Clinics in Mother and Child Health

Preparing for Omega at the Latter Decade of Alpha: The Importance of a Preparatory Time and Interval to Face the Consequences of Menopause

Manosha Lakmali Perera^1* and Irosha Rukmali Perera^{2 1}Department of Molecular Microbiology, Menzies Health Institute Queensland, Griffith University, Queensland, Australia
²Department of Health, Preventive Oral Health Unit, The National Dental Hospital (Teaching), Colombo, Sri Lanka
^*Correspondence: Manosha Lakmali Perera, Department of Molecular Microbiology, Menzies Health Institute Queensland, Griffith University, Queensland, Australia, Email:

Received: 30-Sep-2023, Manuscript No. CMCH-23-23710; Editor assigned: 04-Oct-2023, Pre QC No. CMCH-23-23710 (PQ); Reviewed: 18-Oct-2023, QC No. CMCH-23-23710; Revised: 27-Oct-2023, Manuscript No. CMCH-23-23710 (R); Published: 06-Nov-2023, DOI: 10.35248/2090-7214.23.S20.001

Introduction

The whole world summarized into one socio-ecological niche due to the advances in information technology, communication modalities, and the commonality in the basic needs of Homo sapiens originated from the first and foremost ancestors or evolved according to Darwin’s theory in the lithosphere which divided into seven continents based on plate tectonics [1-4]. Women undergo two milestones: the menarche and the menopause consider ‘alpha’ and ‘omega’ respectively in their reproductive health [5]. The life course of oocytes in a girl starts in the uterus in oogenesis, at the first phase of the embryo-fetal life [6]. Whereas the incident of menarche reveals the onset of the ovulation or release of a viable oocyte from the ovary [5]. Endocrine health is interconnected with reproductive health through the feedback controls in endocrine physiology [5.6]. The endocrine axes (prolactin, thyroid, and adrenal) control the behavioral and reproductive functions comprising the events in the menstruation cycle of a female thus it has a central function [7]. The timing of these two milestones is inevitably essential for a woman’s health trajectory and throughout her life span [5]. The global mean age at menarche ranges from 13 years to 16 years old in the current generation [8,9]. However, most of the prepubertal girls reach menarche at the age of 12 years [8,9]. Menopause is the permanent cessation of menstruation resulting in the loss of ovarian follicle development and fluctuation and declining of sexual hormones especially oestrogen in the climacteric and peri-menopausal period. The ‘omega’ phase confirms physiologically by the 12-month amenorrhea phase not associated with pathological causes or the use of hormonal contraception [10]. The median age of menopause across the world varies from 42.1 years to 53.0 years [11]. Nevertheless, reproductive possibilities of women in their early fifties who used oral contraceptives for a prolonged period preserve ova.

Menarche and menopause ages display individuality and population specificity depending on the hereditary and exposures to environmental factors across the life course [5,12,13]. Hence, hormonal exposures, greater maternal weight gain, lack of physical excises and gestational diabetes, breastfeeding, obesity, smoked tobacco use, secondhand smoke exposure, and Socioeconomic Status (SES) were found to be associated with the timing of menarche and menopause in several epidemiological studies [14-16]. Furthermore, psychological stress has been hypothesized to accelerate the onset of menarche and childhood stress has been hypothesized to decrease the age of menopause because of a higher rate of follicular atresia [17,18]. However, these hypotheses need to confirm by longitudinal studies with large sample sizes controlling for confounders carefully. The association between age at menarche and age at menopause is inconclusive thus further research is necessary [5].

The life expectancy of global women soars more than men due to longer telomere and several other protective factors [19,20]. The burden of menopause mainly includes vasomotor symptoms, problems related to changes in urogenital epithelium, and impaired cognitive behavior and sexual dysfunctions [19,20]. Healthy lifestyle modifications with the body and mind concept pave the way for a pre-menopausal woman to invest in a brighter future if the woman prepares for it well in advance. Accordingly, the current review emphasizes the importance of a preparatory time and interval to become knowledgeable and resourceful to face preventable health consequences which make a negative impact on the Quality of Life (QOL) of a post-menopausal woman whether a Professor Emeritus or non-schooling great granny irrespective of the socio-demographic profile [21].

