Menopause: Women need to focus on healthy lifestyle to prevent complications

What is Menopause?

Menopause is the end of menstruation/ periods &  menopausal syndrome is symptoms associated with the physiological changes that take place in the body as the period of fertility ends. 

• It is a normal consequence of the aging process and a hormone-deficient state that occurs at the age of 45-55 years.  
• Women are usually considered to be menopausal if she has not had a menstrual period for one year without any underlying cause. 
• It is an inevitable phenomenon in a women's life and many years are spent in the postmenopausal phase. This may last 2 to 5 years or sometimes longer.

What causes menopause? 

Ovaries gradually become less active and reduce the production of sex hormones (estrogen and progesterone). As a result, menses cease permanently and finally a complete absence of mature eggs (ova). It is mostly natural but may also be caused by Hysterectomy, Chemotherapy and radiation therapy, and Primary ovarian insufficiency.

What are the symptoms?

Some women experience mild problems or none at all but some women have severe symptoms in this period. Common symptoms include the following

• Irregular periods with scanty or excessive bleeding

• Hot flushes or a sensation of heat
• Night sweats
• Vaginal dryness and itching
• Mood swings
• Joint pain
• Edema
• Sleeplessness
• lassitude
• Excessive hair fall
• Anemia
• Weakness
• Stress incontinence
• Loss of sexual desire
• Wrinkling of skin etc

How are they treated?

It is a natural phenomenon and does not need any treatment. Some women may seek treatment if it starts affecting the quality of their lives. A few options are:

• Hormone Replacement Therapy (HRT):  It replaces the estrogen and progesterone in the body through a simple patch on the skin and oral medication given by the doctor.  Highly effective. 
• Medicines: Serotonin based medicines may be given to combat hot flashes. For vaginal dryness, vaginal estrogen in the form of cream or gel may be suggested. It is best to seek advice from the doctor.
• Cognitive behavior therapy: A type of talking therapy that can help with low mood and anxiety
• Healthy & balanced diet and regular exercise:  maintaining a healthy weight and staying fit and strong can improve some menopausal symptoms

What are the complications?

Menopause may lead to a few complications:

• Osteoporosis: Women start losing bone density in the first few years of menopause. This occurs due to reduced levels of estrogen that cause increased loss of calcium from bone tissue & can lead to osteoporosis.
• Breast cancer: The risks of breast cancer increase with menopause. Exercise and regular scanning can help you reduce the risk.
• Urinary incontinence: Menopause causes the tissues of the vagina and urethra to lose their elasticity, resulting in frequent, sudden, and overwhelming urges to urinate.
• Cardiovascular diseases: Drop in estrogen levels increases the risk of getting cardiovascular diseases.
• Weight gain: Due to slow metabolism. Eat less and exercise more, just to maintain the current weight.

Investigations to be done at menopause:

• Haemogram/CBC
• Pap smear
• Serum FSH levels
• Serum estradiol levels
• Serum L.H. levels
• Ultrasound abdomen
• Bone mineral densitometry
• Mammogram

What should be done?

Accept that the menopause is a natural fact of life and nothing to be embarrassed or worried about. Discuss any unpleasant problems with an understanding friend or your doctor. It is important to lead a healthy life: 

• Quit smoking or using tobacco products, if you currently do.
• Eat a healthy diet, low in fat, high in fiber, with plenty of fruits, vegetables, and whole-grain foods.
• Make sure you get enough calcium and vitamin D.
• Learn what your healthy weight is, and try to stay there.
• Do weight-bearing exercises, such as climbing stairs or dancing, at least 3 days each week for healthy bones. 
• Practice yoga and meditation for stress management
• Check cholesterol levels periodically
• Limit tea/coffee consumption
• Avoid a sedentary lifestyle
•  Cleanliness of genital organs should be maintained,
• It is normal and healthy to continue sexual relations, but a vaginal lubricant such as K-Y gel may be necessary 
• Contraception is advisable for 12 months after the last period.

When to meet your doctor?

