So, what about ovulation?

Doesn’t menstruation mean I am ovulating and that I can get pregnant?

Possibly. Ovulation may begin with menarche or it may not. When there is no ovulation, you are going through anovulatory cycles.

Pregnancy it has been known to occur even before the menarche. You need to understand that menarche may happen without involving the release of ova at all. The blood flow is from the uterine tissue disintegration and that may happen without ovulation. This is why you need to realize that there are many stops where essentially anything can go wrong, resulting in menstrual irregularities.

So what are the irregularities?

Anything in menstrual cycle that is not normal is an irregularity. Here are some common definitions:

No flow:   Amenorrhea

Long cycle(Infrequent):   Oligomenorrhea

Short Cycle:   Polymenorrhea

Heavy Flow:   Menorrhagia

Pain:   Dysmenorrhea

This is the usual nomenclature applied to menstrual irregularities. These are basically the descriptions of the irregularity. The underlying cause is the actual disease or Illness that needs to be treated. This is why an abnormality in your menses is worth following up. Sometimes they may be affected by vague circumstances ,but it is better to end up with a “don’t worry” diagnosis than a late diagnosis of something much more serious.

What are the vague / external circumstances?
These are numerous. Just to explain what these external factors can do, notice the following:
A.    Early onset of menarche (earlier than 12 years of age)
1.    Childhood Obesity
2.    Family Conflicts
3.    Absence of father figure
4.    Ovarian  or other tumors
B.    Late onset of menarche (later than 16 years of age)
1.    Close association with father / father figure
2.    Large family
3.    Abnormal pathology of reproductive tract

The menstrual cycle is itself affected by all these factors and more. These factors are:
1.    Stress: Family related or socially induced
2.    Sudden weight gain or weight loss
3.    Eating or emotional disorders
4.    Excessive exercising
5.    Unhealthy lifestyle i.e. smoking

What possible diagnoses can cause menstrual irregularities?
There is a wide array of possible diagnoses that we can reach depending upon the type of irregularity an individual is facing. We will discuss each possible diagnosis in further detail in the later articles in the series.

Will early diagnosis save me?
Do not assume that you have something untreatable. Having time as your ally is even better. However in order to get started on the treatment, you do need a diagnosis. Getting started as soon as possible is the best option as the majority of the illnesses can be treated medically with a good prognosis.

What is a normal period?
A normal period has the following characteristics:
A normal period is Eumenorrhea.
1.    This is a cycle of 28 days plus or minus 7 days
2.    Bleeding of 2-7 days
3.    Blood loss of 10-80 mL

When there is a deviation from this pattern, you are looking at a menstrual irregularity.

What about pain?
Some amount of pain and mid-cycle symptoms are normal. Excessive pain, intolerable pain in menstruation, called dysmenorrhea, is an irregularity.
We will discuss individual disturbances in the next article.

Once you have entered menopause, you will find yourself free of most of the symptoms of pre and peri-menopause, particularly the menstrual problems i.e. irregularity, heavy flow etc. Not only that, but you may even find yourself more energetic and present-minded than in past 5-6 years during peri-menopause.

So you may ask now, if I have overcome of all the symptoms, what exactly is the big deal about being menopausal?

How long does this post-menopause state go on? Forever?

Technically speaking yes, even if you die at the ripe old age of 120, you are still in menopause, but that does not mean that you are still experiencing symptoms. For example, you can still call yourself postpartum years after your child’s birth because technically you are post-partum.

So what is happening to my body in postmenopause?

Your hormonal levels are juggling in order to settle on a fixed level. If you get your FSH levels tested, you will find a higher level of FSH. This means that more FSH is being produced by the pituitary gland, going into an overdrive, in an effort to stimulate follicular formation in your ovaries. This is indeed a futile attempt on the part of the pituitary gland.

Will I have a high level of FSH throughout my life? Isn’t that dangerous for my health?

Yes, you will have a sustained high level of FSH throughout your life, but this is not dangerous at all. It causes no harm. However, if you go for hormone replacement therapy, this high level of FSH will come down.

Are there any other hormonal differences apart from FSH?

Yes, your estrogen production has changed its production site.  While you were in premenopause, estrogen was primarily produced in your ovaries all your life. However, when in menopause, your fat cells take the major role of production of estrogen.

What if I undergo a hysterectomy before menopause?

