It is the time in life when mothers are at their busiest. With the enormous responsibilities they hold in raising a family, working and running a home, often their health is not given enough attention. The slightly changing physiological processes are often passed off as ‘normal at 40’.
Unfortunately, this is the time that a number of physiological changes occur in women in relation to their reproductive systems. If you are around 40, you should be watchful for this is the time to detect those growing abnormalities early. Normally menopause, for many women will occur around the age of 50 years. Yet, significant individual variations will occur, meaning that it may occur at 48 years or even 53. If your mother or sisters had early menopause, the chances are that you may also experience the same.
Even though menopause usually occurs around the age of 50, the ovaries prepare for the impending ‘shut down’ a few years earlier. So from a few years before, you will start feeling the symptoms of declining oestrogen levels in your body. This transition period is called peri menopause and will last for one year from your last period.
How do you know if you are in peri-menopause?
The common symptoms are:
- Menstrual irregularities
- Irritability, mood swings and fatigue
- Vaginal dryness
- Reduced sexual drive
- Hot flushes and night sweats- a sudden feeling of intense heat which encompasses your entire body and may be followed by day or night sweats
- Lumpy or tender breasts
- Unexplained weight gain
- Urinary incontinence
- Vaginal dryness
Menstrual irregularities at this time could be that the menstrual flow could be heavier or lighter, the time between periods lengthen or shorten, or even become irregular. This could be due to reducing levels of oestrogen and progesterone hormone levels in your body. Some women will experience heavier flow lasting for several days with passing of blood clots.
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If you need to change fully soaked sanitary towels every hour for a few consecutive hours, if you pass large clots, if your clothes are wet by the time you wake up or you have to change sanitary protection at night, if your daily routine is disturbed because of the menstrual periods, or if there is a recent change in the pattern you may need to seek medical advice. Menstrual flow lasting more than 7 days is also considered abnormal.
The common reasons are physiological changes that occur during peri menopause, fibroids, non cancerous polyps, and other medical causes like impaired thyroid gland function or hypothyroidism. Rarely malignant changes in the inner lining of the womb/ uterus which is called the endometrium can give rise to abnormal bleeding.
Clinically the doctor will diagnose what the more likely cause is- whether it is a gynaecological problem - that is something wrong in the reproductive system or a medical problem - a problem related to other organ systems like thyroid gland.
Fibroids or non cancerous growths in the uterus/ womb are present in one in every three women above 30. They are harmless and may be asymptomatic, or can cause heavy periods, painful periods, bleeding or spotting in between two menstrual periods. Uterine polyps, again harmless mucosal growths can also cause spotting or bleeding between two menstrual periods or after intercourse.
However one sinister cause for bleeding after intercourse is cancer of the cervix.
Therefore all women after forty who have bleeding after intercourse should take it seriously and seek medical advice, though it could be due to dryness of the vaginal wall.
If you are over 40, have a pap smear test every three years to exclude cervical cancer or predisposing conditions to cervical cancer. Cervical cancer is a common gynaecological cancer and can be cured if detected early.
Thyroid problems can also affect the menstrual cycle, though they occur with certain other symptoms not solely menstrual.
Whatever the cause, in abnormal heavy bleeding, or shorter menstrual cycles, it is wise to check the blood for haemoglobin level, as the blood loss could make you anaemic. At your first consultation with the doctor you need to tell him/her about the other medical conditions you have or other drugs you are taking as they may have a role in your current problem as well.
Then you need to be seen by a gynaecologist, if other medical problems are unlikely causes. An ultrasound scan will help in identifying uterine fibroids. If there are no fibroids or any other obvious pathology, abnormal uterine bleeding after the age of 40, needs endometrial tissue sampling. That is to collect cells from the endometrium to be examined under microscope so that the abnormalities at the cellular and tissue level can be identified.
This may be done by hysteroscopy, but in our country, the commonly performed procedure is ‘dilatation and curettage’ or ‘D and C’.
This is now done as a day procedure, and usually patients can get admitted with six- hours fasting and go home a few hours after the procedure.
Depending on the histology report, the treatment will vary.
If there are abnormalities in the report, in the first instance the doctor may offer you medication. But if the changes are significant or pre-cancerous, he would discuss with you the possibility of a hysterectomy or surgical removal of the uterus. If there are multiple fibroids and you do not expect to preserve fertility after 40, hysterectomy is the common answer. However, unless you are close to menopause, ovaries can be conserved to produce oestrogen, a hormone that has many beneficial effects. In patients who are close to menopause, hysterectomy will accompany removal of ovaries as those will anyway give up their function shortly at menopause.
The other important point about peri menopause is that even during this time you can get pregnant, though your fertility is reducing. Therefore, if you are not expecting a baby you need to use a contraceptive method.
Menopause before the age of forty is called premature ovarian failure and is associated with a number of disease conditions like osteoporosis, as the beneficial effects of oestrogen are no longer there. So if you experience early menopause or there are signs that you are approaching menopause, seek medical advice. Though it is not possible to stop it, the doctor may advise you on hormonal replacement therapy.