Menopause (climacteric, climacterium)

Assoc. Prof. Ivona Daskalova, Head of Endocrinology Clinic at the Military Medical Academy. There are four specialties: internal medicine, endocrinology and metabolic diseases, clinical pharmacology and therapy, and health management. She has specialized in medical schools and clinics in the USA and Europe.

Why should we talk about the climax?

Climacterium is a condition that occurs not only in women but also in men and is associated with hormonal function.

Climacterium worsens not only a woman’s quality of life, but also changes her health profile. No change in the body will be critical, as this age is called, if already at the initial symptoms women do not think for themselves and do not consult a doctor about how to help themselves.

Climax is a condition that has precursors. Before the onset of menopause, there are so-called. premenopausal state. There are women in whom premenopause and menopause occur much earlier, but it is physiological and normal for pre-climax to begin by age 44-49. Menopause usually physiologically occurs by 49-52 years. A condition we also need to pay a lot of attention to is the postmenopausal state. It occurs after menopause and covers the age of 52-60 years.

There are cases in which menopause occurs very early, they should be given a lot of attention. These women need to be examined in a targeted manner. Aimed to examine their bone system, to examine their bone density. There are also women, of course, in whom menopause occurs after 52-56 years, but these are rarer cases.

About 1 200 000 women in Bulgaria are in menopause, this is the latest epidemiological data. It should be known that every year 50-60 000 women cross the threshold of menopause.

What are the symptoms by which women can tell that hormonal changes are occurring in their body and they are entering menopause and what should be done?

In the first place, the so-called. “warm waves”.  70% of premenopausal and postmenopausal women complain of this symptom. The other symptom is sweating, and the percentage is not small either – 68% of women who go through menopause have this complaint. One should not forget one other disorder – increased irritability, restlessness. 50% of women at this age complain of increased irritability. 49% suffer from sleep disorders. This number is not at all small, neither in terms of the number of women affected, nor in terms of the number of symptoms. These complaints lead to a serious deterioration in the quality of life, and these are active women, women of creative age, who need to be helped with methods and ways to reduce these complaints. On the one hand, this is achieved through medication, on the other – with a change in lifestyle.

What is meant by lifestyle change? This is increased physical activity, use of multiple spa treatments, walks in the fresh air. Every woman should know, at any age, but especially at this one, that she needs to take time for herself. A woman should strive to be vibrant and smile more often. Naturally, when she complains of such symptoms as sweating, restlessness, insomnia, she will be far from this state. Every woman should spend 1 hour a day on herself.  And, of course, then, when she can’t cope, she has to be prescribed the appropriate medication as well.

However, the main rule remains lifestyle change and women need to be aware of this. Measures here include a varied diet, normalisation of body weight, which is very important, and diversification of social life, let women have more cultural activities. I am aware that every woman will say, ‘I have no time!’, but she  must find time, again I stress – one hour a day for yourself, 30 minutes for a walk.

When is medication therapy undertaken during menopause?

Recently, there has been much controversy about hormone therapy, whether to conduct such in this condition or to use non-hormonal means.

Years ago, the use of hormones in premenopause, during menopause and after the onset of menopause was recommended throughout the world. I want to mention that there seemed to be a bit of a hijack here, hormones were taken for 10-15 years, which I don’t think was necessary in any woman. This approach is not good, the new results already say otherwise, ie not every woman is suitable for hormone therapy. But it should be known that in any case, this is not a method that is rejected. A separate issue is that there has been little change in opinion regarding when to start hormone replacement therapy, how it should be started and how long it should last.

Women need to know that therapy cannot be undertaken without consulting a doctor, either a gynaecologist or an endocrinologist. Always hormone replacement therapy should be prescribed by a doctor. I emphasize it because very often women start hormone replacement therapy on their own, which is extremely harmful. Before hormone replacement therapy is started, certain studies must necessarily be conducted.

What are the studies that need to be conducted?

It is mandatory to have an examination with a gynecologist, a smear is taken, a mammogram is performed, as well as hormonal tests. Such therapy is undertaken after consultation with a gynecologist and endocrinologist.

