Menopause

Combined therapy along with Homoeopathic treatment helps in combating Menopause
- Dr. S. Sabarirajan & Dr.S.R. Ameerkhan babu.
Introduction
Menopause is a universal and irreversible part of the overall aging process involving a woman's reproductive system, after which she no longer menstruates. Awareness about these changes is less in our country compared to developed nations. Patients seeking treatment for menopause is less, but we find such patients visiting for their menopause related symptoms like irregular bleeding, fatigue, night sweats, etc. Though we have many rubrics in the repertory for menopause and its symptoms, many a times we fail to provide desirable results. Many physicians find in such cases along with the indicated drug, other managing measures like food modifications, exercise, home remedies and herbs, supplements, micronutrients and vitamins are helpful. This article discusses about such combined therapies along with definition, symptoms, pathophysiology, investigations, rubrics and drugs for menopause.

Definition
The word "menopause" literally means the "end of monthly cycles" from the Greek word pausis (cessation) and the root men- (month), because the word "menopause" was created to describe this change in human females, where the end of fertility is traditionally indicated by the permanent stopping of monthly menstruation or menses. Menopause is a term used to describe the permanent cessation of the primary functions of the human ovaries: the ripening and release of ova and the release of hormones that cause both the creation of the uterine lining and the subsequent shedding of the uterine lining. Menopause typically (but not always) occurs in women in midlife, during their late 40s or early 50s, and signals the end of the fertile phase of a woman's life. It is not uncommon however to see a women menstruate well beyond the age of 50.

Perimenopause refers to the time before menopause when vasomotor symptoms and irregular menses often commence. Perimenopause can start 5-10 years or more before menopause.
Menopause is characterized by a continuation of vasomotor symptoms and by urogenital symptoms such as vaginal dryness and dyspareunia.

The cause of menopause is “burning out” of the ovaries. Throughout a woman’s reproductive life, about 400 of the primordial follicles grow into mature follicles and ovulate, and hundreds of thousands of ova degenerate. At about age 45 years, only a few primordial follicles remain to be stimulated by FSH and LH, and, the production of estrogens by the ovaries decreases as the number of primordial follicles approaches zero. When estrogen production falls below a critical value, the estrogens can no longer inhibit the production of the gonadotropins FSH and LH. Instead, the gonadotropins FSH and LH (mainly FSH) are produced after menopause in large and continuous quantities, but as the remaining primordial follicles become atretic, the production of estrogens by the ovaries falls virtually to zero.

SIGNS AND SYMPTOMS
The menopausal transition can cause
Vascular instability
• Hot flashes or hot flushes, including night sweats and, in a few people, cold flashes
• Possible but contentious increased risk of atherosclerosis
• Migraine
• Rapid heartbeat
Urogenital atrophy
• Thinning of the membranes of the vulva, the vagina, the cervix, and also the outer urinary tract, along with considerable shrinking and loss in elasticity of all of the outer and inner genital areas.
• Itching
• Dryness
• Bleeding
• Watery discharge
• Urinary frequency
• Urinary incontinence
• Urinary urgency
• Increased susceptibility to inflammation and infection, for example vaginal candidiasis, and urinary tract infections
Skeletal
• Back pain
• Joint pain, Muscle pain
• Osteopenia and the risk of osteoporosis gradually developing over time
Skin, soft tissue
• Breast atrophy
• breast tenderness +/- swelling
• Decreased elasticity of the skin
• Formication (itching, tingling, burning, pins and needles, or sensation of ants crawling on or under the skin)
• Skin thinning and becoming drier
Psychological
• Depression and/or anxiety
• Fatigue
• Irritability
• Memory loss, and problems with concentration
• Mood disturbance
• Sleep disturbances, poor quality sleep, light sleep, insomnia
Sexual
• Dyspareunia or painful intercourse
• Decreased libido
• Problems reaching orgasm
• Vaginal dryness and vaginal atrophy

PATHOPHYSIOLOGY
During climacteric, ovarian activity declines. Initially, the ovulation fails, no corpus luteum is formed and no progesterone is secreted by the ovary. Thus the menstrual cycles tend to become anovulatory and irregular (Metropathia haemorraghica).Later oestrogenic activity also diminishes and atrophic endometrium ensues, leading to menopause. As a result of cessation of ovarian activity, and fall in estrogen level, there is a rebound increase in secretion of FSH by the anterior pituitary gland. FSH level may rise as much as 50 fold, thus making menopausal urine a commercial source of Gonadotrophin(HMG). With further advancing years, gonadotrophin activity of the anterior pitiuitary also ceases and a fall in the level of FSH is eventually noticed .

CHANGES IN THE GENITAL TRACT
These changes are of atrophic type and affect the external genitalia as well as the internal organs. They take time to occur – over a number of years. Not only the main pelvic structures reduced in size but, more importantly, the fascial framework and the intra pelvic ligaments supporting the bladder and the genitalia are weakened;this may lead to complications.
Vulva: This shows the flattening of the labia majora, the minor labia becoming more evident. Sexual hair become grey and sparse. The clitoris shrinks.
Uterus: The uterus becomes small with a relatively large cervix- return to infantile proportions.
Tubes and ovaries: These show great shrinkage, the tubes becoming thin, while the ovaries are reduced to small white wrinkled bodies 2-3 cm in length. In addition to the shrinkage of the vaginal introitus, the vagina diminishes in length and its secretions are limited, leading to sexual problems. Changes in the vaginal epithelium increase these problems.

