Understanding your normal physiology

There are numerous popular fads regarding menopause. Some, like getting a tubal reversal after 5 years of tubal ligation can induce menopause, are absurd, while others, such as hot flashes, are certainly true. In order to understand this and pick the truths from the myths, you need to go a bit deeper into the physiology of normal menopause.

An oocyte is an immature cell in the ovary.  A primary oocyte is formed in the ovaries of a woman before her birth. It becomes a secondary oocyte after the onset of menarche (the first menstrual period). This oocyte then becomes an ovum, which is released from the ovary during ovulation and perhaps fertilized by a sperm to form a zygote (a future embryo which then develops into a fetus).

When a female child is born, there are up to 100,000 oocytes in her ovary. Only about 400 are used in her reproductive life. Normal menopause occurs when these oocytes become depleted or non-functional.

A typical menstrual cycle occurs in fixed phases under the effect of various hormones. The following is a simple summary of a menstrual cycle.

A Regular Menstrual Cycle

Follicle Stimulating Hormone FSH and Luteinizing Hormone LH are secreted by the anterior pituitary gland. They are both released under the effect of gonadotropin releasing hormone (GnRH). This GnRH is released by the effect of Estrogen, yet another hormone. This estrogen is released by a mature follicle during the follicular phase. This follicle contains a primary oocyte. When the size of a follicle is big enough, the estrogen triggers a sudden release of LH. LH in turn helps in maturation of the oocyte into secondary oocyte and finally ovum, and it is released from the follicle in the ovary during ovulation. The empty follicle left behind is now called a corpus luteum.  This does not get destroyed right away but persists for some time in the ovary, releasing progesterone.  The progesterone makes a uterus receptive for an embryo to be implanted. This corpus luteum also releases inhibin, which inhibits or suppresses the release of FSH and LH temporarily. The unfertilized egg must then travel through the fallopian tube to reach a sperm coming through the tube from the uterus. (A tubal ligation would prevent this meeting of the egg and the sperm, and a tubal reversal could repair the ligated tube so that the egg and sperm could meet again). If they meet, and fertilization then occurs, the embryo is implanted in the uterus and forms a placenta. The placenta releases hCG which causes the corpus luteum to continue to release progesterone. In case of no fertilization, this corpus is reabsorbed and disappears in most cases. As there is no progesterone now, the mucosal lining of uterus gets destroyed, initiating menstrual bleeding. The effect of inhibin is lifted from FSH and LH, and the increase in FSH causes formation of more follicles to start the process again. Only one follicle matures to become the dominant follicle, the future corpus luteum, holding the primary oocyte.

So this was a normal menstrual cycle, when is normal menopause?

A primary follicle produces estrogen. With age, the oocytes become non-functional. As a result there are fewer primary follicles, reducing the levels of estrogen in the body. Without estrogen there will be no LH surge and no ovulation. No ovulation means no progesterone. That means general thinning of uterine mucosa, vaginal atrophy, and erratic menstruation. Furthermore, the perimenopausal symptoms that you experience i.e. insomnia, irascibility and headaches are due to the lack of estrogen. Post-menopausal urogenital symptoms and osteoporosis are also due to this low level of estrogen. Hormone replacement therapy is often prescribed to cut down the incidence of such symptoms.

Can menopause be induced?

Yes, a hysterectomy can induce menopause if the ovaries are also removed. It will then be called surgically induced menopause.

Will any surgery performed on my uterus induce menopause?

No. Except for removing the ovaries, or some brain surgeries, there are no other surgical procedures that will induce menopause. Neither tubal ligation nor tubal reversal has any effect on menopause.

We can look at 45 as a usual time when premenopausal symptoms first appear.
Unlike the popular misconception, premenopause does not only refer to irritability and mood swings but a whole set of distinct physiological symptoms. These symptoms may be vague independently but together confirm a woman’s ingress into perimenopause.

The symptoms every woman should be able to tell are irregularity of menstruation, hot flashes and associated stress/ irritability. Here irritability is not the primary symptom but an associated one.
There may be associated depression, weight gain, water retention and headaches as well.

At times, these symptoms may cause quite a bit of discomfort, resulting in women thinking of various solutions, many of which are suggested by other peers in small chats and internet chat rooms.

Remember, this is your health we are dealing with. Therefore always consult your gynecologist before considering a drastic measure like hysterectomy or tubal reversal without revealing your true reasons.

How long will this disease last?

Technically speaking, premenopause or menopause is not a disease but merely a switching phase of the body, accompanied with some uncomfortable and, at times, debilitating symptoms. There have been known cases of women who experience sudden cessation of menstruation. However, for the majority, it is the usual grill i.e. approximately 3-6 years of premenopause followed by 2-4 years of postmenopausal symptoms. The symptoms may be mild enough to ignore and severe enough to ask for medications.

