Academic journal article Indian Journal of Psychiatry

Postmenopausal Syndrome

Academic journal article Indian Journal of Psychiatry

Postmenopausal Syndrome

Article excerpt

Byline: Pronob. Dalal, Manu. Agarwal

Menopause is one of the most significant events in a woman's life and brings in a number of physiological changes that affect the life of a woman permanently. There have been a lot of speculations about the symptoms that appear before, during and after the onset of menopause. These symptoms constitute the postmenopausal syndrome; they are impairing to a great extent to the woman and management of these symptoms has become an important field of research lately. This chapter attempts to understand these symptoms, the underlying pathophysiology and the management options available.

Introduction

Menopause is the permanent cessation of menstruation resulting in the loss of ovarian follicle development. [sup][1],[2] The age at menopause appears to be genetically determined and is unaffected by race, socioeconomic status, age at menarche, or number of prior ovulations. Factors that are toxic to the ovary often result in an earlier age of menopause; for example, women who smoke experience an earlier menopause, [sup][3] etc. Women who have had surgery on their ovaries, or have had a hysterectomy, despite retention of their ovaries, may also experience early menopause. [sup][4]

Premature ovarian failure is defined as menopause before the age of 40 years. It may be idiopathic or associated with toxic exposure, chromosomal abnormality, or autoimmune disorder.

Although menopause is associated with changes in the hypothalamic and pituitary hormones that regulate the menstrual cycle, menopause is not a central event, but rather a primary ovarian failure. At the level of the ovary, there is a depletion of ovarian follicles. The ovary, therefore, is no longer able to respond to the pituitary hormones, that is, follicle-stimulating hormone (FSH) and luteinizing hormone (LH), and ovarian estrogen and progesterone production cease. Androgen production from the ovary continues beyond the menopausal transition because of sparing of the stromal compartment. Menopausal women continue to have low levels of circulating estrogens, principally from peripheral aromatization of ovarian and adrenal androgens. Adipose tissue is a major site of aromatization, so obesity affects many of the sequelae of menopause. The ovarian-hypothalamic-pituitary axis remains intact during the menopausal transition; thus, FSH levels rise in response to ovarian failure and the absence of negative feedback from the ovary. Atresia of the follicular apparatus, in particular the granulosa cells, results in reduced production of estrogen and inhibin, resulting in reduced inhibin levels and elevated FSH levels, a cardinal sign of menopause.

Menopausal transition, or 'perimenopause', is a defined period of time beginning with the onset of irregular menstrual cycles until the last menstrual period, and is marked by fluctuations in reproductive hormones. [sup][5] This period is characterized by menstrual irregularities; prolonged and heavy menstruation intermixed with episodes of amenorrhea, decreased fertility, vasomotor symptoms; and insomnia. Some of these symptoms may emerge 4 years before menses ceases. [sup][6] During the menopausal transition, estrogen levels decline and levels of FSH and LH increase. The menopausal transition is characterized by variable cycle lengths and missed menses, whereas the postmenopausal period is marked by amenorrhea. The menopausal transition begins with variability in menstrual cycle length accompanied by rising FSH levels and ends with the final menstrual period.

Menopause is defined retrospectively as the time of the final menstrual period, followed by 12 months of amenorrhea. Post-menopause describes the period following the final menses. [sup][7]

The ovary is a women's only source of oocytes, her primary source of estrogen and progesterone, and a major source of androgens. Menopause results in infertility secondary to oocyte depletion. …

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