MENOPAUSE - A HOLISTIC APPROACH TO COMMON MENOPAUSAL DISORDERS.

Menopause, also known as the climacteric, is the time in most women's lives when menstrual periods stop permanently, and the woman is no longer able to have children. Menopause typically occurs between 45 and 55 years of age. Menopause is occurring 12 months after last menstrual period and marks the end of menstrual cycles. Menopause is a natural biological process. Although it also ends fertility, but can stay healthy, vital and sexual. Some women feel relieved because they no longer need to worry about pregnancy. 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. Women may notice changes before and post menopause. They has three phase as peri            menopause, menopause & post menopause.

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.

AETIOLOGY

The hormones estrogen and progesterone regulate menstruation - more specifically, estrogen regulates menstruation while progesterone is more involved with preparing the body for pregnancy. When the ovaries start producing less of these two hormones, the peri-menopause will start. In fact, by the time a woman is in her late 30s the ovaries start producing less progesterone and estrogen. By the time she is in her 40s, the post-ovulation spike in progesterone becomes less emphasized. A woman's fertility starts to decline a long time before she may notice any menopausal or peri-menopausal symptoms.

As time passes and the ovaries produce less and less estrogen and progesterone, the ovaries eventually shut down completely and the woman no longer has any more menstrual periods. The vast majority of females experience a gradual change in menstrual activity, while some go on normally until they suddenly stop.

Some women may experience premature menopause - their ovaries fail earlier than they are supposed to (before the age of 45). Ovarian failure can occur at any age - but very rarely - and often the doctor and patient will never find out why. Some who experience ovarian failure may still have periods and some degree of fertility for a while.

Premature menopause may be caused by:

·        Enzyme deficiencies

·        Down's syndrome, Turner's syndrome

·        Addison's disease, Hypothyroidism

·        Removal of the ovaries (bilateral oophorectomy surgery),

·        Radiotherapy to the pelvic area

·        Chemotherapy

·        Hysterectomy surgery (the uterus - womb - is surgically removed)

·        Some infections - such as mumps or TB (tuberculosis), malaria and varicella. However, in all cases risk of ovarian failure is extremely small.

·        Genetic factors - scientists have been able to identify genetic factors that influence the age at which natural menopause occurs.

·        Being a twin - twins are more likely to have a premature menopause.

CLINICAL MANIFESTATIONS

The menopause is a normal part of life - it is a milestone, just like puberty - it is not a disease or a condition. Even though it is the time of the woman's last period, symptoms may begin many years earlier. Some women may experience symptoms for months or years afterwards.

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

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 becomes 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.

MANAGEMENT

General

Exercise regularly. Get regular physical activity or exercise on most days to help protect against heart disease, diabetes osteoporosis and other conditions associated with aging.

Eat a balanced diet. Include a variety of fruits, vegetables and whole grains. Limit saturated fats, oils and sugars.

Practice relaxation techniques. Techniques such as deep breathing, paced breathing, guided imagery, massage and progressive muscle relaxation can help relieve menopausal symptoms.

Get enough sleep. Avoid caffeine, which can make it hard to get to sleep, and avoid drinking too much alcohol, which can interrupt sleep. Exercise during the day, although not right before bedtime.

Cool hot flashes. Dress in layers, have a cold glass of water or go somewhere cooler. Try to pinpoint what triggers your hot flashes. For many women, triggers may include hot beverages, caffeine, spicy foods, alcohol, stress, hot weather and even a warm room.

Hormone Replacement therapy and Its Contraindications

Conventional therapy majorly depends on the Hormone replacement therapy (HRT). HRT can be administered in the form of oral medications, dermal patches or gels for local application, depending on the patients needs. 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.

Home remedies

Black cohosh is derived from a species of buttercup. Studies have had mixed results on whether black cohosh is effective in reducing hot flashes. Some studies indicate it may help with mild hot flashes and night sweats for short-term treatment. May lower blood pressure, as well.

Flaxseed has omega3 fatty acids and lignans, which act as phytoestrogens. Results from studies have been mixed, but it may help symptoms in some women. It is also believed to help lower cholesterol. Avoid whole flaxseed because it is difficult to digest.