PRINCIPAL CHANGES IN THE SERUM HORMONE LEVELS
Once menopause is well established , the plasma estrogen level may remain low at 10 to 20 pg/ml. Oestrone level varies between 30 and 70 Pg/ml. the ovary also secretes a small amount of testosterone which may be responsible for mild hirsutism noticed after the menopause. The gonadotrophin hormone (FSH) appears in high concentration at menopause, because it is not inhibited by the prevailing low levels of estrogen.

Mensturation may gradually decrease, suddenly cease or become irregular. Oestrogen levels fall over the 5 years preceding ovarian failure which occurs usually between 45 and 50 years of age, with an average around 50 years. The fall in oestrodiol has a positive feedback on the pitiuitary, increasing production of FSH and LH.

The ovaries eventually produce androstenidione, which is also produced by the adrenals, and is converted in peripheral fat into weak oestrogen oestrone

INVESTIGATIONS
Assessment and evaluation prior to initiating treatment:
The following plan is recommended, it helps in finding the actual pathology and progress of symptoms, which helps in finding the constitutional or antimiasmatic remedies and further way of treatment.
1. Detailed family and personal history, physical examination - height , weight and BP.
2. Examination of breast.
3. Pelvic examination.
4. Evaluation of menopausal symptoms and need for medication.
5. Evaluation of the individual risks versus benefits from treatment.
6. Routine screening tests like blood routine, urine routine, Fasting and post prandial blood sugars.
7. Lipid profile and cardiovascular risk assessment. (Plasma lipids have been known to be altered by the with in month variations in the female hormonal system. The early menopausal subjects shows a significant increase in the total cholesterol level and slightly higher in late menopausal subjects.)
8. Transvaginal sonography and assessment of endometrial thickness.
9. Routine mammography.
10. Endometrial histology – in cases of post menopausal bleeding or family history of uterine cancer. Or past history of late menopause, infertility, and PCOD.

HORMONE REPLACEMENT AND ALLIED THERAPY
The basic objective of oestrogen replacement therapy is to increase the circulating levels of oestrogen to physiological levels of 45- 200 pg / ml to alleviate the climacteric symptoms resulting from oestrogen deficiency. Semi- synthetic hormones are used for hormone replacement therapy (HRT) because they are more physiologic in their actions. HRT can be administered in the form of oral medications, dermal patches or gels for local application, depending on the patients needs.
There are many contraindications to HRT as follows:
Conventional therapy majorly depends on the Hormone replacement therapy (HRT). But many studies suggest that HRT has got many unwanted side effects. For example, the results of a major study, called women’s health initiative (established by the Government of United States of America), had explored many health risks. In fact this important study was stopped early because the health risks outweighed the health benefits. Women taking the hormones greatly increased their risk for breast cancer, heart attacks, strokes and blood clots. However all hormone replacement therapies probably do carry some health risks, including high blood pressure, blood clots, and increased risks of breast and uterine cancers.
1. Presence of active endometrial cancer and hormone dependent tumours.
2. Active breast cancer and oestrogen progesterone receptor positive cancers.
3. Presence of or suspicion of pregnancy.
4. Undiagnosed vaginal bleeding.
5. Severe liver disease or abnormal liver function tests.
6. Acute vascular thrombosis.
7. History of thrombo embolism.
8. Estrogen dependent vascular thrombosis.
Other relative symptoms are - Strong family history of breast cancer, History of migraine and severe headaches. Thrombo phlebitis, uterine fibroids, Endometriosis, Gall bladder disease, Glucose intolerance.

HOLISTIC APPROACH TO MENOPAUSE
A holistic approach considering the lifestyle, personal habits, food habits, inclusion of nutrients and herbal diet, etc. along with homoeopathic treatment helps in overcoming menopausal symptoms. Information on each such intervention has been given under respective titles.

I. Life style changes and personal habits:
1. Exercises- Brisk walking fro 40 – 60 minutes atleast 5 times/week.
2. Physical workouts-Weight bearing exercises for limbs and back strengthening.
3. Yoga and meditation- Breathing exercises (Pranayama) beneficial in reducing stress.
4. Simple diet- Containing liberal amounts of vegetables and fruits (fibres and vitamins) lower contents of saturated fats and restricted sugar content.
5. Fluid intake- Consume fluids liberally to maintain tissue hydration.
6. Control or abstain- Smoking , alcohol intake, unrestricted consumption of tea / coffee.