Of course, to relieve menopausal symptoms, non-hormonal preparations are now also available, which, however, resemble hormonal action. That’s why they say it’s a phytotherapy, the phytoestrogens. They are different groups, different names. They have their advantages, and most of all they lead to an improvement in the condition of women, i.e. they reduce menopausal complaints, sweating problems, insomnia…

Can phytotherapy be considered better than hormone replacement?

No. There are groups of patients who are suitable for phytotherapy, and others who require hormone replacement therapy. This very much depends on the individual case and will be decided by the attending physician.

Can it be determined which group of women are suitable for hormone replacement therapy and which for phytotherapy?

Many times with early onset of menopause, it is appropriate to administer hormone replacement therapy. But I emphasize, it can not be generalized and determined without the patient has undergone the mandatory examinations and examinations before the start of therapy.

What changes occur in a woman’s body during menopause and are they associated with health risks?

It should be known that menopause is a period of women’s lives when not only these neuro-vegetative complaints, sweating, hot flashes, irritability, are a problem. Usually these complaints decrease with the intake of phytoestrogens, of course, and with hormone replacement therapy. But it should be known that in this period in the body of a woman changes occur, in the lipid profile, and also in bone density.

What is the change in the lipid profile – an increase in cholesterol and triglyceride values occurs. And, of course, with the change in lipid profile comes the danger of cardiovascular complications. If high cholesterol and triglyceride values are added to high blood pressure values, a serious cardiovascular risk develops. This is why prevention of cardiovascular disease, ischemia, myocardial infarction, stroke…

Another test that women should have regularly at this age is mammography.

With a decrease in the level of estrogens, which occurs in the climacterium, osteopenia occurs, and in many patients and osteoporosis.

What health problems is menopause associated with? What is the prophylaxis ?

Menopausal, premenopausal and postmenopausal women are among the risk groups for the onset and development of osteoporosis. At this age, women must necessarily undergo an examination to measure bone density and treat bone density deviations according to their degree. When osteopenia is detected, one course of action is taken; when osteoporosis is detected, another course of action is taken. But in any case, measures should be taken, since osteoporosis is a disease that can lead to fractures – femoral neck, vertebrae of the spine. If the disease is left the woman may become disabled later, which should not be allowed.

Prevention is achieved, I will point out again, with a change in lifestyle and diet.  Osteoporosis is perceived as a disease characteristic of advanced age and therefore its prevention from an earlier age is neglected. And the fact is that prevention against osteoporosis starts from childhood. It is advisable to feed the child with products from our Bulgarian cuisine, to offer him a lot of dairy products – cheese, cheese, milk, as well as fruits and vegetables. In young girls, then, it should be known that subjecting them to fad diets that  deprive them of many beneficial nutrients are extremely harmful. In my practice, many times when we have looked for the causes in women with severe osteoporosis, we have found that they have had eating disorders, they have been subjected to incorrect diets that are not physiological and should not be undertaken.

Young girls, and not only them, people in general should know that overweight is the result of dietary mistakes, and it occurs not only because junk food, “fast food” and other fast food products are consumed, but also because the food is not vitamin-rich enough. The way of eating is also important – do not starve all day long, and in the evening after seven and a half ingest food whose caloric value exceeds 2000-2500 kcal. Naturally, with such a regime, there will be overweight. We need experts to recommend how people should eat properly and how to prepare their food in a healthy way. It is necessary to avoid heavy foods, high-fat foods. These are recommendations that apply even more to the climax.

Second is lifestyle – increasing physical activity. Obesity is also already a problem for Bulgarians, a problem that is very serious in the USA and Western Europe. Changing the standard of living also changes the way we eat. From the car you sit on the computer and vice versa, i.e. no physical activity. This is a gross error. Every single prevention of all diseases involves increased physical activity. People should learn to take walks, on weekends to indulge in active pursuits, preferably in nature.

There are two other factors I want to address. These are smoking and alcohol consumption.