Literature Review

Health consequences and distressing symptoms associated with the menopause

By 2050, the world’s women aged 50 years and older will project a total of 1.6 billion, up from 1 billion in 2020 [22]. Furthermore, about 1.2 billion universal women will be non- reproductive in the menopausal and post-menopausal stages in 2030, with 47 million new entrants each year [23]. The menopausal age of Sri Lankan women varies between 49 years and 51 years [24,25]. Moreover, the peri-menopause period ranges from 2 years to 8 years before commencing the menopause [26,27]. Distressing symptoms associated with menopause broadly be divided into physical, physiological, and psychological [28]. Perhaps, the most common climacteric physiological symptoms in around 75% of women are Vasomotor Symptoms (VMS), including hot flushes or flashes,night sweats, and insomnia or sleep disturbance [28].

Genitourinary Syndrome of Menopause (GSM), palpitations, headaches, bone/joint/muscle pain, asthenia, tiredness, breast tenderness, skin thinning, and scanty hair consider physical symptoms associated with menopause [28].

Psychological symptoms comprise memory loss, irritability, poor concentration, and loss of confidence [28]. Insomnia aggravates neurological symptoms and behavioral disorders. Moreover, GSM with changes in the bladder, vulva, and vagina due to vulvovaginal atrophy affects almost half of post-menopausal women. Symptoms of vaginal dryness, vaginal irritation, itching elasticity, dyspareunia, urinary urgency, dysuria, and recurrent urinary tract infections will deteriorate with time from the menopausal transition if left untreated [28]. Osteoporosis, heart disease, diabetes, obesity, osteoarthritis, and cognitive decline make menopausal syndrome [28]. In 2019, Rathnayake and colleagues evaluated pre and post-menopausal symptoms using the menopause rating scale under three subscales: psychological symptoms, somatovegetative symptoms, and urogenital symptoms in women aged 30 years to 60 years in the Galle district, Sri Lanka [26]. The Mean (SD) ages of pre and post-menopausal women were 46.1(3.7) and 55.8(3.8) respectively. Accordingly, in premenopausal women, the most frequently reported menopausal symptoms were mental exhaustion (49.5%), joint and muscular discomforts (48.5%), and irritability (41.3%) [26]. In contrast, physical and mental exhaustion (53%), irritability (48.2%), depressive mood (43.4%), and hot flushes (42.2%) were most frequently reported in the post-menopausal women [26].

The skin is the largest and target organ of hormones estrogens, androgens, and cortisol. The skin and hair symptoms often receive less attention than other menopausal symptoms with noticeable menopausal effects. Dryness and pruritus, thinning and atrophy, pigmentation, wrinkles and sagging, poor wound healing, and reduced vascularity consider common mucosal and skin menopausal symptoms. Menopausal symptoms affecting hair include scanty hair growth and thinning on the scalp (diffuse effluvium due to follicular rarefication and/or androgenetic alopecia or female pattern), altered hair quality and structure, and increased unwanted hair growth on facial areas [28]. This array of menopausal symptoms, especially the vasomotor and sexual symptoms, are associated with poor quality of sexual life in married women [29,30]. In 80% of women experience cessation of severe menopausal symptoms after 5 years of confirmation of menopause or continuing further as mild symptoms. Unfortunately, 20% of menopausal women may have symptoms for up to 10 years or longer [26]. Neglected peri- menopausal symptoms could affect Gross Domestic Production (GDP) negatively, though nobody has surveyed it so far [31].

