Menopause is a phenomenon that occurs as a consequence of the exhaustion of the functional capacity of the ovary.

• Perimenopause is an imprecise period that begins with the first changes in the ovarian cycle and ends one year after the last menstruation. Variable duration menstrual irregularity occurs as a consequence of fewer ovulatory cycles secondary to the decrease in the number of follicles.

• Postmenopause is the period after menopause (12 months later) until senility. Follicular function disappears and hormone production depends on the ovarian stromal cells. The main estrogen produced by women in this period is estrone (adipose tissue), and with less estrogenic potency than estradiol, and insufficient to maintain normal trophism of estrogen target tissues.

The decrease in the levels of female hormones until their total disappearance causes a series of related signs and symptoms to appear, as well as an increased risk of some disorders and pathologies. The appearance of each of them, as well as their severity and importance with respect to the worsening of the quality of life, depends on each woman.

Three changes associated with menopause:

• Decreased production of hormones (estrogen and progesterone)
• The ovaries stop releasing eggs
• The completion of menstrual cycles

Symptoms of menopause

Irregular menstrual cycles are usually the first sign of menopause. Since this symptom can occur many years before the onset of menopause, it is more typical of the premenopause stage. With the passage of time, menstruation disappears and the date of the last menstruation determines the onset of menopause.

• Vasomotor symptoms

The term hot flash describes the sudden onset of flushing on the skin of the head, neck, and chest, accompanied by a sensation of body heat that sometimes ends with profuse sweating. It is present in 40% of premenopausal women and 85% of postmenopausal women. It ranges from a few seconds to several minutes, can be occasional or very recurring, and is more frequent and intense at night. They persist between one and three years, 25% of cases lasting more than 5 years. Other vasomotor symptoms are: palpitations, paresthesias, nausea, headaches and tinnitus.

• Depressive disorders

It is frequent to observe emotional lability, irritability and nervousness.

• • Sexual dysfunctions

Hypoestrogenism affects all spheres of female sexual health: disorders of arousal, interest, orgasm. The hormonal deficit produces trophic and functional changes in the vagina, with the consequent decrease in vascularization and vaginal lubrication, in the form of pain (dyspareunia).

• Involutive changes of the genital apparatus.

After menopause there is a loss of elasticity of the vulvar introitus and a reduction in the activity of the vaginal glands and the thickness of the vaginal squamous epithelium, which leads to decreased lubrication and, in some women, vaginal dryness and dyspareunia. As postmenopause progresses, vaginal atrophy is more important and the symptoms of vaginal dryness and dyspareunia are more evident.

• Sleep disturbances

Disrupts the circadian rhythm of sleep.

• Skin changes

The gradual thinning of the epidermis that occurs with age intensifies after the menopause. The dermis presents a decrease in its thickness and cellularity, as well as a flattening and widening of the dermal papillae. The main component of the dermis is collagen, which undergoes morphological, chemical, and physical changes at menopause very similar to those of actinic injury. 30% of collagen is lost in the first five years of menopause. All these changes lead to a loss of skin elasticity, decreased secretion of sweat and sebaceous glands, and changes in microcirculation.

Long-term repercussions of hypoestrogenism

• Cardiovascular disease

Female hormones have a protective function in the life of women against cardiovascular diseases, acting on the maintenance of vascular flow, developing a vasodilator action and controlling levels, for example, of total cholesterol or triglycerides. However, with menopause, this protection disappears and cardiovascular risk increases. It should not be forgotten that cardiovascular risk factors linked to lifestyle habits such as smoking, leading a sedentary life, obesity or stress play the most important role in the appearance of cardiovascular complications.

• Metabolic syndrome

Menopause is associated with metabolic changes that often lead to an increase in body fat. Sedentary life accelerates this process.

• Thrombotic phenomena

Age and menopause increase the thrombotic risk.

• Osteoporosis

It is a systemic skeletal disease characterized by the decrease in bone mass and the deterioration of the microarchitecture that conditions an increase in fragility and flexibility.

Susceptibility to bone fracture. It is the leading cause of fractures in postmenopausal women. Its diagnosis is made fundamentally by clinic and densitometry.

• Sarcopenia

During menopause there is a higher prevalence of sarcopenia and loss of balance, which increases the risk of falls and fractures.

Treatments in menopause

To determine if any treatment should be recommended for the symptoms of menopause in a woman, it must be established what stage the woman is in and what are the specific symptoms she is suffering from. In addition, it is essential to take into account the perception of the quality of life of the woman herself, as well as her preferences.

Hygienic-dietary measures in menopause

Any therapeutic initiative for menopause must consider dietary hygiene measures that include physical exercise, the consumption of calcium or vitamin D or the abandonment of toxic habits such as smoking or excess alcohol.

