FOR women, it seems as if life is a never-ending rollercoaster. As we hit puberty, and life just starts to get interesting, there are the monthly periods. Sometimes if we are lucky, it is regular and pain free and with no-associated symptoms. But if we are not, there is PMS with those dreadful symptoms. There are also times when our menstrual cycles are so heavy, that we become anemic and require hospitalisation and there are times when we skip it for months. There are the occasions when we are stuck with an unwanted and unplanned pregnancy and must mentally and emotionally endure an abortion and then there are times when we want a pregnancy so badly and it does not happen, or then it does only to have a miscarriage or various miscarriages. Let us not forget all the physical changes that our body goes through during pregnancy and delivery and the horrendous pain of both labour and delivery.

Sadly, the complications of being a woman do not end there. As we age, our eggs deplete and with that our estrogen level and once again we are subjected to further changes- the transition to menopause (called perimenopause) and the eventual changes of menopause. So, this brings me to the question.

WHAT IS PERIMENOPAUSE?
A few years before menopause, menstrual periods become irregular, and the bleeding pattern changes. This period can last for several years. It usually begins around age 45 to 55.
Some women may experience very heavy bleeding that interrupt their quality of life. It is therefore important for a woman to seek medical attention to rule out other causes of this type of bleeding and to receive the necessary treatment.
WHAT IS MENOPAUSE?

Menopause is one year after menstruation stops. This happens because the ovaries stop producing hormones and releasing eggs for fertilization. This marks the end of a woman’s reproductive years. The actual menopause happens at around 50 years of age, although the exact timing differs among individuals.
When women go through menopause before the age of 40, it is considered to be early menopause and is called premature ovarian insufficiency.

WHAT CHANGES DOES A WOMAN EXPERIENCE DURING MENOPAUSE?
Around 80 per cent of women suffer from some additional menopausal symptoms, though some women have few symptoms apart from the ending of menstruation.

Hot Flashes: The most common menopausal symptoms are hot flashes and night sweats. These happen most commonly within the first year after the last period, although they can occur earlier. Sometimes they are so severe, that it causes weakness and loss of energy and together with the night sweats can disturb normal sleeping patterns. The good news is that their severity tends to decrease with time.

Vaginal Dryness and a decrease in libido: Decreased production of estrogen causes vaginal changes such as dryness and loss of muscle tone, which can make sexual intercourse uncomfortable or painful. This, along with sleep or mood changes, can lead to loss of interest in sex, also known as reduced libido.

Depression, anxiety and panic attacks: may occur, but it is not clear whether these are related to life changes that are likely to happen around the same time in a woman’s life, such as ‘empty nest syndrome’ (when children leave home or lifestyle changes significantly). Some women may experience problems with urinary control (incontinence), particularly those who are overweight or who have had multiple births.

The decrease in estrogen also causes a woman to start developing abnormal cholesterol levels, and hypertension, which puts her at risk for cardiovascular disease and stroke.

Osteoporosis: Women start losing their bone density, which puts them at risk for fractures.

WHAT HAPPENS TO A WOMAN WHO ENTERS MENOPAUSE AT AN EARLIER AGE, OR HER OVARIES ARE REMOVED DURING SURGERY?
Menopause, especially if early and abrupt, can cause severe morbidity for a woman. Occasionally, due to cancer treatment (chemotherapy and radiotherapy), or other benign conditions (non-cancerous), a woman’s ovaries either loses its function or are surgically removed. Because this is not a gradual transition, the consequences are harsher than for a woman who transition naturally. She ages faster and is subjected to all the changes of menopause at an earlier age.
I remember this patient during my fellowship training that had undergone surgery for Ovarian cancer as a teenager, and after 10 years, she had aged drastically.

REMOVING A WOMAN’S OVARIES DURING HYSTERECTOMY
It has been a common practice for women to have their ovaries removed during a hysterectomy for a benign condition (especially fibroids), with the rationale that by removing her ovaries, it will reduce her risk of ovarian cancer. However, there are many studies that have demonstrated that for women who are not at high risk for developing ovarian cancer, removing the ovaries, increases their chances of premature death.
While there is treatment to help women manage their menopausal symptoms, guidelines (such as NICE) exist and can guide doctors regarding the use of hormonal replacement therapy (HRT). We should not deny women in their late 30’s and 40’s HRT. However, in benign conditions in women of reproductive age, and in moderate risk women (for ovarian cancer), tremendous efforts should be made to preserve a woman’s ovaries during surgery. It is important, that as physicians we discuss the risks/ benefits of surgical removal of a woman’s ovaries so that she can make an informed decision.

Although perimenopause and menopause can be difficult for some women, it is important that they are aware of treatment options and lifestyle changes that can make their lives more comfortable. Family support and understanding is also important for these women.