A woman’s life is beautiful at all ages, after entering the age of 40 should also have the beauty of maturity, however, the years are like water, time is like an arrow, the fallen flowers have quietly come to the season. The original black and shiny hair began to be interspersed with white silk, smooth and clear skin also gradually lost firmness and elasticity …… estrogen secretion reduction directly led to perimenopausal women into the eventful autumn. This article will provide a systematic analysis of perimenopause (menopause) in women, answer various questions about women’s menopause, analyze the characteristics, causes, clinical symptoms, treatments and common medications, and guide perimenopausal women to enjoy their lives better.
I. Definition
Perimenopausal syndrome refers to a series of physical and psychological symptoms caused by fluctuation or decrease of sex hormones due to the decline of ovarian function and decrease of estrogen in women before and after menopause.
Changes in the age of menopause and factors affecting women
At present, the average life expectancy of Chinese women has reached 75 years, and the age of menopause usually ranges from 45 to 55 years. In clinical practice, menopause before the age of 40 is called “early onset menopause” or “premature ovarian failure”, and menopause after the age of 55 is called “late onset menopause”. If the ovaries have been removed due to some disease, or if the ovaries have lost their function due to radiation or chemical drugs, and menopause has occurred as a result, it is called “artificial menopause”. The most important factor in determining a woman’s age at menopause is the number of oocytes in her body. As a woman ages, her ovaries decline in function and stop ovulating, resulting in a gradual decrease in oocytes and menopause. The age of menopause may be related to the following factors.
1. Genetic and family factors: If the mother and sisters have menopause earlier, she will have menopause earlier; if not, she will have menopause later.
2, nutritional status: related studies have found that women with chronic malnutrition, short stature and low weight are generally menopausal earlier. While the nutritional status of good, taller, relatively heavy women are later menopause.
3, disease factors: in general, suffering from systemic chronic wasting diseases, metabolic diseases, endocrine diseases, etc., can lead to early menopause in women. In addition, women suffering from malignant tumors after radiotherapy can also cause premature ovarian failure and lead to menopause. Women suffering from uterine fibroids, cervical cancer, breast cancer and other diseases can have a delayed age of menopause.
4. Marital status: Generally speaking, married women have later menopause than unmarried women; women with fewer pregnancies have earlier menopause; women with longer breastfeeding periods have later menopause. This is because pregnancy and lactation can temporarily inhibit ovulation, thus relatively prolonging the ovulation time of a woman’s life and delaying menopause.
5, smoking and alcohol abuse: smoking is an important factor in the early age of menopause in women, which is caused by nicotine affecting the blood supply to the ovaries, causing premature failure of ovarian function. Alcohol can directly damage the gonads and lead to ovarian atrophy.
6, mental factors: studies have shown that women with a good relationship and a harmonious sex life have a later age of menopause than women with a bad relationship, indulgence or lack of sex life. Especially women with high mental stress, overwork, long-term depression, anxiety, more likely to early menopause.
7, surgery or cancer treatment and other “artificial menopause”: surgery to remove two ovaries will lead to early menopause. Women who are induced (by surgery or cancer treatment) to go through perimenopause tend to have more severe menopausal symptoms because their estrogen is suddenly and significantly reduced, unlike women who enter menopause naturally, whose estrogen levels are gradually reduced over a period of years.
The main symptoms of perimenopause
1, menstrual disorders: is a common symptom of the menopausal transition, manifested as irregular menstrual cycle, long duration, increased menstrual volume or even heavy bleeding, can also be manifested as dripping bleeding, anovulatory bleeding is more common. When abnormal uterine bleeding occurs, we should be alert to the occurrence of endometrial cancer and seek medical attention in time. If necessary, biopsy should be taken from the endometrium to exclude endometrial cancer and cervical cancer.
2. Symptoms related to estrogen decline.
(1) Psychoneurological symptoms: often manifest as excitement-type manifestations such as emotional irritability, agitation, insomnia, headache, inattention, talkative, loud crying, etc.; or anxiety, inner turmoil, memory loss, lack of self-confidence, slow action, and in severe cases, depression-type manifestations such as apathy to the outside world and depressed mood, or even developing into severe depressive neurosis.