• If you have a return of unusual bleeding.
• Heavy bleeding is not responding to medication
• Menopausal syndrome associated with fracture 
• Menopausal syndrome associated with other serious systemic illness

References :

1. John M. Murtaghs Patient Education. of 6th revised ed edition. North Ryde NSW: McGraw-Hill Australia. 2012
2. https://www.nhp.gov.in/menopausal-syndrome_mtl
3. https://happyaging.in/menopause-overview-symptoms-and-treatment/
4. https://www.mayoclinic.org/diseases-conditions/menopause/symptoms-causes/syc-20353397#:~:text=Menopause%20is%20the%20time%20that,is%20a%20natural%20biological%20process.
5. https://www.nhs.uk/conditions/menopause/
6. https://www.nia.nih.gov/health/infographics/menopause-tips-healthy-transition photo credit
7. https://www.verywellhealth.com/is-this-perimenopause-3522477 photo credit
8. https://www.sepalika.com/menopause/the-complete-list-of-menopause-symptoms-all-35-of-them/ photo credit
9. https://www.nia.nih.gov/health/infographics/menopause-tips-healthy-transition photo credit

Burning micturition among women

Introduction:

Burning micturition is a burning sensation or discomfort while urinating/voiding urine. It is a very common problem among women due to close proximity of urethra to vagina & anus. 

Common causes:

• Urinary tract infection (Cystitis)
• Post coital UTI
• Vaginitis
• STDs like Chlamydia, Gonorrhea, Herpes
• Urinary tract stone/stricture
• Reaction to soaps, perfume etc
• Bubble bath
• Use of spermicides
• Trauma (eg. by foley's catheters)
• Certain drugs (eg. cancer medications)
• Drinking less water

Urinary tract infection (UTI) is most common cause of burning micturition. Let's know about it in detail. It may be of two types

(a) Uncomplicated UTI:  When occurring in the un-instrumented non-pregnant female without structural or neurological abnormalities.

(b) Complicated UTI:  When it is associated with anatomical or functional abnormalities (e.g. diabetes, urinary calculi) that increase the risk of serious complications or treatment failure.

 

☝If following symptoms occur:

• Burning or stinging sensation when passing urine
• Passing urine more frequently (frequency)
• Pain while passing urine (dysuria)
• Pain in the back or low abdomen 
• An urge to pass urine often (urgency)
• Passing only small amounts of urine
• Feeling of incomplete voiding of urine
• Discoloured and smelly urine (sometimes blood in urine)
• Fever (may be associated with chiils, rigors, sweating, headache, nausea, vomiting etc)
• Feeling generally not well

                                 👇

It may be Urinary tract infection/Cystitis (Inflammation of bladder)

The most vulnerable times are at starting sexual activity (hence the term ‘honeymoon cystitis’), during pregnancy and after menopause.

Causative organisms:      

        👇

Mainly bacteria 

• Escherichia coli,  
• Staphylococcus saprophyticus,  
• Klebsiella  sp.  
• Proteus  sp.
• Enterococci  sp.
• Streptococcus faecalis 

Associated risks are:

• Cystitis is very uncomfortable and irritating, but is not a serious problem & can be treated easily. 
• But an untreated infection can spread up to the kidneys and this is a serious issue.

🚗Visit your physician for examination, diagnosis & to rule

 out any complication (if the attack lasts more than 24 hours) 

Diagnostic test:

Microscopy & culture sensitivity of urine done on a fresh 

midstream specimen of urine, collected after proper washing of vulva.

Management is done as:

General measures:

• Self-help
• Keep yourself rested and warm.
• Drink a lot of fluid: try 2 to 3 cups of water at first, and then 1 cup every 30 minutes.
• Try to empty your bladder completely each time.
• Gently wash or wipe your bottom from the front to the back with soft, moist tissues after going to the toilet.
• Take analgesics such as paracetamol for pain.

💊Medications:

Specific antibiotics will be prescribed which should be taken only after physicians advice.

• Trimethoprim 300 mg (o) daily for 3 days (first choice) or    
• Cephalexin 500 mg (o) daily for 5 days   or  
• Amoxycillin/ +  clavulanate 500/125 mg (o) 12 hourly for 5 days   or 
• Nitrofurantoin 100 mg (o) 12 hourly for 5 days   

• Your doctor may advise making the urine alkaline (if pH of urine is acidic)  
• A follow-up urine test will be necessary. 
• If the antibiotics do not work or if you have more attacks, some special tests (including KFT, X-rays, USG) may be necessary to check your urinary tract.