Tobacco is damaging and contraindicated in women with osteopenia, let alone women with osteoporosis. Alcohol has its relation to both body weight and spasm of the vessels. Smoking and concentrate should be restricted. Smoking is relevant not only to lung cancer, but also in all people who have diabetes mellitus. Cigarette causes the same damage to the blood vessel that high blood sugars have. Patients who have diabetes mellitus should know that one time their blood vessels are damaged by the high sugars characteristic of the disease and a second time, additionally, they are damaged by nicotine. Therefore, the aspiration should be smoking cessation and normalization of blood sugar.

Smoking also has a negative effect in osteoporosis. Already, numerous studies and research have shown that smokers have a much higher rate of osteoporosis, a much higher rate of stroke, heart attack, etc. than patients who are not smokers.

What are the prophylactic measures during menopause when it is assumed that the deteriorated conditions are already present? Is vitamin intake recommended?

Yes of course, it is good to take vitamins and trace elements, then, when they are not sufficiently supplied by food. Especially in autumn and winter. Both to reduce the consumption of fatty foods, of fried and to consume a high percentage of cheese.

In osteopenia, osteoporosis, it is recommended to consume food rich in calcium. Then, when a patient lacks calcium at the discretion of the doctor is prescribed such a preparation.  

At this age, there is a need for magnesium, for selenium, as well as other trace elements that the doctor judges that his patient needs.

I want to draw attention to a problem. In our country it is a common practice to take medicines that are not prescribed, but are taken because a friend takes them. The patient should not turn into a self-healer, this is a gross mistake. It is the doctor’s job to decide what preparation to prescribe, in what dose and for how long to take, even when it comes to vitamins.

Recommendations on how a patient should eat for a given disease, even for  its prevention, should also be given by the treating physician.

We advise our patients, both women and men, because, after all, menopause is not characteristic only of the fair sex, to consume a bucket of yoghurt a day, but real.

A woman can take precautions herself – to maintain a normal weight, for physical activity and proper nutrition. And then in terms of therapy – it should already be prescribed by a doctor who should decide after the tests whether it is for hormonal therapy or non-hormonal treatment. When complications occur in high fats, in osteoporosis or complaints in the heart area, drugs are prescribed by a specialist.

There is evidence of a lowering of the lower age limit for the onset of menopause. What do you think premature menopause is caused by and how can these still very young women help themselves?

Everything is very individual. An early menopause can be due to hormonal deficiency, to dieting when the woman’s desire was to lose a lot of weight, to high blood sugar… In women with diabetes, too. Basically they should be aware that with high blood sugar menstruation can stop. There is a group of young people who are affected by type 2 diabetes who are not insulin dependent. Usually these people are not aware of their disease, do not get tested, and the disease develops. Menopause also occurs early in them.

The reasons are very different and individual, so I would not undertake to generalize and determine what they may be.  Even one strong stress can also lead to early menopause. Or nervous tension, an upset that we generally think will not affect us…  

Any early onset of menopause should be clarified thoroughly with a specialist. In such cases, there must necessarily be consultations with a gynecologist and endocrinologist.

And one recommendation, in these cases hormonal treatment should not be prescribed immediately. I have a patient who was prescribed hormone replacement therapy without the necessary tests. Without anyone having thought to check her glycated haemoglobin, which turned out to be high, it was a menstrual cycle disorder, amenorrhoea, i.e. absence of menstruation for a month or two, due to poor blood sugar control.

In general, in the case of cycle disorders, every woman or girl should first go to her personal doctor, who will refer her to a gynecologist, endocrinologist, if necessary, to another specialist.

The specialist must find the cause and prescribe the specific treatment. Self-medication should not be undertaken.

But it should be borne in mind with regard to complaints that it is possible that a woman may have a condition whose symptoms are similar to those of the menopause. For example, sweating, hot flashes, may be due to a thyroid disorder, hyperfunction or, conversely, hypofunction or another disease to coincide with the menopausal period. Any self-respecting doctor is able to recognize these symptoms and prescribe adequate therapy.

There are women who are apprehensive to perform prescribed hormone replacement therapy during menopause because of the risk of developing breast cancer. Do they have grounds for this?

No, they don’t. That is why, before the appointment of hormone replacement therapy, a certain set of mandatory examinations and examinations is carried out to rule out this risk.


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