Menopause

IN most of her family photos taken when she was a teenager, Maria was the one with the widest, most mischievous grin. She was short in stature, but made up for it with her quick wit and sense of humour. But in her 40s the light in her eyes had dimmed. The once carefree Maria, who had become a wife and mother, had entered early menopause and was struggling to cope. Her family knew she was depressed, but didn't understand the extent of her suffering.

Then one day in early March, Maria ended her life, leaving her family and friends devastated and in disbelief.

Maria left behind many questions, some of which were answered in the pages of her diary, where she wrote obsessively about her depression-- which for her was a minute by minute, day to day battle with psychological pain.

Menopause is most commonly understood as something that all women must go through eventually, but given the symptoms and effects of menopause - one of which is depression (a recent study revealed that perimenopause increases risk of depression by 40%) - it is important that we understand what menopause is, how it affects the body and the management options that are available.

Award-winning obstetrician/gynaecologist Dr Sherene Kalloo is committed to bringing menopause out of the shadows and getting more people to talk about the condition, which not only affects the reproductive system but many other systems of the body, causing significant physiological, emotional and psychological symptoms.

'From my professional and personal experience, menopause and the changes that result, are underestimated and poorly understood,' Kalloo said.

'It is not taken as seriously as it should by spouses and other members of society. Menopause is defined as the absence of menstrual periods for 12 consecutive months; it is a single point in time and not a process.

'Menopause is the time when the function of the ovaries ceases, therefore a pregnancy can no longer occur. The ovaries are the main source of female hormones which control the development of female body characteristics, such as the breasts, body hair and shape. The hormones also regulate the menstrual cycle and pregnancy and keep us looking younger,' she said.

The menopausal transition starts with varying menstrual cycle lengths and ends with the final menstruation period. The word 'perimenopause' refers to the menopausal transitional period and it typically lasts four to eight years. The average age menopause occurs is 51 but typically takes place between 45 and 51, said Kalloo.

'It can also begin earlier for some women who have had surgical menopause when the ovaries are removed surgically.

Going through menopause between the ages 40 to 45, which occurs in around 5% of women, is referred to as early menopause. If menopause occurs in women under the age of 40 - which happens in less than 1% - it is called prema- ture ovarian insufficiency," said Kalloo.

Menopause affects every woman differently, said the gynaecologist. Some may have few symptoms or none at all, while others may experience quite severe and multiple symptoms.

Some symptoms may come and go over an extended period of time for some individuals.

The most common symptoms are hot flashes (the fire with in) - which can last up to ten years - tiredness, night sweats, palpitations, vaginal dryness accompanied by pain, itching, discomfort during sex with pain, reduced sex drive, joint stiffness, aches and pains, insomnia, headaches, mood changes and memory and concentration problems (brain fog).

Menopause results in osteoporosis, cataract, gum disease, urinary incontinence, heart disease and slower metabolism, which leads to weight gain, said Kalloo.

Additionally, the changes in hormones affect the brain's chemistry increasing irritability, anxiety and depression that are not due to external causes.

'It can be frustrating to a woman who can't snap out of these changes; sometimes her productivity may falter,' said the gynaecologist. 'She may not understand why she is becoming this different person.'

Menopause rage - an intense surge of anger or frustration - can manifest in both physical and verbal forms, such as excessive crying or shouting, aggressive behaviour or even violent outbursts.

Given such serious symptoms, is it any wonder why, according to Kalloo, there is a correlation between the age at which most women seek divorce and the onset of perimenopause or menopause (between 45 and 55)?

'Over 60% of divorces are initiated by women in their menopausal years. Unbelievable!' exclaimed Kalloo. 'This phenomenon of menopausal divorce must be taken seriously as we now wonder if some marriages can survive menopause.'

Management options include exercise, yoga, vitamins, alternative therapies, non-hormonal medical treatment, cognitive behavioural therapy and healthy lifestyle changes. Hormone replacement therapy (HRT) options are also available for usage.

Kalloo remembers seeing a woman who was so depressed she would not even leave her car, after taking the woman's thorough history and doing her own investigation, Kalloo prescribed Hormone replacement therapy. A month later, the woman walked into Kalloo's office smiling. Depression linked to menopause is more serious than we imagine, warned Kalloo. She urges those suffering to recognise, accept and seek help.

Once depression is detected early, HRT may not be necessary, psychotherapy alone may be effective.

In 2019, the Ministry of Health (MoH) issued some guidelines on the recognition and treatment of menopause. Last September Kalloo attended a meeting hosted by the MoH sensitising health care professionals around the subject of menopause. Still, Kalloo insists that women need to be educated about the many faces of menopause.

'Women also need to educate their partners that mood changes may be due to this hormonal decline and their understanding and support are needed in this transition of a woman's life,' she said.

Our changing social structure has disadvantaged menopausal women, she added.

'We have an aging population with more single women living alone, due to death or divorce of their husbands, and children leaving the home. The decrease in intergenerational families living together has seen menopausal women, who transitioned into revered matriarchs of their homes, now reduced to lonely, depressed women suffering from empty nest syndrome,' she said.

Kalloo is appealing to the Ministry of Health to ensure HRT in various other forms such as transdermal patches, is made available for better compliance and less side effects.

Award-winning obstetrician/ gynaecologist Dr Sherene Kalloo.