• Physical exercise

Regular physical exercise with a better state in numerous health indicators, a better quality of life, and with the prevention and treatment of ailments that occur with age. We can infer that physical activity constitutes a form of therapy in itself. Regulated physical activity also prevents or treats sarcopenia and increased tendency to falls. Weight loss could be beneficial options in the prevention and treatment of vasomotor symptoms. Aerobic physical exercise (walking, running, cycling) and resistance training programs are recommended for the prevention of osteoporosis in pre and postmenopausal women. On the other hand, physical exercise can have other beneficial effects, such as preventing falls.

• Calcium intake

Calcium supplements are indicated for the prevention of osteoporosis and risk of fracture in women older than 65 years with a high risk of fracture.

• Vitamin D intake

Vitamin D 2000 IU lowers the risk of femoral fractures by 18% in women older than 50 years.

The combination of calcium and vitamin D supplements is indicated for the prevention of osteoporosis and risk of fracture in women over 65 years of age with a high risk of fracture.

• The abandonment of toxic habits such as smoking excessive alcohol

Moderating the intake of alcohol and caffeine is recommended for the prevention of osteoporosis

Moderating the intake of alcohol and caffeine is recommended for the prevention of osteoporosis

Avoiding tobacco use could be beneficial options in the prevention and treatment of vasomotor symptoms.

• Drinking cold drinks and avoiding spicy foods, coffee, alcohol, and hot situations could alleviate vasomotor symptoms in some women.

Menopausal Hormone Therapy (MHT)

It is well established that MHT can improve many of the symptoms associated with menopause, not only vasomotor symptoms but also night sweats, insomnia, genitourinary problems, and dry skin and mucous membranes. Likewise, its efficacy has been observed to correct mental symptoms (depression, irritability), as well as to improve sexual satisfaction and orgasm, and overall in the “quality of life”. However, MHT is not a panacea for menopausal problems, as it presents risks and is not well tolerated by all women, so its prescription must be individualized and the duly informed patient must decide whether to take it and how long to take it. Your job.

In general terms, the balance between the benefits and the risks of MHT depends on the moment of administration, the dose, formula and administration schedule.

Recommendations of the AEEM-SEGO for the use of THM:

• Treatment of vasomotor symptoms remains the main indication for MHT.
• MHT improves bone mineral density.
• MHT is cardioprotective although it is not indicated for cardiovascular prevention.
• The risk / benefit balance is more favorable with lower doses, time of use and time since menopause. A woman under 60 is safe taking THM. The age is not limit for the duration of the THM.
• There is no clear evidence regarding the type of estrogen or the route of administration.
• The relationship between MHT and breast cancer is unclear based on the available evidence. It has been linked to the type of progestin, the route of administration, the duration of treatment or previous exposure to other HT, but above all to the characteristics of the user herself. However, even considering that there may be some risk, it is negligible.
• Additional tests are not needed in a woman who is on MHT.

THM Types

• Estrogens with or without progestogens
• Estrogens with or without progestogens are effective and continue to be appropriate in the treatment of severe vasomotor symptoms that affect quality of life.
• In women with a uterus and vasomotor symptoms, progestogens should be added to LT with estrogens.
• HT with estrogens should be administered at the lowest effective dose and for the shortest possible time.
• It is convenient to start with the minimum effective dose and gradually adjust the dose, reviewing the need for treatment every 12 months.
• Progestogens

Progesterone is a moderately effective treatment and could

be an alternative for vasomotor symptoms.

• Tibolone

Treatment with tibolone is effective and is an alternative in the treatment of vasomotor symptoms.

Selective Estrogen Receptor Modulators (SERMs). SERMs constitute a group of compounds, of diverse structure, that bind to the estrogen receptor, exerting agonist-antagonist actions depending on the target tissue and the physiological context. They reproduce the beneficial effects of estrogens on the skeleton and cardiovascular system and avoid the agonist effects on breast tissue and endometrium.

Phytoestrogens

They are non-steroidal substances produced by plants, which have weak estrogenic activity. T hey are the isoflavones (genistein, daidzein and glycetin) whose concentration is higher in soybeans. Other isoflavones such as formononetin and biochanin-A are isolated from red clover. Isoflavones have shown to be effective in the treatment of mild-moderate climacteric syndrome. They behave like weak estrogens, so they have no effect on the endometrium and the breast. The effect on bone and as a prevention of cardiovascular disease has yet to be categorically demonstrated.

Vaginal atrophy treatment with hyaluronic acid

Treatment with hyaluronic acid is fast, safe and effective to treat the intimate area of women, hospitalization or postoperative is not required. It is done on an outpatient basis. Hyaluronic acid is a substance naturally produced by our body, hyaluronic acid is a completely natural product, so the risk of allergies is minimized and rejection reactions rarely occur.

It is a minimally invasive therapy in order to biostimulate, rehydrate and re-tone the female intimate area.