Dr. Unni Answers Queries on Menopause
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There are a reasonable number of women coming in for HRT nowadays. It’s not as prevalent as abroad but yes–the awareness in increasing and a lot of doctors also recommend it. We, besides holding awareness programs for women are holding awareness programs for doctors, also for GPs, for specialists, and update them with current knowledge. We are telling women as well as doctors that HRT is not the see all and end all of it. Not that HRT is prescribed to every woman.
When is it necessary to prescribe HRT?
It is necessary for women who have had a premature menopause. Some go into menopause very early or for women having high risk for osteoporosis or they have a family history for it. Or the other factors like they are thin built or they are on steroids or they have sedentary jobs. HRT protects against osteoporosis. Then there are women who have had their ovaries removed either surgically at a young age or by chemotherapy or radiotherapy, in case of cancer. So if their ovary function as gone due to this then they need the estrogen and the other group is the women who have the symptoms and who are actually under growing menopause and showing symptoms like hot flushes or psychological problems. This is the main group which will benefit greatly from HRT.
What are the physical symptoms of menopause?
Hot flushes, sweating, palpitations, tiredness, fatigue, irritability, mood swings and not being able to keep very well. Sometimes they have problems like frequency of passing urine, they might wakeup often at night (nocturia). They might have the feeling that they have to go and that’s very urgent. They may have sexual difficulties like pain during intercourse due to dryness and thinning of vagina. There may be a loss of libido and they may have bleeding due to trauma. There is hair loss, nails become brittle, skin becomes thin and facial hair may increase.
What is the family support that should be there during this time?
The family support is not there. That is why the women also want the family to know about their problems. Nowadays women are coming to the clinic with their husbands. Children also need to be told about it. It is a time when a mother might not be able to provide the same support she used to earlier, because she herself needs a little bit of support, which is what we tell them and ask them to help the women to go through this phase. If required, help of a psychiatrist is also taken.
Are there cases where the lady really needs psychological or psychiatric help?
This happens more so when women resist to going to a psychiatrist. Often they are more comfortable talking to the family physician or the gynecologist because they have this feeling that they go to a psychiatrist only in case of a mental illness. They accept psychological help generally if they understand and if they have a good rapport with their doctor. We are trying to establish links with counselors who are professionally trained to counsel women of this age. Many a time putting on the HRT solves 50% of their psychological problems, but it is usually difficult to determine which woman needs psychiatric help and the one who needs HRT.
What about increased risk of heart attack and reduced level of estrogen?
Estrogen prevents heart attacks and osteoporosis. Women’s risk of heart attack is less before menopause but it is the same in men and women after menopause. Estrogen changes the HDL–LDL ratio. It also increases the rate of amount of blood flow through the vessels. Women at HRT is protected against heart attack. A woman is at a risk of fracture (fracture of wrist, femur and cervical fracture of the neck) more than a man of the same age. After menopause if a woman has not had HRT, by the age of 70 she is more at a risk of fracture than a man of 90. Women can take calcium supplementation, good diet and exercise if they are not taking HRT, foods like soya, are very rich in estrogen.
How does irregular lifestyle and stress play a part in early onset of menopause?
These factors do not play a part but they do play a part in increasing risk of osteoporosis like excess of alcohol, smoking, sedentary jobs or excessive exercise, prolonged bed rest and hereditary factors.
What kind of cancers are seen after menopause?
Ovarian cancer in late 40’s, in the 50’s cancer of uterus is seen and after 50’s it’s cancer of the womb and breast. These things are detected early if a woman is under treatment and coming for regular checkup. There is slightly increased risk of breast cancer for women under HRT and over 50. The risk increases only after five years of HRT. Five years of HRT is required for long term protection against osteoporosis. As for breast cancer they are taught to examine themselves and undergo mammography. Even if they get breast cancer the tumors are very low grade and get cured very easily. Studies show mortality rate due to breast cancer is lower in patients who have taken HRT, than those who have not. As they are slow growing tumors and because of increased surveillance they are picked up earlier.
What about women who have had an early hysterectomy due to some or the other reason?
Women who have had an early hysterectomy may develop menopause much earlier than normal even if their ovaries are retained they could reach menopause within a period of anywhere between 2 to 5 years. If ovaries are removed menopausal symptoms are seen within two to three months, that’s why we are discouraging hysterectomy nowadays.
What are the pre and post menopausal syndromes?
There is one called climacteric, which is the period before menopause when all the symptoms starts. It may occur even one to three years before menopause. This is the most difficult period as the symptoms are at their worst. After a year or so of menopause the symptoms normally subside on their own even without HRT. But the long term effects on the bones and heart keep getting worst as the years progress. Menopause has become more significant now, as the longevity of women is on the rise, as they are spending one third of their lives after menopause. That is why it is all the more important now that we deal with their health.
Do you recommend any kind of special diet for these women?
They should have a calcium rich diet as it builds their bones. As far as cardiac protection goes the diet should be low in fats and they must have regular exercise. Soya and its products are very rich in estrogen like substances. They should eat plenty of fresh fruits, vegetables, pulses, milk and milk products. The amount of fatty substances like butter, eggs (especially, egg yokes) red meat should be reduced. Dairy products low in fats are also good, milk and curds are very good. Paneer (cottage cheese) is much better than processed cheese. After the age of 40, women should take additional calcium supplementation as the amount provided by the diet can never be enough. The calcium tablet is best taken on an empty stomach not associated with any meal or with tea or coffee, as it doesn’t get absorbed.