Mrs A., a middle aged woman walked into the clinic with her daughter. "Welcome Ma, how may l help you" I asked. "I'm pregnant, I want you to check it " she replied. "OK. When was your last menstrual period (LMP)" I asked again. "It's over a year now" she replied. Oh!! another case of unsure LMP, l thought.

After the rest of the history taking, i went on to physical examination on the woman. I was not able to palpate the uterus. The Abdominal findings were all normal.

"I'm afraid you are not pregnant " I said. " But she doesn't see her menses" her daughter said barely allowing me to complete my statement.

"Well she is 55(which i got from history), I guess she has started her menopause" I said. "But I feel the baby moving and kicking" she replied.

This is psycho-somatization, I thought, but how do I explain that to her. "You need to get an ultrasound of the abdomen and pelvis then" I told her.

I sent Mrs A. for abdomino-pelvic uss. It was obvious from her look she did not believe me. For all she cares, it's only pregnancy that can make someone miss her period. She never came back with the result.

In as much as many people are not as naive as Mrs A., they only know menopause as the cessation of menses and are totally ignorant of others physiological manifestions associated with it.
It's a period they begin to treat malaria and typhoid every week especially in the tropics here, while others spend fortune of time in prayer houses as they believe they are under spiritual attacks.

source:Wikipediacommons.com

Menopause

Menopause is a retrospective diagnosis, defined as the permanent cessation of menstruation for a period of a year or more. This can occur between ages 45 and 55, but has been documented to mostly occur between ages 49 and 51. It is usually preceded by periods of irregularities in menstruation cycle (climasteric) which could be in the form of reduction in days of flow, prolonged cycle length, intermittent(dysfunctional) uterine bleeding or sporting until finally cessation of the menstruation. But menopause is not just about stoppage of menstruation, it is associated with lots of other body changes ranging from vasomotor, metabolism and psychological changes, and ultimate loss of fertility. The degree of these changes varies from one woman to another, and in severe cases may require pharmacotherapy.

Cessation of menstruation before 40yrs is termed premature ovarian failure and this has array of causes ranging from genetic to treatment induced causes.

The control of normal menstrual cycle

The normal menstrual cycle is controlled by interplay and feedback mechanism involving the hypothalamus, anterior pituitary glad and ovary called hypothalamo-pituitary ovarian axis(HPO-axis)

The hypothalamus produces gonadotrophins releasing hormone ( GnrH) , produced in pulsatile manner, which act on the anterior pituitary to stimulate production of follicle stimulating hormone (FSH) and leutenizing hormone (LH). The FSH and LH acts on the ovary.

Though there is always an interplay between these two hormones in any time of the cycle, the FSH is majorly responsible for early follicular development while the LH brings about ovulation and changes that occur afterwards. The hormones produced by the developing follicles and ovarian stroma (estrogen, progesterone and inhibin send back feedback to the pituitary and hypothalamus so that normal cycle is maintained.

source :wikipediacommons.com

The ovary and follicular development

The ovary has an outer cortex containing the follicles and inner medulla.
The follicular development starts in the womb but It gets arrested at prophase of first meiotic division and individual is borne and then resumed at puberty. Along the line of maturation millions are lost to atresia. The highest number of follicles is seen at 5th month of IUL and its about 7 million. At birth it's about 700 thousand to two million and then about 400 thousand at puberty, thanks to atresia. 15 to 20 is recruited monthly, though only one gets to mature and be ovulated while the rest lost to atresia
This follows that there is increasingly loss of the follicles and ovarian reserve as the woman ages. The rate of follicular atresia also increases with increasing age.

pathophysiology of menopause

Menopause is believed to be caused by loss of ovarian reserve and aging of oocytes, and impaired DNA repair mechanism caused by decreased expression of genes involved in such repair.

It is characterized by decreased sensitivity of the oocytes(follicles) to the pituitary hormones and loss of negative feedback by inhibin, and as a result marked increase in FSH, then LH. There is also marked reduction in Estrogen level due to loss of follicular development, loss of ovulation and menstruation.

Other associations

Menopause is also associated with vasomotor symptoms, atrophic changes, increased risk of cardiovascular diseases, osteoporosis and pathological fracture and psychological problems.

Menopause and vasomotor symptoms

The vasomotor symptoms associated with menopause is believed to be caused by reduced estrogen and vascular response to a central disturbance in thermoregulatory centre in the hypothalamus.
It manifest as feeling of hotness especially in the head and trunk(hotflushes), palpitations, shivering, night sweating, headache.

Menopause and atrophic changes

The atrophic changes associated with menopause is as a result of lack of estrogen. Estrogen enhances epithelial developed and regeneration. Estrogen withdrawal cause atrophy of the epithelial lining of the vagina, uterus, bladder and other urogenital organs.

This can result in vaginal dryness, itching and dyspareunia(painful intercourse), itchy and dry skin, irregular bleeding , decreased libido, urethritis and atrophic cystitis which could be mistaken to urinary tract infection.

Menopause and cardiovascular diseases

Estrogen in premenopausal women discourages atherosclerosis. It causes changes in lipid profile decreasing total cholesterol and LDL and at the same time increase HDL level. HDL Has been found to be cardio-friendly. It also induce the production of nitric oxide which causes coronary vasodilation, improved blood flow and reduced risk of ischaemic heart diseases.
Estrogen withdrawal can as such predispose to cardiovascular diseases

Menopause and osteoporosis

Menopausal women are at risk of osteoporosis due to loss of bone mineral density. This is because the breakdown of bones is increased while it's formation is maintained at the premenopausal rate. Short bones of the body like the backbones, wrist and ankle are more commonly affected.

Menopause and psychological changes

Psychological changes that has been associated with menopause including anxiety, depression, mood swing, insomnia, increase memory loss, irritability, loss of self esteem.

Although the exact cause of this has not been known, it's believed to be associated with poor sleep and estrogen depletion.

In Summary

Menopause is natural and physical loss of fertility which is marked by cessation of mensuration but is also associated with other body changes that could upset the woman, hence the need for understanding the physiology.

Treatment for the major symptoms will be discussed in future article.

Thank you for reading.

References

Medscape : Menopause, practically essentials, overview and physiology

PATHOPHYSIOLOGY. ORG : Menopause

Wikipedia: menopause

MedicalNewsToday: Menopause, symptoms, causes and treatments