Menopausal Hormone Therapy (MHT) or Hormone Replacement Therapy (HRT)

There have been a lot of speculations about the symptoms that appear before (climacteric and peri-menopausal), during (menopausal), and, after the onset of menopause (early post- menopause) [32,33]. The major consequences of menopause are related primarily to estrogen and progesterone deficiency [32-36]. Women typically begin the shift from a reproductive state to a non-reproductive state of complete termination of ovulation due to the depletion of ova during their mid-to-late 40s while, declining of the sexual hormones estrogen, androgens, and glucocorticoids [32-35]. Menopausal Hormone Therapy (MHT) or Hormone Replacement Therapy (HRT) [36-40] is the most effective pharmacological treatment modality to reduce bothersome issues of vasomotor symptoms and cognitive dysfunction in peri-menopausal, menopausal, and post-menopausal women abiding to state of the art of internationally accepted post-reproductive health guidelines. In Hormone Therapy (HT), Oral and transdermal administration of estrogen-progestin and estrogen-alone Hormone Therapy (HT) conditionally to Past Medical History (PMH) or risk profile and individual preference is widely recommended at present [36,37]. Temporal administration in appropriate doses is beneficial not only for the protective effects against cardiovascular diseases but also for bone loss [36]. Promising new data on the direct effect of estradiol on the arterial wall and recent serum lipid results obtained during percutaneous administration of estradiol in post-menopausal women concluded that similar outcomes of cardio protection could be obtained from both peroral and percutaneous administration [36].

Complementary and Alternative Medicine (CAM) for menopausal women

Menopausal Hormone Therapy (MHT) or Hormone Replacement Therapy (HRT) is not suitable for each woman as there is an increased risk of stroke, venous thromboembolism, gallbladder disease, and breast and ovarian cancer [41-43]. As a result, nearly 51% of women in the recent past stood on CAM. Furthermore, above 60% perceive it as better than HRT for menopausal symptoms [41]. Antidepressants and psychoactive agents effective as non-hormonal alternatives for vasomotor symptoms in menopausal women who are also hormone-dependent cancer survivors [44,45]. Moreover, Gabapentin and pregabalin are anticonvulsant drugs capable of decreasing the frequency of HFs by binding to calcium channels in the hypothalamus and, accordingly, better modulating thermoregulatory activity [46]. Selective Serotonin Reuptake Inhibitors (SSRIs) and selective Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) are two examples of antidepressants to treat vasomotor symptoms [46-48]. The United States of America used them for a shorter period to relieve bothersome and embarrassing vasomotor symptoms. In 2012, Aidelsburger and colleagues assessed the efficacy and the cost-effectiveness of alternative methods for women with post-menopausal symptoms in Germany. However, they did not conclude their findings by making recommendations [48].

Women make up half of the workforce. However, about 80% of menopausal women experience problematic symptoms whether they make up the workforce or not [19,49]. Professional women in administrative and technical positions prioritize their carrier life with their inconvenient and embarrassing menopausal symptoms [19]. In this situation, Complementary and Alternative Medicine (CAM) provides a better option for menopausal women [49]. Lifestyle modifications and habit interventions center on the physical, physiological, and spiritual well-being of a woman. According to Johnson et al., CAM interventions for menopause be broadly divided into two categories [49].

Mind body practices: Hypnosis, Cognitive Behavioral Therapy (CBT), relaxation, biofeedback and relaxation training, Mindfulness-Based Stress Reduction (MBSR) and yoga [49]. Aromatherapy, Herbal Products, Vitamins, and Supplements like Black Cohosh (Cimicifuga racemosa), Wild Yam (Dioscorea), Dong Quai (Angelica sinensis), Maca (Lepidium meyenii), Pollen Extract, Evening Primrose Oil (Oenothera biennis), Phytoestrogens and Vitamin E [49].

Whole system alternative medicinal approach: Reflexology, Homeopathy, Acupuncture and Traditional Chinese and East Asian Medicine [49].

Essentially, post-reproductive health is an integral part of women's health. Considerable progress in reducing maternal and perinatal mortality and morbidity was an achieving goal even in a Low-Middle Income Country (LMIC). Integrating and implementing Complementary and Alternative Medicine (CAM) in women’s health guidelines and protocols locally, regionally and internationally may be challenging. However, the same success would be achieved in menopausal medicine to improve the quality of life for women. These attempts generate new concepts on well-being of menopausal women depending on their compliance with treatment options.

