Menopause

Original Editor - Nicole Sandhu Top Contributors - Nicole Sandhu, Khloud Shreif, Regan Haley, Kim Jackson, Nicole Hills, Lucinda hampton, Chrysolite Jyothi Kommu, Safiya Naz, Amanda Ager and Aminat Abolade

Introduction

Natural menopause occurs when there is a complete, or near-complete, ovarian follicular depletion of a female's ovaries and loss of ovarian follicular activity, resulting in the permanent cessation of her menstrual cycle. It occurs at a median age of 51.4 years and the months and years leading up to this are called peri-menopause. Menopause before the age of 40 years old is considered abnormal. The transition into and through menopause can have various physical, psychological, and social effects on a woman's life, and the ability to cope with these changes can be impacted by socioeconomic status, income, level of education, work-life, and social relations.

Types of Menopause

Physiological Menopause: Also known as a spontaneous progressive decline of the menstrual cycle due to the decline of ovarian function, the average age is between 40-51 years of age.

Pathological Menopause

• Premature menopause: cessation of ovarian function before the age of 40. Females who experience premature menopause have a greater probability of developing early mortality and morbidity rates.
• Artificial or surgical menopause: permanent cessation of ovarian function due to surgical intervention, or medical treatment like chemotherapy or pelvic radiation therapy.
• Delayed menopause: cessation of ovarian function after the age of 51.

Clinical Exam

Subjective

Symptoms of menopause and peri-menopause:

Symptoms	Information
Hot flashes	A hot flash typically begins with a sudden sensation of heat in the upper chest, face, and back, often associated with perspiration. Occurs in up to 85% of women. Hot flashes can begin in the late reproductive years and symptoms become more common through early menopause, late menopause, and the early post menopause period.
Vaginal dryness and/or Sexual dysfunction	Genitourinary syndrome of menopause (GSM) refers to atrophic symptoms that women may have in the vulvovaginal and bladder-urethral areas from the loss of estrogen that occurs with menopause. Epithelial lining of the vagina and urethra are estrogen-dependent tissues, therefore, estrogen deficiency leads to thinning of the vaginal epithelium, resulting in vaginal atrophy, which leads to dryness, itching, and often dyspareunia. Estrogen deficiency leads to a decrease in blood flow to the vagina and vulva, which causes decreased vaginal lubrication and sexual dysfunction. One of the earliest signs of estrogen insufficiency is noticed when there is a decrease in vaginal lubrication upon sexual arousal. Vaginal dryness affects up to 85% of women over 40 years of age, with an additional 29-59% reporting dyspareunia and another 26-77% reporting vaginal itching and irritation. Women may also experience heavy and unpredictable bleeding.
Depression	There is a significant risk of new-onset depression during menopause when compared to pre-menopausal women. There are many hypotheses as to why the rate of depression increases in menopausal women. For example, middle-aged women tend to be faced with many other challenges throughout the transition into menopause, such as grown children leaving home, marital difficulties, physical disease, and the death of parents, which can all impact one's ability to cope. Changes in body shape, weight, and size, as well as sleep disturbances and changes in skin, hair, and sexual function can all contribute to depression in the menopausal years.
Sleep disturbances	Women with menopause report an increase in sleep difficulties more than women perimenopause such as, difficulty falling asleep and nighttime awakening. This may also be secondary to hot flashes and mood changes. Anxiety and depression may have a negative effect on sleep during this time. Treatment of sleep disturbance depends on clinical presentation.
Joint pain/ arthritis Musculoskeletal pain/arthralgia	Joint pain appears to increase during menopause, which may be due to estrogen deficiency. Analgesic drugs such as oral NSAIDs or intra-articular injections can be used as treatments. Although still under review, HRT (hormonal replacement therapy) has not been shown to decrease joint pain. Musculoskeletal pain increases in both pre and post menopause, however, the mechanism in which estrogen causes musculoskeletal pain is still not clear. Weight control and regular exercise are recommended as the best treatments for musculoskeletal pain during menopause.
Cognitive changes	Estrogen plays a role in cognitive function therefore, with estrogen deficiency women may experience memory loss and difficulty concentrating.

Objective

Stages of Reproductive Aging Workshop (STRAW) is a staging system developed from data from multiple longitudinal cohort studies. This system is considered the gold standard for assessments with menopausal women and includes criteria for the reproductive years, the menopausal transition, perimenopause, final menstrual period (FMP), and postmenopause based upon bleeding patterns, endocrine findings, and symptoms. The STRAW system is used mainly in research, however, it may be helpful in the clinical setting for patients and clinicians to assess fertility potential, contraceptive needs, and the potential need for hormone therapy.

Stage	Signs/Symptoms
Late reproductive years	May begin to notice changes in her menstrual cycle (ie. a shorter cycle)
Early menopausal transition	Marked by increased variability in menstrual cycle length
Late menopausal transition	Marked by the occurrence of amenorrhea of 60 days or longer Characterized by increased variability in cycle length and extreme fluctuations in hormonal levels
Early postmenopause period	Corresponds to the end of “perimenopause,” a term still in common usage that means the time around menopause
Late postmenopause period	Symptoms of vaginal dryness and urogenital atrophy become increasingly prevalent at this time

Long term Effects of Menopause

Health Concerns	Information
Bone loss	The loss of cortical bone affected by estrogen deficiency and age related trabecular bone loss.
Cardiovascular disease	The American College of Cardiology/American Heart Association (ACC/AHA) Guidelines recognize the postmenopausal state as a risk factor for CVD. The increased risk may be due to a change in the lipid profile - an increase in low density lipids (LDLs) in women going through menopause.
Body composition	During the postmenopausal period women often gain fat mass, central abdominal fats, and lose lean mass. Spontaneous decrease of activities, decrease in energy expenditure, and decreased metabolic rate. Decrease in estrogen levels accompanied by an increased level of follicle stimulating hormone.
Balance	Estrogen deficiency has been linked with impaired balance in postmenopausal women.