If you also have your ovaries removed, you will then bring your body into a surgically induced menopause. The effects will still be the same as if your ovaries quit working in a natural way, but the effects will be sudden rather than gradual.

Can a tubal reversal accelerate menopause or perimenopause?

No, tubal reversal surgery is not related with the onset of menopause in any manner. If you are looking to reverse your tubal ligation, do not consider menopause as a risk of tubal reversal surgery.

Are my bones and teeth going to be affected?

There is a potential to develop decreased bone mineral density after menopause. You should continue to follow a healthy lifestyle and have this condition screened on your visits to Dr. Morice. Osteoporosis is a risk that we all face as we age. As such, it is of utmost importance that women adopt a healthful lifestyle, especially before menopause. However, if you have not done so earlier, it is never too late.

You need to develop positive habits and get rid of negative ones i.e. smoking, excessive drinking, overeating etc. You should also take a minimum of 1000 mg of calcium per day in order to avoid significant osteoporotic changes.

There are many nutrient supplements available in the market. Make sure you take adequate vitamins, especially vitamin D and calcium.

You should also work out and exercise regularly. It does not have to be a vigorous routine, but a 15-minute daily walk can do wonders.

Is adjusting to menopausal life hard?

Not at all! It is the peri-menopause that gives women the most trouble. By the time you are in menopause, most of the dreadful peri-menopausal symptoms are gone. You are no longer irritable or moody since you have had ample time to adjust physically and mentally to the end of menstruation. The childbearing years are long gone and you have more time to spend on yourself, your health, and your body. Most of the career women are now settled comfortably into their professional lives and the earlier professional stress is often dissipated as well.

Menopause, for many, is actually the beginning of a life free of stress and tension. Menopause often marks the beginning of a new era in a woman’s life, where she can now concentrate on her own well-being.

Menopause is still considered a taboo subject and is not open to public discussions. Women find it easier to rely on word of mouth than consulting an authority on the subject. Some even look at menopause as a dreaded evil.

Through this section we will try to cover as many random queries related to menopause as possible. These include home remedies as well as issues like pregnancy and menopause.

I am taking hormone replacement therapy. I still experience lethargy and stress. Why?

That is quite a normal occurrence. This also depends on the type of therapy you are taking. Many women find progestin-only therapy much more suitable as compared to a combined pill. As for the stress, you might benefit from lifestyle changes, coping mechanisms, or other medications. Consult Dr. Morice for further advice.

What can I do, without medications, in order to ease the symptoms of menopause?

1. Take better care of your body. It may sound a little trite, but this may offer protection from all sorts of illnesses as well as postmenopausal symptoms.
2. Eat well. Make sure your daily intake of calcium and iron is adequate, since menopause effects bones too. A fiber-rich diet that is low in fat is best.
3. Go for supplements. If you think you cannot cover essential nutrients like calcium or vitamins in your normal diet, take supplements.
4. Exercise regularly. Walk daily. Do cardio exercises for your heart. Try investing a few minutes a week in Yoga or Pilate.
5. Remove stress-inducing factors from your life. Work out the stressful aspects of your life and get rid of them for once and all.

Is pregnancy possible once I am into perimenopause?

Yes. Although not common, it is known to occur. Unless declared menopausal, you can never rule out the possibility of a pregnancy. Make sure you take adequate contraceptive measures if you are not interested in getting pregnant.

I have been having recurrent vaginal infections ever since I entered perimenopause. Are the two related?

There is no direct causal relationship. You may have read earlier, that in perimenopause, there is direct effect on urogenital system and vaginal dryness too. This dryness can be a precipitating factor in vaginal infections, however, menopause does not predispose you to infections in any way.

Is menopause known to be related to neurological disorders?

No. There is no known association of menopause or perimenopause with neurological disorders. However, since this is quite a stressful period in a woman’s life, stress, depression, mood swings, and other psychiatric complaints do occur quite frequently. Many also complain of lack of concentration and a preoccupation with these symptoms.

Does one put on weight in menopause?

Quite a few times, yes. But a lot of it is due to depressive binging of food and lethargy. If you eat healthy and work out regularly, there is no reason why you should put on weight in menopause.

How does one get surgically induced menopause?

Removing the ovaries (oophorectomy), which often occurs with hysterectomy, will result in surgically induced menopause almost immediately. Other procedures such as tubal ligation or tubal reversal do no cause menopause.

Does any clinical condition induce menopause?

Yes, with premature ovarian failure, there can be early menopause.

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.