Prevention of further attacks:

• Get into the habit of drinking plenty of fluids, especially on hot days.
• Pass urine often and when you feel like it—do not let it build up.
• Make sure you empty your bladder each time.
• Wash your bottom gently after each bowel motion, using mild soap and soft tissues.
• Empty your bladder immediately after intercourse.
• If your vagina is dry, use lubrication for intercourse 
• Wear cotton underwear; avoid tight jeans and nylon pantyhose.
• Avoid the use of bubble baths and perfumed soaps, talcum powder and vaginal deodorants around the genital area.
• Cranberries as either juice or capsules have been shown to help prevent recurrences of urinary infection in those prone to getting it.

Reference:

1. John M. Murtaghs Patient Education. of 6th revised ed edition. North Ryde NSW: McGraw-Hill Australia. 2012
2. Murtagh J, Leggat PA. John Murtagh’s General Practice Companion Handbook.
3. John M. Murtaghs Patient Education. of 6th revised ed edition. North Ryde NSW: McGraw-Hill Australia. 2012
4. https://www.leogenic.com/urinary-tract-infection-causes-symptoms-complications-diagnosis-treatment-prevention/ photo credit

Pain during periods (Menstruation)

Introduction:

Pain during periods is also known as dysmenorrhoea. It is very common, but most cases are mild and do not require medical attention. It is of two types

(a) Primary dysmenorrhoea: When pain occurs as part of an otherwise normal menstruation cycle & associated with ovular cycles without any pathologic findings

(b) Secondary dysmenorrhoea: When painful periods caused by a problem that has developed in the uterus (womb), suchas fibroid tumours or an infection

Primary (functional) dysmenorrhoea:   

This pain usually starts within 1–2 years after the menarche and becomes less severe with age. It affects around 50% of menstruating women and up to 95% of adolescents

Causes:

High levels of prostaglandins which is 

• Natural substances produced by the lining of the uterus 
• Causes the muscles of the uterus to contract tightly, thus producing cramping sensations

☝Presents with following clinical features:

• Lower midline abdominal pain 
• Pain radiates to back or thighs 
• Varies from a dull dragging pain to a severe cramping pain
• Maximum pain at beginning of the periods
• May start up to 12 hours before the menses appear
• Usually lasts for 24 hours but may persist for 2–3 days
• May be associated with nausea and vomiting, headache, syncope or flushing 
• No abnormal findings on examination 

 💊Management is done as

First line treatment:

• Full explanation and appropriate reassurance 
• Adaptation of a healthy lifestyle: regular exercise, avoid smoking and excessive alcohol
• Do relaxation techniques such as yoga 
• Avoid exposure to extreme cold
• If you get severe pain, rest in bed
• Place a hot water bottle over the painful area and curl the knees onto the chest   

Second line treatment:

Medication options include (trying in order):

• Simple analgesics (e.g. Aspirin or Paracetamol) 
• NSAIDs (e.g. Naproxen, Ibuprofen 200–400 mg per oral thrice a day at first suggestion of pain in the first 3 days of the period ( and if simple analgesics ineffective) 
• Vitamin B1 (Thiamine) 100 mg daily 
• Combined oral pills (OCPs- low-oestrogen triphasic pills preferable)  
• Progestogen-medicated IUDs 

Secondary dysmenorrhoea 

It usually begins after the menarche (after years of pain-free menses) & as a dull pelvic ache 3–4 days before the menses and becomes more severe during menstruation The patient is usually over 30 years of age. 

Causes: 

• Endometriosis (a major cause)
• PID (a major cause) 
• IUCD 
• Submucous myoma
• Intra-uterine polyp 
• Pelvic adhesions     

Diagnostic tests include:

• Laparoscopy 
• Ultrasound and (less commonly) 
• Assessment of the uterine cavity by dilation and curettage 
• Hysteroscopy or hysterosalpingography  

💊Management involves treating the main cause

🚗When to visit the doctor?

