02 - 2334418

Climacterium or menopause

When climacteric symptoms disturb your daily life, it is worth while to consult a gynecologist. If you have significant gynecological problems, like unexpected bleeding after menopause, you should book a time to see gynecologist for examinations. 

The word climacterium refers to the time period when the function of the ovaries gradually decreases and finally ceases. Strictly speaking, the word menopause refers to the cessation of menstrual bleeding, but often climacterium and menopause are used interchangeably. The menopausal symptoms are a consequence of a decreasing number of ovarian follicles which causes ovulation to cease; this leads to a decline in the production of the female sex hormone estrogen.

Among Finnish women, the menopause takes place at an average age of 51 years, the variation is between 45 and 55 years. The climacterium is considered to begin when the time since the last periods is one year. The menopause may occur earlier, if the ovaries are removed or get radiotherapy or if the patient has received certain cancer drugs. The menopause comes on average 1–2 years earlier for smokers than non-smokers.

Climacteric symptoms may emerge before the periods cease, but usually symptoms are worst within the year following the menopause. For some women, the climacteric symptoms may continue for a long time, but there are also women who have no symptoms at all. Hot flushes are experienced by 70–80% of the women, but only some 10-20 % have severe hot flushes. Within 1–5 years sweating is usually relieved. Sweating is especially common at night, it comes in bouts and disturbs sleep. Daytime sweat bouts may also affect the woman’s working capacity, in addition to the poor night sleep due to night sweats. Many women experience at the same time heart pounding (palpitations) and facial flushing. The reason for the hot flushes is not well known. Sleep disturbances are common also among women who do not have night sweats.

Estrogen deficiency leads to thinning of the mucous membrane of the vagina, which is experienced as vaginal dryness, and occasionally as a burning sensation and as painful intercourse. Urinary urgency and other urinary symptoms are possible, as well. Bone mineral loss accelerates after the menopause. Some women have musculoskeletal symptoms, e.g., joint and muscle pain. Irritability, melancholy and loss of initiative are also associated with the climacterium. Poor sex drive occurs.

Lab tests are not usually needed to diagnose the climacterium. Occasionally, e.g., if early menopause is suspected, the concentration of follicle stimulating hormone (FSH) in a blood sample is checked, and if the concentration is high, this would be typical for the climacterium.

Treatment depends on the impact that the symptoms have on the woman’s life. Regular exercise may alleviate symptoms. It may be prudent to avoid coffee, very spicy food and smoking – all known to worsen climacteric symptoms. Overweight provokes symptoms. Clinical drug trials have failed to prove effectivity or safety of natural products.

If selfcare does not provide enough help, hormone replacement therapy (HRT) may be used. Estrogen alleviates the climacteric symptoms. However, estrogen alone may only be used by women whose uterus (womb) has been removed, because estrogen increases the risk of uterine cancer. Because of this risk, estrogen must be combined with a cancer-protecting agent, a progestin (derived from progesterone). HRT is possible with tablets, drug-containing gel or skin patches or a hormonal IUD. Estrogen has beneficial effects not only on climacteric symptoms but also on the skeleton. Local application of estrogen on the vaginal wall alleviates the symptoms originating from the vaginal mucous membranes, reduces urinary tract infections and alleviates urinary incontinence.

This treatment is contraindicated in patients who have had breast cancer, a venous blood clot, who have a familiar tendency to get blood clots and who have untreated hypertension. HRT seems to be associated with a mildly increased risk of breast cancer. Population studies have shown that the increased risk becomes evident only after at least three years of hormonal treatment. The risk increase caused by estrogen treatment without other active drugs is smaller than the risk of estrogen + progestin. The risk decreases gradually and reaches baseline by four years after treatment has been discontinued.

Of the other risks of HRT, the impact on the risk of coronary artery disease depends on at what age and at what stage of the climacterium treatment is started. HRT probably protects against cardiac events if treatment is started for healthy women soon after the menopause, but if treatment is started later, cardiac events increase. The risk of stroke (brain infarction) increases, especially with age. Use of estrogen alone or of combination hormonal treatment is also associated with a slight increase in the risk of blood clots; this risk is highest soon after HRT has been started.

Thus, HRT has beneficial effects which improve the woman’s quality of life, but it does have some risks. A Finnish panel of experts has recommended that for women with no contraindications who have climacteric symptoms that need to be treated, the best is a dose of hormone that provides symptom relief which is as small as possible and which is used for as short a period of time as possible.