(2) Vasodilatory symptoms: Hot flashes are the hallmark symptom of perimenopause and are related to the dysfunction of vasodilatation due to the decrease of estrogen. It manifests as flushing of the skin on the face and neck with sensation of heat followed by sweating. This unstable state usually lasts for about 1 year, sometimes up to 5 years or longer.
(3) Cardiovascular disease: When estrogen decreases, vasodilatory function is dysregulated, leading to perimenopausal hypertension with predominantly elevated and fluctuating systolic blood pressure. As estrogen levels decrease after menopause, blood cholesterol levels rise, various lipoproteins increase, and the HDL/LDL ratio decreases, putting women at increased risk of cardiovascular accidents.
(4) Genitourinary symptoms: manifested as breast atrophy and sagging; vulva and vagina atrophy, vulvar skin itching, vaginal dryness, susceptible to bladder and rectal bulge and uterine prolapse. The contraction of bladder muscle decreases, causing poor urination and increased residual urine, and the urethral mucosa is thin and easily damaged, which can cause recurrent urinary tract infections. Urethra shortening, mucosal atrophy thinning sphincter muscle relaxation, often occur stress incontinence.
(5) Osteoporosis: 25% of perimenopausal women suffer from osteoporosis. Estrogen can promote the secretion of calcitonin, an inhibitor of bone resorption by the thyroid gland, which has a protective effect on bones, and bone resorption increases when estrogen is insufficient. In addition, the main hormone that stimulates bone resorption after menopause, parathyroid hormone, is hyperfunctioning, leading to increased bone resorption. Osteoporosis mostly occurs in vertebral bones.
IV. Diagnosis
Diagnosis is not difficult based on medical history and clinical manifestations, but organic diseases with related symptoms, thyroid diseases and psychiatric diseases need to be excluded. Laboratory tests such as ovarian function evaluation can help in diagnosis.
Blood FSH value and estrogen (E2) value measurement: to understand ovarian function. Blood FSH >10 IU/L during the menopausal transition indicates decreased ovarian reserve function; amenorrhea, FSH >40 IU/L and E2 <10-20 pg/ml indicates ovarian failure.
V. Treatment
The purpose of drug treatment for perimenopausal syndrome is to treat and relieve perimenopausal symptoms, treat menstrual disorders, and prevent long-term diseases such as cardiovascular diseases, osteoporosis, fractures, skin aging, sexual organ atrophy and senile dementia. Perimenopausal psychoneurological symptoms can be aggravated by unstable neurological type, or unsound mental state, and should be treated psychologically.
1, general treatment: patients with milder symptoms can be given patient explanation and comfort to eliminate concerns and encourage them to participate in physical exercise regularly. If necessary, the amount of sedative drugs can be given to help sleep. In order to prevent osteoporosis, older women should insist on physical exercise, supplement calcium and vitamin D and E, establish a reasonable diet structure, and increase the amount of protein and calcium-rich diet.
2. Sex hormone replacement therapy (HRT) is a medical measure for perimenopausal women to supplement exogenous hormones to correct the changes caused by estrogen deficiency in the body, which is conducive to adjusting the endocrine balance, controlling and improving the symptoms caused by the lack of estrogen, and preventing distant diseases. The principles of sex hormone supplementation are: physiological supplementation, individualized treatment, and achieving the best effect with the minimum amount.
3. Indications for the application of HRT: Menopause-related symptoms; problems of genitourinary tract atrophy; prevention of low bone mass and postmenopausal osteoporosis.
4.Time to start the application: It can be applied after the ovarian function starts to decline and the related symptoms appear.
5. Contraindications to the application of HRT: known or suspected pregnancy; unexplained vaginal bleeding or endometrial hyperplasia; known or suspected breast cancer; known or suspected sex hormone-related malignancies; active venous or arterial thromboembolic disease within 6 months; severe liver and kidney dysfunction; hematoporphyria, otosclerosis, systemic lupus erythematosus; progestin-related meningioma.