Consult your Physician/Gynecologist if the pain worsens or if you develop period pain following 3 or 4 years of relatively pain-free periods.

References:

1. John M. Murtaghs Patient Education. of 6th revised ed edition. North Ryde NSW: McGraw-Hill Australia. 2012
2. Murtagh J, Leggat PA. John Murtagh’s General Practice Companion Handbook.
3. John M. Murtaghs Patient Education. of 6th revised ed edition. North Ryde NSW: McGraw-Hill Australia. 2012

Lower abdominal pain among women

 Introduction:

Pain in the lower abdomen is one of the most frequent symptoms experienced by women. It may occur as acute, chronic or recurrent pain.

Causes:

Acute pain:

• Genital: Acute salpingitis, Pelvic peritonitis, Bleeding Rupture or torsion of ovarian cyst, Threatened or incomplete abortion, Rupture or aborting tubal ectopic pregnancy, Rupture or bleeding endometrioma 
• Non-genital: Acute appendicitis, Bowel obstruction, Urinary tract infection (cystitis), Ureteric colic (calculus)
• Functional: Primary dysmenorrhoea, Retrograde menstruation 

Chronic pain:

• Genital: Endometriosis/adenomyosis, Pelvic inflammatory disease (chronic; adhesions), Ovarian neoplasm, Fibromyomata (rarely) 
• Non-genital: Diverticulitis, Bowel adhesions, Irritable bowel syndrome, Urinary disorders e.g. urethral syndrome
• Functional: Secondary dysmenorrhoea—IUCD, polyp; Irritable bowel, chronic bowel spasm

☝If the pain occurs with following features:

• Average patient in mid-20s
• First pregnancy in one-third of patients
• Patient at risk:  H/o previous ectopic pregnancy, PID, abdominal or pelvic surgery, especially sterilisation reversal, IUCD use, In vitro fertilization /GIFT
• Pre-rupture symptoms (many cases): Abnormal pregnancy, cramping pains in one or other iliac fossa, vaginal bleeding
• Rupture: excruciating pain, circulatory collapse
• Pain may radiate to rectum (lavatory sign), vagina or leg
• Signs of pregnancy (e.g. enlarged breasts and uterus) usually not present 

                        👇

🚗Immediately Visit your Gynecologist for examination & management

Examination finding :

• Deep tenderness in iliac fossa 

• Vaginal examination: tenderness on bimanual pelvic examination (pain on cervical provocation i.e. cervical motion tenderness),  palpable adenxal mass, soft cervix    

• Bleeding (prune juice appearance) 

• Temperature and pulse usually normal early 

Diagnostic tests: 

• Urine pregnancy tests may be +ve
• β-HCG assay (may need serial tests) if >1500 IU/L invariably +ve
• Vaginal US can diagnose at 5–6 weeks (empty uterus, tubal sac)
• Laparoscopy (the definitive diagnostic procedure)

                           👇

It may be Ectopic pregnancy

💊Management done according to the severity & possible options are surgery, medical or watchful expectancy 

• Treatment may be conservative (based on US and β-HCG assays); 

• medical, by injecting methotrexate into the ectopic sac; laparoscopic removal; or laparotomy for severe cases. 

• Rupture with blood loss demands urgent surgery.

☝If the pain occurs with following features:

• Onset of pain in mid-cycle
• Deep pain in one or other iliac fossa (RIF > LIF)
• Often described as a ‘horse kick pain’
• Pain tends to move centrally
• Heavy feeling in pelvis
• Relieved by sitting or supporting lower abdomen
• Pain lasts from a few minutes to hours (average 5 hours)  
• Patient otherwise well 

                                 👇

It may be Ruptured ovarian (Graafian) follicle (mittelschmerz) (When the Graafian follicle ruptures a small amount of blood mixed with follicular fluid is usually released into the pouch of Douglas) 

                                   👇

🚗Visit your Gynecologist for examination & to rule out other causes

💊Management done as 

• Explanation and reassurance to the patient
• Simple analgesics: aspirin or paracetamol is given for pain
• ‘Hot water bottle’ gives comfort if pain severe 

☝If the pain occurs with following features:

