that it can grow up to 10 years in 10%. It is possible to talk about sleep disorders, irritability, mood disorders, depression tendency and occasional sexual desire disorders due to the reduction of estrogen.
In the late period, due to the fact that estrogen is close to zero, the cardiovascular system can no longer be protected adequately and the rate of heart attack associated with it, increase the risk of brain bleeding, increase the frequency of thromboembolic events, osteoporosis, skin wear, vaginal dryness and sexual dysfunction.
Medical Approaches and Examinations in Menopause
The main requirement of this period is to consult the physician and have the necessary examinations and examinations and to obtain detailed information about the menopause period.
The most important step in the woman’s application is to question her life well, to determine the severity of the complaints and to take the family story very well. Because these points always lead in treatment requirements and limitations.
Then, a very gentle, careful, practical and as fast as necessary gynecological examination should be performed, and the external genital area (vulva) and vagina should be examined with a single amount of vaginal lubricant if necessary, without increasing the sense of anxiety of the woman, pap smear should be taken and then the uterus (uterus), endometrium (intrauterine tissue) and ovaries (ovaries) should be evaluated in detail by ultrasonography.
In women who have never had sexual intercourse before, only the vulva can be evaluated, but since the speculum cannot be attached, smears cannot be taken and there is no need. Rectal examination can be done in special necessity situations, but it is usually sufficient in abdominal or rare rectal ultrasonography examination.
Then comes the second stage of the examinations, which is; breast screening. Mammographic search begins at the age of 40 and is repeated based on the woman’s personal and family history, compared with the previous examinations in 1-2 years. Ultrasonography accompanied by mammographic evaluation and, if necessary, performing breast ultrasonography annually reduces the possibility that early breast cancer cannot be screened. It should always be remembered that the fact that ultrasonography works with the principle of sound wave, does not contain radiation. It should be remembered that the chance of early diagnosis can be eliminated in a woman who does not have a mammogram with the belief that she will have breast cancer if she gets mammography. The remarkable rate in the age distribution of breast cancer is that 75% of them are seen after the age of 40. Failure to scan the 25% frequency seen before the age of 40 presents an early diagnosis difficulty and it seems quite rational to start scanning with breast ultrasonography at 35 years of age.
Osteoporosis occurs as a result of the bone-building rate not meeting the destruction rate, and this process may be more negatively affected by estrogen deficiency. Bone densitometry provides information on bone density, but the age of onset and frequency of examination should be completely adjusted to the characteristics of the woman herself and her family. Endocrine diseases such as the use of drugs such as early or severe osteoporosis, cortisone and hypothyroidism in the family are risk factors for osteoporosis and this group should be handled with more careful reasons. Due to fractures in the spine that occur with osteoporosis, shortening of length, hump and even rarely paralyzed. The most important problem of osteoporosis is hip fractures where death rates up to 15% are given.
Other biochemical tests, such as liver function tests, should also be performed if blood biochemistry specifically provides information about blood fats and hormone replacement.
Treatment in Menopause
Let’s come to the most controversial topic: should we use hormone replacement therapy in menopause? We should use it?
It is a common medical practice to use estrogen instead of decreasing natural hormone since the 1970s. Basically, for treatment estrogen and progesterone hormones are used together to protect women from endometrial cancer in women without a uterus. Hormone therapy has been used safely by many women for years and is particularly effective in flushing, sweating, skin protection and psychological problems. Hormone replacement therapy is known to be highly effective in osteoporosis or osteopenia (reduced bone density). However, the prevention of heart attack and its protective effect on cardiovascular diseases are controversial.
In HERS 1 and HERS 2 studies published in JAMA in 1995, it was stated that if the woman had a heart attack before, the risk of thromboembolism increased in the first years of hormone replacement therapy. In terms of cardiovascular diseases, no difference was found between women who received hormone replacement and women who did not.
The most comprehensive menopause study is the WHI study, which was attended by 16,000 women between the ages of 50-79 and continued for 5 years. In this study, the risk of breast cancer increased from 3/1000 to 4/1000 with hormone replacement therapy, the risk of having a heart attack increased from 3/1000 to 4/1000, the possibility of brain bleeding increased 1/1000, and the frequency of thromboembolic events increased 2/1000. It indicated. In addition, it has been stated that colon cancer is reduced by 40% and the likelihood of osteoporotic hip (femur) fracture is reduced by 35%. In March 2002, it was decided that the risks were high in the profit-loss rate and the study was terminated early. Afterwards, the study was criticized and terminated early due to standardization problems such as wide age range, evaluation of smoker and obese women in the same group as normal weight and non-smoker group. It was also emphasized that the frequency of breast cancer in women taking only estrogen does not change, and the combined treatment with progesterone should be discussed. Although it was mentioned about heart attack, brain haemorrhage and thromboembolic increases, it was found that mortality rates did not change between the group who received and did not take hormone replacement therapy in the following years. At the end of the day, the WHI study caused women to have a great fear of hormone therapy and to leave hormone therapy almost worldwide. Hormone replacement therapy after many years of study, after the health problems caused by the menopause process, it was started to be discussed again. In our day, where the expected life expectancy of women exceeds 80 years, I think that if the woman’s health conditions of the post-menopausal period is appropriate and meticulously followed, she should be supported with hormones.
Hormone replacement therapy in menopause is started as combined (preferably mirena + estrogen) in the woman with uterus, and only estrogen in the non-uterus woman. Estrogen can be used by mouth, glued to the skin or rubbed into the skin in gel form. Here, among all of this information, the most valuable issue is the product to be chosen in hormone therapy. All the tablets we take orally are synthetic. Hormones that enter the systemic circulation and have a liver transition may increase the risk of thromboembolism. In addition, this group constitutes the core of the discussion in terms of breast cancer risks. However, preparations used as a patch or gel from the skin bypass the transition to the liver and go directly to the systemic circulation. It does not increase the risk of thromboembolism. In addition, patch and gel products that are used in transdermal way are considered bioequivalent hormones and do not change the risk of natural breast cancer in women due to lifestyle and family history.
Starting treatment at an early stage of menopause is always more effective and can be continued for 5-10 years. As always, the treatment should be organized entirely for women, and a profit-loss calculation should be made every year by evaluating the situation with the dentist and the continuation of the treatment should be decided together. The fact that hormone replacement therapy is essentially beneficial in menopause as long as the woman meets her own conditions should not be forgotten, but it should be kept in mind that the woman receiving the replacement cannot continue treatment without being followed up.
I PROOFLY SELECT PATIENTS WHICH ARE SUITABLE FOR HORMONE TREATMENT IN THE LIGHT OF ALL THE BASIC MEDICAL INFORMATION, CURRENT PUBLICATIONS, COMPILATIONS AND MENOPAUSE ASSOCIATIONS IN THE WORLD. In my menopausal patients, I question the family story and the patient’s own story very well, and then evaluate it with gynecological examination and PAP smear, gynecological ultrasonography, mammography, breast ultrasonography, bone density, detailed blood tests. I start treatment in patients with suitable conditions and I continue with continuous cooperation and meticulous follow-up. In this area, I give a detailed consultation on Bioequivalent hormone use, detailed nutrition, exercise plans, weight management and most importantly stress management by evaluating with a functional medicine perspective. The menopausal period is a period that covers at least one third of our life and it is necessary to work in close cooperation in order to spend this in the healthiest way.