Management

Physical Therapy Intervention

As part of the healthcare team, physiotherapists should be aware of the menopausal process and the symptoms that can come along with this transition. Many of the symptoms and health concerns described above can have a negative impact on women's health and overall quality of life. It is crucial to be able to identify symptoms in menopausal women through individualized assessments and provide appropriate management strategies, such as exercise and pain management, or referrals to other healthcare professionals when needed.

Sexual Health

Vaginal canal before and after menopause

Sexual health may be negatively impacted by some of the issues stated above. Simple, non‐hormonal interventions for sexual dysfunction are often overlooked. Several studies show that education on vaginal lubricants, moisturizers, and dilator use (as needed) can have a positive impact on sexual health. Pelvic health physiotherapists are well-positioned to assist patients with this.

Exercise

Classified into:

1. Weight-bearing exercise:

• Low impact weight-bearing activity such as walking, Tai Chi, and yoga.
• High impact weight-bearing activity such as jogging and vibration platforms.

2. Resistance and Strength Training Exercise:

• Examples include weight lifting, swimming, cycling.

Physical activity and exercise have been shown to have reduce the risk of osteoporosis, cardiovascular disease depression and obesity.

Osteoporosis and Bone Density

BMD, especially of the vertebrae, decreases with menopause

Studies show that physiotherapists are able to assist in providing guidance around exercise and exercise prescription in people at risk of osteoporosis and reduced bone density. However, not all exercises have the same osteogenic effects on bone mineral density (BMD). Resistance exercise has a stronger osteogenic effect, and for exercise to be effective its mechanical load should exceed that of activities of daily life.

To obtain the best results, a combination of exercises that include both resistance and weight-bearing exercises is the best choice to optimize strength and function. Resistance exercise affects muscular loading whereas weight-bearing exercises have a mechanical loading effect on bone.

The mechanisms in which exercise impacts bone density is still not clear but research suggests that exercise increases the activity of osteoblasts and inhibits osteoclast activity. Enhanced bone strength increases the cross-sectional area due to mechanical loading, which in turn increases bone resistance. A systematic review encompassing only randomized controlled trials, conducted by Howe et al. (2011), examined the effectiveness of exercise interventions in preventing bone loss and fractures in postmenopausal women, and they found that exercise was a safe and effective way to prevent bone loss in this population.

Additionally, higher levels of participation in physical activity were independently associated with lower weight, waist circumference, and risk of substantial weight gain.

Cardiovascular Disease (CVD)

Regular and gradual aerobic exercise programs can improve cardiorespiratory endurance and decrease the risk of Cardiovascular Disease (CVD). Some research suggests that exercise increases levels of high-density lipoproteins (HDL), decreases low-density lipoproteins (LDL), and controls hypertension, which in turn improves cardiovascular health.

Depression

Exercise therapy has the ability to relieve some symptoms in persons with depression when compared to participants without clinical depressive symptoms.

Research shows an increase in levels of brain-derived neurotrophic factor (BDNF) in the depressed population, however, this did not result in an improvement in depressive symptoms. The mechanisms in which exercise impacts depression is not clear.

Obesity

Regular exercise programs show to increase metabolic rate and energy expenditure, promoting the loss of abdominal fats and helping with obesity.

Aquatic Therapy

Exercise in the water allows for a reduction of stress on muscles and joints. Aquatic therapy could be a good alternative for women who experience pain due to stress on joints.

Benefits of Aquatic Therapy

• The Bouncy effect protects joints from the stress of exercise that in turn relieves joint pain from conditions like arthritis.
• Improves general blood circulation and reduces swelling.
• Provides a comfortable environment for strengthening exercise programs
• Improves cardiorespiratory capacity and endurance.
• Can help to improve balance.

Diet

Physicians or a Registered Dietitian/Nutritionist can advise on the dietary needs of women going through menopause. Vitamin D and calcium supplements may benefit this population, however, a dietician or a naturopathic doctor should be consulted when determining supplementation.

Low caloric diet (calculated according to each individual's total calorie intake) with exercise shows to be most effective for weight loss and loss of abdominal fats. Van Gemert and colleagues (2019) looked at an exercise program involving 4hrs/week, 60 minutes/day exercise varying between resistance and endurance exercises.

Medical Interventions

Patients should discuss treatment options with their physician and healthcare team. This may include menopause hormone replacement therapy to aid with the issues listed above. Hormonal replacement therapy (HRT) may be a supportive method includes estrogen with progestin, for example, Resveratrol (phytoestrogen) has been shown to positively affect improvements in cognitive decline and cerebrovascular function.

Psychological Intervention: Connecting with other women going through menopause or speaking to a therapist may add extra support for menopausal women.

Resources

American College of Obstetricians and Gynecologists: Menopause Resource Overview

For further information on managing menopause, please refer to this presentation by Dr. Kathryn Macaulay