• Patient usually 15–25 years
• Sudden onset of pain in one or other iliac fossa
• May be nausea and vomiting
• No systemic signs
• Pain usually settles within a few hours 

                               👇

🚗Visit your Gynecologist for examination & to rule out other causes

Examination findings:

• Tenderness and guarding in iliac fossa
• PR: tenderness in rectovaginal pouch   

Diagnosis tests:

• Ultrasound  ±  colour Doppler (for enhancement)

                              👇

It may be Ruptured ovarian cyst (cysts tend to rupture just prior to ovulation or following coitus)

💊Management done as

• Appropriate explanation and reassurance  
• Conservative: For simple cyst <4 cm, internal haemorrhage,    minimal pain
• Needle vaginal drainage: By ultrasonography for a simple larger cyst
• Laparoscopic surgery: For complex cysts, large cysts, external bleeding 

☝If the pain occurs with following features:

• Severe cramping lower abdominal pain    
• Diffuse pain
• Pain may radiate to the flank, back or thigh
• Repeated vomiting 
• Exquisite pelvic tenderness 
• Patient looks ill 

                                  👇

🚗Immediately Visit your Gynecologist for examination & management

Examination findings:

• Smooth, rounded, mobile mass palpable in abdomen 
• May be tenderness and guarding over the mass, especially if leakage 

  Diagnostic tests:

•  Ultrasound  ±  colour Doppler 

                            👇

It may be Acute torsion of ovarian cyst ( Torsions are mainly from dermoid cysts and, when right-sided, may be difficult to distinguish from acute pelvic appendicitis)

💊Management done as

• Laparotomy and surgical correction 

References:

1. John M. Murtaghs Patient Education. of 6th revised ed edition. North Ryde NSW: McGraw-Hill Australia. 2012
2. Murtagh J, Leggat PA. John Murtagh’s General Practice Companion Handbook.
3. John M. Murtaghs Patient Education. of 6th revised ed edition. North Ryde NSW: McGraw-Hill Australia. 2012

Breast pain (Mastalgia)

 Introduction:

It is a very common problem among women of age group 30-50 year (peak age 35-45 years). It usually presents as a heaviness or discomfort in the breast or as a pricking or stabbing sensation which may remain confined or radiate to adjacent areas. It may be cyclical or non-cyclical.

Causes May be: 

• Hormonal (Cyclical mastalgia)
• Pregnancy (common during the first trimester) 
• After childbirth (breasts may become swollen with milk and painful) 
• Breastfeeding (accidental chewing by baby)
• Infection (e.g., inflammation of the breast, known as mastitis/ abscess)
• Breast lumps
• Certain drugs
• Weight gain
• Poorly fitting bras

☝If the pain occurs with following features:

• Age group is ~ 35
• Discomfort and sometimes pain (diffuse) present
• Usually bilateral but one breast may dominate
• Mainly occurs in later half of menstrual cycle (premenstrual days)
• Breasts may be diffusely nodular or lumpy
• Variable relationship to the pill
• Rare after the menopause

                        👇

It is Cyclical Mastalgia (It has a hormonal basis & is not harmful)

                        👇

🚗Visit your physician for exclusion of a diagnosis of carcinoma &  

💊Management done according to the severity by Progressive step wise therapy

 Step 1: Reassurance

• Proper brassiere support
• Regular review & breast self examination
• Stop smoking (if applicable)
• Diet—exclude or minimize caffeine
• Weight reduction
• Analgesics like Paracetamol 
• Adjustment of oral contraceptives (if applicable)

Step 2: Addition of vitamins

• Vitamin B1 100 mg daily
• Vitamin B6 100 mg daily

Step 3: Substitute

• Evening primrose oil 1000 mg/day (Only taken after consultation with the doctor)

Step 4: Addition of

• Danazol 200 mg/d or Norethisterone 5 mg/d (Only taken after consultation with the doctor)

☝If the pain occurs with following features:

• Breast pain that does vary with menstrual cycle  
• May be unilateral/bilateral & diffuse
• Continuous or intermittent
• No obvious physiological or pathological basis

                  👇

It is Non-cyclical Mastalgia (Less responsive than cyclical mastalgia & difficult to treat but worth a therapeutic trial)