II. Herbs and plant products:
Plants are a source of phyto oestrogens which have mild oestrogenic and some anti estrogenic effects. Soya has been the most extensively investigated plant. Phytooestrogens are a source of aglycones and isoflavones, coumestones and lignans.common Indian foods rich in phytooestrogens- isoflavons are found in Bengal grams, cereals fruits like apples and berries,and red clover. Lignans in whole grain, pulses, legumes and beans, sunflower seeds and saponins in herbs like turmeric fenugreek or methi ginger and also in root vegetables yam and grains.

An intake of 50 mg of isoflavones per day has been beneficial in reducing hot flushes, preventing osteoporosis, reducing ldl cholesterol. Also there is an evidence that soya exerts a protective action against breast cancer. The hot flushes can be managed with Wearing cool clothing, Drinking cold water or juice at the onset of flush, shower with tepid water.

III. Micronutrients and antioxidants:
These are essential to the body and required in very small amounts. These include vitamins minerals, essential amino acids, essential fatty acids. Many of these are antoxidants also. Antoxidants protects against the tissue damage. Menopausal women are vulnerable because of the loss of the protective effects of oestrogens and the age related effects.

IV. Calcium and vitamin D3:
In ageing women, the need for calcium supplementation increases to about 1000- 1500 mg / day Provided the calcium should be properly absorbed and utilized. Thus it slows down the process of age related osteoporosis.

This has been justified by Ried et al in 1993 in their research with supplementation of calcium carbonate and lactate- gluconate to post menopausal women in doses of 1 gm / 24 hours for 5 years and demonstrated significantly slowed axial and appendicular bone loss.
Chapuy et al in 1992 has demonstrated both suppression of bone loss and reduction of fracture.

IV. Calcitonin:
Many clinical studies have produced evidence to suggest that calcitonin is able to prevent bone loss in the spine in post menopausal women. Calcitonin injection has been known to cause side effects like nausea and vomiting , flushing and intertrigo, intranasal administration remains another alternative.

V. Biphosphonates:
These are stable active analogues of pyrophosphate, which act by inhibiting bone resorption. These compounds are worth considering in women in whom oestrogens are contraindicated, or for those averse to Hormone Replacement Therapy.

Aroma therapy, Herbalism, Accupressure, Accupuncture, Nutrition and supplements can be suggested as the supportive line of treatments for menopausal complaints.

HOMOEOPATHIC APPROACH
The advantage of homoeopathy is that it considers the patient as whole. Since the symptoms of menopause are not limited to one system or location, a drug selected on the totality is of more helpful than the “single complaint specific drugs”. Our repertory has covered the menopausal symptoms directory or indirectly. Below is a reportorial analysis on the common symptoms of menopause. Therapeutics of menopause follows the analysis.

THERAPEUTICS
Many authors have discussed about the drugs that are commonly indicated during the time of menopause or the climaxis, as referred to in many of the writings. The commonly indicated remedies for General Menopausal symptoms are Amyl Nitrosum, Belladona, Bellis perennis, Cactus grandiflorus, Calcarea carbonicum., Caulophyllum, Cimicifuga racemosa, Castoreum, Conium ,Crotalus Horridus, Erigeron, Gelsemium, Glonine, Graphitis., Kali-carbonicum, Kreosotum, LACHESIS, Manganum, Mag.phos , Murex., Nux-vomica, Nux moschata, Oophorinum, Psorinum, Pulsatilla , Sabina, Sangunaria, Sepia, Sulphur, Sulphuric acid, Thlasi bursa , Tuberculinum, Ustiligo, Vibrunum opulus and Zincum Valerianum.

Aliments from menopause
Lachesis. (It’s a Well Specific Remedy for Menopause)

Ailments during menopause
For hot flashes and night sweats: Amyl nitrosum, Belladonna, Ferrum metallicum, Lachesis, Pulsatilla, Pilocarpus microphyllus, Sepia and Valeriana.
For sleeplessness (insomnia): Aconitum napellus, Arsenicum album, Belladonna, Chamomilla, Coffea crude, Lycopodium clavatum ,Passiflora incarnata, Sulphur and Viburnum opulus.
For constipation: Hydrastis, Iris versicolor. Magnesia muriatica, Magnesia phosphorica and Sepia
For incontinence of urine: Pulsatilla and Zincum metallicum.
For vaginal dryness: Aconitum napellus, Apis mellifica, Belladonna, Bryonia, Ferrum phosphoricum Hydrophobinum, Lycopodium, Natrum muriaticum and Spiranthes.
For depression, fear, nervous or irritability: Aconitum napellus, Amyl nitrosum, Arum Metallicum, Borax, Chamomilla, Ignatia amara, Lachesis, Nux vomica, Passiflora incarnata, Sepia, Stramonium and Viburnum opulus.
For bone related problems like Osteophorosis: Bellis perennis and Calcarea carbonica
For menorrhagia: Lachesis, Sepia, Argentum mettalicum and Cimicifuga racemosa
For painful and enlarged breast: Sangunaria
For painful breast: Cimicifuga racemosa
For burning, palm, sole and vertex: Sulphur, Sangunaria and Lachesis
For excessive perspiration: Sepia
For earache: Gelsimium
For rheumatic pain: Caulophyllum
For headache: Glonine, Sangunaria, Sepia and Cimicifuga racemosa