6. Precautions for the application of HRT.
1) HRT is a necessary medical treatment for menopause-related health problems. In order to reduce the increase of liver burden and the effect on blood lipids by a long course of treatment, natural estrogen and progestin are generally used.
2) Menopause and related symptoms (such as vasodilatory symptoms, genitourinary tract atrophy symptoms, neuropsychiatric symptoms, etc.) are the primary indications for the application of HRT.
3) the application of HRT is an effective method for the prevention of postmenopausal osteoporosis.
4) HRT should not be applied for primary and secondary prevention of cardiovascular diseases.
5）For women with an intact uterus, the application of estrogen should be accompanied by the application of an appropriate amount of progestin to protect the endometrium; for women who have had their uterus removed, the addition of progestin is not necessary.
6) When HRT is applied, the lowest effective dose should be used with comprehensive consideration of the purpose and risk of treatment.
7) HRT can be applied after the appearance of menopause and related symptoms, and the HRT regimen should be selected according to the hormonal abnormalities.
8) Application of HRT should be individually evaluated at least once a year to decide whether to continue or apply it for a long time; a short course of treatment can be used for those with menopausal symptoms, and a long course of treatment is needed for those with osteoporosis, and the length of the course should be decided according to the evaluation.
(9) When menopause-related symptoms appear and other diseases exist, HRT can be applied while controlling the complications when contraindications are excluded.
7. Treatment options.
1）Single estrogen therapy is suitable for women who have undergone hysterectomy.
(2) Single progestin therapy: cyclic application is suitable for the menopausal transition period to improve the symptoms of menstrual disorders that occur during the process of ovarian function decline, and is mostly used continuously in the second half of the menstrual cycle.
3）Estrogen and progestin sequential therapy: Simulating the natural cycle, 28 days is a cycle, on the basis of continuous application of estrogen, progestin is added on the 15th to 28th day of the cycle, menstrual-like bleeding will occur after taking one cycle, and then the next cycle is taken. It is suitable for women in perimenopause and early menopause who wish to have menstrual flow.
(4) Continuous combined application of estrogen and progestin: Daily simultaneous administration of estrogen and progestin without interruption, without withdrawal bleeding, but irregular drenching bleeding may occur. It is suitable for women who have been menopausal for many years.
(5) Route of administration: divided into oral, vaginal administration, skin patch and cream, etc.
(6) medication course: short-term application in order to alleviate the symptoms of perimenopause, when the symptoms disappear, you can stop the drug; long-term use of drugs to prevent osteoporosis, prevention of cardiovascular disease, HRT at least 5-10 years.
VI. Side effects and risks
At present, the long-term application of HRT is safer through the reasonable combination of estrogen and progestin and the monitoring during treatment. However, there are still some side effects and dangers. For example, the side effects caused by sex hormones themselves; abnormal uterine bleeding needs to be paid attention to and parallel scraping to exclude endometrial lesions; long-term application of single estrogen can cause endometrial hyperplasia and increase the risk of endometrial cancer, but if estrogen and progestin are combined, the risk of endometrial cancer does not increase; the degree of correlation between breast cancer and postmenopausal HRT is still very controversial, and the data from the International Menopause Society Randomized controlled data show that there is no increased risk of breast cancer among women using HRT for the first time over a period of 5-7 years.
Hormone supplementation in perimenopausal women has been increasingly valued by physicians and women in general, and starting hormone supplementation during the perimenopausal period (“time window”) and continuing it over time provides good skeletal and cardiovascular protection as well as other benefits; the safety of hormone supplementation is highly dependent on age, and women younger than 60 years of age are generally better off with hormone therapy. The safety of hormone supplementation depends largely on age, and women younger than 60 years old basically do not need to consider the safety issue when using hormone therapy; the current relevant literature and studies prove that the beneficial effects of HRT will far outweigh its potential risks if it is scientifically, rationally and regularly applied and regularly monitored when there are indications and no contraindications.