                            👇

🚗Visit your physician for exclusion of a diagnosis of carcinoma & it is managed as 

💊First-line treatment is:

• Proper brassiere support
• Regular review & breast self examination
• Stop smoking (if applicable)
• Diet—exclude or minimize caffeine
• Weight reduction
• Analgesics like paracetamol if pain present
• Adjustment of oral contraceptives (if applicable)
• Exclude caffeine from diet
• Vitamin B1 100 mg daily
• Vitamin B6 100 mg daily

💊Second-line treatment is:

• Norethisterone 5 mg/d (taken only after consultation with the doctor)

☝If the pain occurs with following features:

• Pain is acute, intermittent or chronic
• The breast is normal to palpation
• Palpable swelling ~ 4 cm from sternal edge due to enlargement of costo-chondral cartilage
• X-rays normal
• Aggravated by deep breathing and coughing
• Self-limiting, but may take several months to subside

                               👇

It may be Costochondritis (Tietze’s syndrome)

                              👇

🚕Visit your physician for exclusion of a diagnosis of carcinoma & 

💊Management is done as

• Analgesics like NSAIDs or Paracetamol given for pain
• Infiltration with LA and corticosteroid (with care & only taken after consultation of doctor)

☝If the pain occurs with following features:

• A lump and then soreness (at first)
• A red tender area
• (possibly) fever, tiredness, muscle aches and pains

                 👇

It may be Mastitis (inflammation of breast)

🚕Visit your physician for exclusion of a diagnosis of carcinoma &

💊Management is done as:

Treatment  of systemic symptoms:

• Antibiotics: resolution without progression to an abscess will usu. be prevented by antibiotics 
• Di(flu)cloxacillin 500 mg per oral four times a day for 10 days (IV if severe) or Cephalaxin 500 mg per oral four times a day for 10 days
•  Aspirin or Paracetamol for pain
• Therapeutic ultrasound done
• For candida infections Fluconazole 200-400 mg per oral daily for 4 weeks, second line Nystatin 500000 U oral TDS given

Instructions to patients:

• Keep the affected breast well drained.
• Continue breastfeeding: do frequently and start with the sore side.
• Heat the sore breast before feeding (e.g. with hot shower or hot face washer).
• Cool the breast after feeding: use a cold face washer from the freezer.
• Empty the breast well: hand express if necessary.

☝If a condition develops quickly with following features:

• Florid redness, swelling, dimpling and breast heaviness. 
• Not as painful as it appears—confused with mastitis but unresponsive to antibiotics. 

                              

                                          👇

🚕Visit immediately to Breast surgeon for exclusion of a diagnosis of carcinoma 

                                            👇

because it may be Inflammatory breast cancer (mastitis carcinomatosa)

☝If a pain develops with following features:

• If tenderness and redness persist beyond 48 h and 
• An area of tense induration develops, 
• Then a breast abscess has formed. 

                                      👇

🚕Visit immediately to Breast surgeon for exclusion of a diagnosis of carcinoma and treatment  

                                 👇

Because it may be Breast abscess & 

• It requires surgical drainage under general anaesthesia or 
• Preferably aspiration with a large bore needle under LA every second day until resolution
• Antibiotics (e.g. dicloxacillin 500 mg per oral four times a day for 10 days) 
• Rest and complete emptying of the breast
• Continue breastfeeding from the affected side or express milk if this is not possible.

Reference:

1. Murtagh J, Leggat PA. John Murtagh’s General Practice Companion Handbook.
2. John M. Murtaghs Patient Education. of 6th revised ed edition. North Ryde NSW: McGraw-Hill Australia. 2012
3. https://cmijournal.files.wordpress.com/2016/08/23-26-mastalgia.pdf photo credit
4. https://plasticsurgerykey.com/breast-pain/ photo credit
5. https://www.drthindhomeopathy.com/disease/costochondritis/ photo credit
6. https://step2.medbullets.com/gynecology/121861/mastitis photo credit
7. https://www.memorangapp.com/flashcards/32575/Inflammatory+Breast+Cancer/ photo credit
8. https://www.bmj.com/content/353/bmj.i2646 photo credit