Soy has isoflavones, which are phytoestrogens (plant estrogens). Some studies have observed that soy may be effective in reducing menopausal symptoms. However, other studies have found no benefit. Only food forms of soy, like tofu and soy milk, are recommended. Soy in tablet or powder form is not advised.

Ginseng may help with some menopausal symptoms, such as mood symptoms and sleep disturbances, and with one's overall sense of well-being. However, it has not been found to be helpful for hot flashes.

HOMOEOPATHIC MANAGEMENT

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. The advantage of homoeopathy is that it considers the patient as whole. It means that homoeopathic treatment focuses on the patient as a person, as well as his pathological condition. The homoeopathic medicines are selected after a full individualizing examination and case-analysis, which includes the medical history of the patient, physical and mental constitution etc.. 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.

Indicated Remedies	Indications
Aconite	The symptoms that may indicate the need for Aconite include anxiety, panic attacks, fearfulness, depression, fainting, physical and mental restlessness, hot flushes (particularly in the evening), dry eyes, insomnia, nightmares and tachycardia. A dry vagina and painful intercourse may also be noted here. Symptoms are better for open fresh air, rest, perspiration and movement. They may be aggravated by being in a stuffy warm room, becoming heated, in very hot weather and before midnight.
Amyl nitrate	The usefulness of this remedy may be indicated by anxiety, feelings of insecurity, a feeling as if there were a plug in the throat, a premonition that something bad is about to happen and a need for support and encouragement. The sufferer requires constant movement and frequently needs to stretch.
Calc carb	Calc carb may be of use where the following are present. Hot flushes that tend to move upwards and are accompanied by perspiration on the face and hands, anxiety (particularly about dying), claustrophobia, agoraphobia, poor memory, confusion, irritability, weepiness, feelings of inadequacy, palpitations, chills, fatigue, metrorrhagia, cramps in the limbs and dry skin. The sufferer may complain that her legs “fall asleep”, that there is backache, particularly in damp weather, swelling of the finger joints, leftsided headaches, tinnitus, and weight gain.
Cimicifuga	The person who responds to this remedy may be talkative, irritable, restless, fearful of disease or death, expresses a fear of insanity and is frequently heard to sigh. She wants to be freed of her social or family ties but fears being alone. Symptoms are better for rest, warmth, wrapping warmly and in open air, better for continuous motion and pressure, and are worse in the morning, at night, during a change of weather, as well as worse for standing still or consuming alcohol.
Ignatia	The proving symptoms that apply here include hot flushes, frequent sighing, anxiety which is worse during hot flushes, vaginal sensitivity, severe depression which often alternates with excitability, perspiration occurring in isolated areas, especially during the forenoon. Symptoms are worse from consolation, in the morning, in open air, cold, after food, from tobacco, smoking, worse on the right side and worse for standing.
Lachesis	Suits especially women who never get well from the change of life; “have never felt well since that time.” It corresponds to many climacteric troubles, such as haemorrhoids, haemorrhages, vertigo,burning on the vertex and headaches. It is remedy for women worn out by frequent pregnancies, with sudden cessation of the menses, trembling pulse, headache, flushing of the heat and rush of blood to the head, cold feet and constriction about the heart.
Bellis perennis	English confreres use this remedy quite extensively in what is termed a “fagged womb.” The patients are very tired, want to lie down, have a backache. There is no real disease, but a marked tiredness all the time. Carduus is of supreme importance for liver troubles at the climaxis Ustilago. Often rivals Lachesis in controlling the flooding during the climaxis. Vertigo is characteristic.
Sepia	This is a common prescription for menopause, the symptoms for which include fatigue, depression which is worse in the morning, indifference to loved ones, aversion to company or sympathy, irritability, claustrophobia or agoraphobia. Hot flushes that tend to ascend and are accompanied by anxiety may also be seen, as are heavy or droopy eyelids, nausea, profuse offensive perspiration (particularly about the genitals) and night sweats, palpitations, fainting, weight gain despite poor appetite, migraine headaches, hair loss, constipation and chills.
Sulphur	It may be of use where there is depression, nervousness, irritability, fatigue, the sufferer appears to want to cut herself off from others, and there is a craving for sweets. The eyes may water in the morning but dry up as the day progresses. There may be hot drenching sweats, especially about the face, scalp, back and thighs that leave the sufferer thirsty. A sensitivity to heat may be noticed

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