Do I need medication?

That is for you and your doctor to decide. If you are experiencing nonadjustable problems, you should seek proper medical advice. The symptoms are basically due to hormonal fluctuations. Most women complain of lack of energy in addition to the above-mentioned symptoms.

In either case, you may consider many alternatives.

How will it affect me in future?

In the best way possible! You will not have to experience menstruation and associated body cramps. You won’t have to worry about unwanted pregnancies. The depression and stress is momentary and will pass away before you even notice. This phase is tough but will be gone soon.

Is there anything that I did to cause this?

No. This is inevitable and unavoidable. You may have accelerated its onset but no matter what you did, this was nonetheless bound to happen. It is a natural process.

What do you mean by my accelerating its onset?

Yes it is a possibility that certain aspects of your lifestyle caused an earlier onset of menopause. Those aspects are:

1. Hysterectomy (as it only removes the uterus, not the ovaries)
2. Smoking
3. No history of pregnancy
4. Treatment history of pelvic radiation or chemotherapy

How do I know when to go to a doctor for my premenopausal symptoms?

In case of unusually heavy bleeding, longer menstruation i.e. more than 9 days, shorter cycle, and spotting in the middle of cycle, you need to see your gynecologist regardless of appearance of other symptoms.

Is this dangerous? Will I have to undergo a surgery? Will the surgery be reversible?

Whoops, lots of questions there. No it isn’t dangerous and you will not necessarily have to undergo a surgery. Most of the times, hormone replacement therapy HRT is advised. This therapy may be a combined pill or a progestin only therapy, depending upon your spectrum of symptoms.

Occasionally endometrial ablation is performed that is destruction of uterine mucosal lining. This is a surgery and not reversible. Even if you opt for a hysterectomy, that is not reversible. The reversible procedure you might be thinking of is tubal reversal which is done to reverse a tubal ligation. That has no effect on menopause at all.

Although we started with tubal ligation, we will proceed with this health education in a systematic fashion. The reason we wrote about tubal ligation before anything else is because we received most of the queries pertaining to tubal reversal, the symptoms and other associated areas.

We have decided to cover the vast area of menopause in various educatory sessions in a similar manner and hope to satisfy the curiosity of our loyal readership.

Comprehending Menopause

More than anything else, women need to learn about menopause in a much more detailed way than ever before. Even their male counterparts need to know about this so that they will understand what it is that women must endure.

Menopause is mandatory. Whether you like it or not, it is going to happen. It is nature’s way of relieving the women of their childbearing labor and giving them official rest. You can choose to enjoy this phase of your reproductive life, or worry endlessly because of countless unanswered questions.

Rather than avoiding discussing it, menopause should be embraced with an open heart and mind.

Clinical view of Menopause:

The verbatim definition for a layman:

Menopause is “the permanent cessation of menstruation, occurring usually between the ages of 45 and 55”.

A clinical definition of menopause which you all should know is:

Menopause is one day- the date when 12 months have gone by since your last period.

When you hear people around you, saying that X or Y is going through menopause, what they are actually referring to is perimenopause. Perimenopause is truly the span of transitional years around the last period ever, both before and after. Perimenopause can be understood in 2 phases.

1. Pre-Menopause
2. Post-Menopause

Together, they can be referred to as perimenopause or as the general public sticks to saying, menopause.

Around what age is usually perimenopause and menopause expected?

Where majority of the women undergo perimenopause between 45-55 years of age, variants have been noticed. We have seen as young as 34 and as old as 64 to undergo perimenopause, however such cases are rare.

When explaining about a medical condition such as menopause or perimenopause, we usually stick to the normal age range of the state, and hence in this case we will talk of the 45-55 years bracket.

Exactly how do I know I am in the brackets of Perimenopause?

If you are above 40 years of age, are experiencing a marked difference in your usual menstruation pattern and are having the trademark “hot flashes” and night sweats, it is highly probable that you have entered the perimenopause.

Do not account mood swings for the diagnosis since they alone are a highly undependable factor and have a multifactorial origin.

Is there any way I can delay it?

Menopause is nothing to be ashamed of, or to be delayed. It is as natural a change as menarche, the onset of menstruation. You only need to take care of yourself and your body. This change is important since as you grow older, your body loses the kind of power and energy required for carrying a pregnancy as well as a laborious child birth.

You may hear all sorts of false suggestions to delay menopause, like hysterectomy, tubal ligation, tubal reversal, or hormonal therapy, but this is inevitable and should be anticipated and prepared for, instead of against.

Embrace it instead of fearing it.

