Metorrhagia

Metrorrhagia refers to vaginal bleeding among premenopausal women that is not synchronized with their menstrual period.

The word Menopause literally means the physiological cessation of menstrual cycles, from the Greek roots 'meno-' (month) and 'pausis' (a pause, a cessation). However, in reality menopause is not simply a matter of the permanent stopping of periods, it is a phenomenon which involves the shutting down of the whole of a woman's reproductive functioning. The root cause of menopause is not what is happening to the uterus, the whole process of menopause is triggered by the faltering and shutting down of the ovaries. This process usually normally occurs more or less in midlife.

Clinically speaking, menopause is referred to with a date: the date of the day after a woman's last period ever finishes.

The normal age range for last period ever is between age 45 to 55, with the peak being at about age 51. An "early menopause" is defined as last period ever at an age between 40 to 45. Age 55 to 60 for last period ever is described as a "late menopause". Last period ever prior to age 40 is considered a "premature menopause", and this is not viewed as being due to normal causes.

In common everyday parlance however, the word "menopause" is most often used to refer to the menopause transition years, also known as the change of life or the climacteric. This time of life is also sometimes known as perimenopause, (literally meaning around menopause).

"Perimenopause" refers to the years both before and after the last period ever, when many women find that they undergo symptoms of hormonal change and fluctuation, such as hot flashes, mood changes, insomnia, etc.

The term "premenopause" refers to the years leading up to last period ever, and the term "postmenopause" refers to the years after last period ever.

A woman who still has her uterus can only be declared to be in post-menopause once she has gone 12 full months with no flow at all, not even any spotting. At that point she is one year into post-menopause. The reason for this delay in declaring a woman post-menopausal is because periods become very erratic at this time of life, and therefore a reasonably long stretch of time is necessary to be sure that the cycling has actually ceased.

In women who have no uterus and therefore have no periods, post-menopause can be determined by a blood test which can reveal the very high levels of FSH or Follicle Stimulating Hormone typical of post-menopausal women.

The ovaries are the essential organs; they are endocrine glands and produce hormones. Because of this, removal of the uterus, hysterectomy, does not itself cause menopause, although pelvic surgery can sometimes precipitate a somewhat earlier menopause perhaps because of a compromised blood supply to the ovaries. Removing the ovaries however, causes an immediate and powerful surgical menopause, even if the uterus is left intact.

Menopause does also exist in some of the other few mammal species that experience menstrual cycles, such as rhesus monkeys and some cetaceans.

Overview
Menopause occurs as the ovaries begin to fail to be able to produce an egg or ovum each and every month, which in turn after a number of years, leads to the somewhat chaotic shutting down of the whole reproductive system. The break-up of the pattern of the menstrual cycle causes the reproductive hormones to fall out of phase with one another and this causes extreme and unpredictable fluctuations in the levels of several reproductive hormones. After a number of years of erratic functioning, the ovaries stop producing estrogens, progestin and testosterone, and the entire reproductive system gradually shuts down.


Age of onset

The average onset of menopause is 51 years, but some women reach menopause at a younger age, especially if they have had cancer or another serious illness, and have undergone chemotherapy.

Premature menopause (or premature ovarian failure) is defined as last period ever occurring before the age of 40; it occurs in 1% of women. Causes of premature menopause include autoimmune disorders, thyroid disease, and diabetes mellitus. Premature menopause is diagnosed by measuring the levels of follicle stimulating hormone (FSH) and luteinizing hormone (LH); the levels of these hormones will be higher if menopause has occurred. Rates of premature menopause have been found to be significantly higher in fraternal and identical twins; approximately 5% of twins reach menopause before the age of 40. The reasons for this are not completely understood. Transplants of ovarian tissue between identical twins have been successful in restoring fertility.


Menopause in other species

Unlike humans, other mammals rarely experience menopause. This may simply be due to their comparatively shorter lifespans. However, recent studies have shown menopause to exist in gorillas, with an average age of 44 at onset.

The Grandmother hypothesis considers that the menopause arose in human evolution, because later life infertility could actually confer an evolutionary advantage by causing women to divert their attention away from any new offspring, in order to free up time to help with the care of her existing children and grandchildren.


Perimenopause

Perimenopause refers to the time preceding and immediately after menopause, during which the production of hormones such as estrogen and progesterone diminish and become more irregular, often with wide and unpredictable fluctuations in levels. During this period, fertility diminishes. When twelve months have passed without any menstruation, a woman is considered to be one year into postmenopause.

Symptoms of perimenopause can begin as early as age 35, although most women become aware of them about 10 years later than this. Perimenopause, the menopause transition time, can last for a few months, for several years, or for 10 years or even longer. In this respect it resembles adolescence, a similar process that surrounds puberty. In fact menopause has been compared to "puberty in reverse." The actual duration of perimenopause in any individual woman cannot be predicted in advance or during the process.