“Well woman” concept to address the menopausal symptoms to achieve healthy womanhood

Especially in the last 6 years, menopausal symptoms focus as inevitable signs of the end time of reproductive health [29,49]. Besides, prevention and control by lifestyle-related habit intervention, strengthening of ancient herbal therapies comprising spa therapies, alternative medicine, and nutritional remedies of evidence-based treatment modality essentially with less or no harmful effects of co-morbidities associated with menopause [29,48,49]. The life expectancy of women across the globe increased due to the advancements in knowledge based on evidence-based medicine and improvements in technologies of medical diagnostics and healthcare service deliveries even in low- middle-income countries [5,19,22,24-26,29].

The importance of a plant-based diet, refraining from poly saturated fatty acids, engaging in regular physical and intellectual activities, and meditation recognizes in this 4th industrial revolution era as the benchmark of universal strategies to manage menopausal symptoms effectively [49,50]. Investments in a healthy lifestyle prevent devastating non-communicable diseases associated with obesity, sedentary lifestyle, depression, and lack of coping skills due to life course risk factors.

The mission of revolutionizing post-reproductive health not only from the point of view of General physicians, obstetricians, and Gynaecologists but also endocrinologists and physiotherapists opened up a multidisciplinary approach to treating menopausal women. This approach widens the horizons of the existing knowledge of the health benefits of vegetarian food habits [49,50]. There is a demand for placebo-control randomized clinical trials based on antioxidants, micronutrients, and fibers rich plant-based diets, fermented food, and the Mediterranean diet pattern to overcome menopausal symptoms by CAM [46,49]. According to the findings, the combination of a low-fat, vegan diet and whole soybeans were associated with reduced frequency and severity of hot flashes and improved quality of life in vasomotor, psychosocial, physical, and sexual domains in post-menopausal women [50]. During the 12-week study period, the majority of intervention-group participants became free of moderate-to-severe hot flashes following the study conducted by Barnard and colleagues in 2021 [50].

The Importance of a preparatory time and interval in prevention and management of menopausal syndrome: At least 10 years ahead of alpha

Strengthening the justification of current perspective, an online survey on peri-menopausal women to determine their attitudes and knowledge of the menopause in English speaking women older than 40 years in London, United Kingdom carried out [51]. Lack of education caused peri-menopausal, women to suffer unnecessarily even in the United Kingdom without appropriate medical care. Based on this conclusion authors recommends the initiation of menopausal education at school for adolescent girls, to consider it as a normal event in their lives [51]. It is a well-known fact that menopausal syndrome mostly contributed to the poorer QOL in both pre- and post-menopausal women [5,19,24,26]. Hence, being resourceful with adequate knowledge can make peri menopausal woman to battle against ill effects of aging and out casted as an invalid menopausal woman. Vegan meal enriched in phytoeoestrogens, isoflavones, carotenoids, and flavonoids may help to maintain peri-menopausal ideal Body Mass Index (BMI) in post menopause phase as well [49,50]. Spa therapies and cosmetical medical protocols might help to enhance self-esteem and confidence in post-menopausal woman [49,50]. Hence at the onset of peri-menopausal period is the fundamental and ideal time to challenge the menopausal syndrome as well as prevention of non-communicable diseases including cardiovascular diseases and type II diabetes.

Conclusion

In addition to sufficient preparatory time and interval for every woman to face the consequences of the menopausal syndrome and awareness of healthcare professionals on CAM for menopausal syndrome emerge as an achievable goal in the era of evidence-based personalized medicine. Moreover, the prevention of non-communicable and communicable diseases in peri- menopausal women and the management of co-morbidities in post-menopausal women are established as public health obligations irrespective of cultural barriers.

Author Contributions

Perera ML and Perera IR equally contributed to conception, information acquisition, interpretation and writing of this manuscript especially sharing their personal experiences as post- menopausal academic professionals.

Acknowledgment

The support and guidance provided by Sri Lanka Ranjana Sir Sabaratnam Arulkumaran; Professor Emeritus of Obstetrics and Gynaecology, Dr. Anil Jasinghe; former Director General of Health Services, Dr. Sanath Lanerolle; The President Menopause Society of Sri Lanka.

Conflict of Interest

The authors declare no potential conflicts of interest with respect to the authorship and/or publication of this article.

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