Vaginal atrophy can affect women of all ages but it is more common that women between the ages of 40 to 59 will suffer from dryness, itching, and burning related to vaginal atrophy. In the top ten afflicting problems of menopausal women, this is often at the top of the list. It is not expected or predictable. Vaginal dryness is because of many reasons. In younger women, dryness can be caused by birth control pills, surgical treatments (like cystectomy or tubal ligation), emotional issues, and multiple other medical conditions.

Vaginal dryness is often experienced when there is a lack of vaginal lubrication, often caused by a lack of estrogen production. Some will develop female sexual dysfunction which can cause one to dread intercourse and to avoid sex. Intercourse can be very painful. These women may also experience libido problems as well. Hormonal imbalance is also the cause of vaginal dryness, as well as chronic yeast infections, bacterial infections, or some kinds of cleansing of the vagina.

Many couples use condoms and foam or a method that involves a gel of some kind. Birth control pills sometimes do not provide the required level of estrogen and production of testosterone to maintain vaginal lubrication and necessary libido.

To resolve these issues there are many steps which can be followed. Use of a water soluble lubricant like Astroglide may be helpful. Estrogen therapy is useful if there is only vaginal dryness. Women who use vinegar, bubble baths, hand lotions etc can cause this dryness to become more complicated and lead to infectious.  Use of multivitamins or mineral supplements can be useful as well. Balanced diets can and proper nutritional intake can help maintain a healthy lifestyle and reduce some of the complicating issues surrounding vaginal dryness.

Many women who don’t want to have babies for the rest of their lives permanently they go for tubal ligation surgery. After tubal ligation women experience many side effects in which hormonal changes are the one most common. But with the change in life circumstances, some women want their own babies they want to reverse the process. Many will elect to undergo a tubal reversal. Other than having their own babies, women will proceed with a tubal reversal for many reasons. Women who undergo the process of tubal ligation may experience irregular and painful periods, vaginal dryness, menstrual related problems, trouble sleeping, hot and cold flashes, loss of libido, early onset menopause, mood swings, palpitations etc To resolve some of these issue they seek out a tubal reversal. While tubal reversal my not be the best solution for these problems, some women find that a tubal reversal procedure may help them feel more psychologically sound. Many will attribute a tubal reversal with the resolution of some of these complaints.

When you make love and have pleasant feelings, sometimes you find that you start bleeding, and this may ruin the moment for many couples. Many women ask ‘why does this happen?’

The reasons are many. While this could be the beginning sign of some serious disease, usually it is not. You should consult your doctor because this may lead to problems like infertility issues, uterine polyps, fibroids, some vaginal infections, or a lack of estrogen in vagina to lubricate it.  These all can lead to the heavy menstruation with clots and other serious vaginal issues. Vaginal infections can be bacterial and may cause burning, itching, inflammation, and swelling.

Usually spotting after intercourse is caused from uterine bleeding, but may be from cervical bleeding as well. It may be due to a lack of lubrication from low levels of estrogen in the vagina. This makes the vaginal lining thing which can easily bruise during intercourse. If you are a breast feeding mom, this is very likely because breast feeding moms have less estrogen in the vagina.

Also, during intercourse, some women experience vaginal tears because of lack of lubrication or too rough sex. This can also be due to an infection that causes the cervix to become very sensitive and to bleed after intercourse.

Tubal reversal is the process of reattaching the fallopian tubes that were separated in the tubal ligation process. It is now completely possible to reverse this procedure for those couples who change their mind and decide that they want to have more children. The advancements made in tubal reversal surgery are very good news for those who wanted to have babies again after a tubal ligation.

In tubal ligation, doctors may clip, burn, tie, or cut the fallopian tubes. To adequately counsel the patient and her partner, we must have the detailed previous report of the tubal ligation surgery. Depending on the type of tubal ligation, we can access how many places the tubes are burned, or how much of the fallopian tube was destroyed. If these details are not mentioned, the tubal reversal success rate will not be as accurately determined prior to the surgery. In order to reattach the tubes, there must be some healthy part of fallopian tube for the tubal reversal. The total length of a fallopian tube is normally about 10cm. At least 5 cm of healthy tube on each side is optimal to conceive again with success rate of as high as 80%. Although pregnancies do occasionally occur with tubal lengths as little as 3 cm.

In the burning procedure of a tubal ligation, the normal practice of doctors is burning of three points of 1 cm each on both fallopian tubes. The process can also be performed with burning of tubes from two points. The success rate of a tubal reversal is directly related to the final length of healthy fallopian tube left after the tubal reversal.

Dr. Morice and his team provide the excellent surgical care that maximizes the chances of a successful tubal reversal. Dr. Morice is an experienced expert in performing tubal reversal surgery with Microsurgical Tubal Reanastomosis (MTR) techniques.