Not every woman suffers symptoms during perimenopause. About one third of all women get no noticeable symptoms other than their periods becoming erratic and then stopping. Another one third of women have moderate symptoms. The remaining one third of women have very strong symptoms which tend to have a longer duration. The tendency to have a very strong perimenopause may be inherited in some cases.

One piece of recent research has appeared to show that melatonin supplementation in perimenopausal women can produce a highly significant improvement in thyroid function and gonadotropin levels, as well as restoring fertility and menstruation and preventing the depression associated with the menopause.


Etiology

A natural or physiological menopause is that which occurs as a part of a woman's normal aging process. However, menopause can be surgically induced by bilateral salpingo-oophorectomy (removal of both ovaries and both fallopian tubes), which is often done in conjunction with hysterectomy; the resulting cessation of menses as a result of reproductive organ removal is sometimes called "surgical menopause".

The cessation of menses that is not due to surgical removal of the reproductive organs, is the result of the eventual atresia of almost all oocytes in the ovaries. This causes an increase in circulating FSH and LH levels as there are a decreased number of oocytes responding to these hormones and producing estrogen. This decrease in the production of estrogen leads to the post-menopausal symptoms of hot flashes, insomnia, osteoporosis, atherosclerosis, vaginal atrophy and depression.

Cigarette smoking has been found to decrease the age at menopause by as much as one year, and women who have undergone hysterectomy with ovary conservation go through menopause 3.7 years earlier than average. However, premature menopause (before the age of 40) is generally idiopathic.


Symptoms
As the body adapts to the changing levels of natural hormones, vasomotor symptoms such as hot flashes and palpitations, psychological symptoms such as depression, anxiety, irritability, mood swings and lack of concentration, and atrophic symptoms such as vaginal dryness and urgency of urination appear. Together with these symptoms, the woman may also have increasingly erratic menstrual periods.

The clinical features of menopause are caused by lessening amounts of estrogen, progesterone, and testosterone in the woman's body.

Vasomotor instability

hot flashes, hot flushes, including night sweats
sleep disturbances
Urogenital atrophy

itching
dryness
bleeding
watery discharge
urinary frequency
urinary urgency
urinary incontinence
Skeletal

osteoporosis
joint pain, muscle pain
back pain
Skin, soft tissue

breast atrophy
skin thinning
decreased elasticity
Psychological

mood disturbance
irritability
fatigue
memory loss
depression
Sexual

decreased libido
vaginal dryness
problems reaching orgasm
dyspareunia
A cohort study found that menopause was associated with hot flushes; joint pain and muscle pain; and depressed mood. Menopause was not associated with poor sleep, decreased libido, and vaginal dryness.


Treatment of symptoms
While menopause is a natural stage of life, some symptoms may be alleviated through medical treatments. Hormone therapy (HT) provides the best relief, but certain forms appear to pose significant health risks. Some drugs afford limited relief from hot flashes. A woman and her doctor should carefully review her symptoms and relative risk before determining whether the benefits of HT or other therapies outweigh the risks. Until more becomes known, women who elect to use hormone replacement therapy are generally well advised to take the lowest effective dose of HRT for the shortest period possible and to investigate whether certain forms may pose fewer dangers of clots or cancer than others.

Hormone therapy
In addition to relief from hot flashes, hormone therapy (HT) remains an effective treatment for osteoporosis. In HT, estrogens, progesterone or other hormones are administered to compensate for the body's own insufficiency to produce them. There are several types of therapies, with various side effects.

Conjugated equine estrogens
Conjugated equine estrogens contain estrogen molecules conjugated to hydrophilic side groups (e.g. sulfate) and are produced from Equidae-animals (horses).

Adverse effects
Women had been advised for many years that hormone therapy after menopause might reduce their risk of heart disease and various aspects of aging. However, a large, randomized, controlled trial (the Women's Health Initiative) found that women undergoing HT with conjugated equine estrogens (Premarin), whether or not used in combination with a progestin (Premarin plus Provera), had a slightly increased risk of breast cancer, heart disease, stroke, and Alzheimer's disease sufficient to justify stopping the study.

After these results were reported in 2002, the number of prescriptions written for Premarin and PremPro in the United States dropped almost in half, as many women discontinued HT altogether. The sharp drop in prescriptions for Premarin and PremPro following the mid-2002 announcement of their dangers was followed by large and successively greater drops in new breast cancer diagnoses at six months, one year, and 18 months after that announcement, for a cumulative 15% drop by the end of 2003. Surprisingly, no similar drop in Canada's breast cancer rates was observed during the same period, though prescriptions of PremPro and Premarin were reduced in Canada as well. Studies designed to track the further progression of this trend after 2003 are underway, as well as to determine if the drop is related to the reduced use of

Metorrhagia