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Sudden MenopauseRestoring Health and Emotional Well-Being
By Debbie DeAngelo
Hunter House Inc., PublishersCopyright © 2001 Debbie DeAngelo
All right reserved.
Chapter OneSudden Menopause: What Is It?
While having lunch with two of my close friends, I expressed frustration over trying to find information about sudden menopause. They both paused, stared at me blankly, and asked, "What is that?"
I explained that since my ovaries were removed at the time of my hysterectomy, I entered menopause instantaneously, instead of naturally, over a period of years. One of my friends said, "You went through menopause at your age? You're only 26!"
At that moment I realized why I was unable to find much information about sudden menopause. Many people either do not know about the condition or do not understand it.
An Information Gap
Although the level of awareness about natural menopause has increased over the years, the level of awareness about sudden menopause has remained low. This gap in information does not exist only among the general public; health-care professionals also have limited knowledge about what a woman experiences when she is thrown into sudden menopause.
The subject often is glossed over by physicians when theyexplain the aftereffects of a total hysterectomy or the potential side effects of chemotherapy. Because sudden menopause usually is the result of a hysterectomy with removal of the ovaries, or of a condition that results in ovarian damage, it often takes a backseat to the "pressing" medical problem that caused the sudden menopause. To the physician, the sudden menopause may be looked upon as secondary in importance, but to the woman facing the possibility of an instant change or who is in the throes of severe hot flashes or memory loss, its importance is very real.
Sudden menopause can result from a variety of conditions that instantly render a woman's ovaries incapable of producing the crucial female hormones estrogen and progesterone, as well as the male hormone testosterone. This immediate depletion throws the woman's body into a hormonal tailspin. Sudden menopause can be induced by surgical intervention or by ovarian malfunction or damage. Let's take a look at each of these circumstances.
DORIS is a 40-year-old schoolteacher who began experiencing heavy bleeding during her periods. She also noticed that she was making more frequent trips to the bathroom to urinate. She went to her gynecologist, who performed a pelvic exam and an ultrasound of her reproductive organs. She was told that she had two large uterine fibroid tumors (noncancerous), and that one was pressing on her bladder
Doris's doctor recommended and performed a hysterectomy. Both of her ovaries were removed at the same time because she was told and she believed that she was getting closer to menopause and "did not need them anyway." When I met with her, she was in the throes of sudden menopause. One comment she made remains clearly etched in my mind: "I didn't even know I had options other than a hysterectomy."
The greatest challenge I faced while working with Doris was helping her to work through her feelings of guilt. In retrospect, she realized that she had completely turned her health needs over to her doctor and abandoned any responsibility for her treatment and its outcome. Once I was able to help her focus on the present instead of dwelling in the past, we discovered strategies to help her cope with her anxiety and night sweats. She enrolled in a yoga class so that she could learn relaxation strategies and proper breathing techniques. These helped her deal with the night sweats as well as the anxiety. Dietary modification and changes in her sleeping environment also contributed to reducing the frequency and severity of her night sweats.
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Hysterectomy is the second most commonly performed surgery in the United States. Approximately 600,000 hysterectomies are performed annually, with the ovaries removed in about half of these cases.
A total or complete hysterectomy is a surgical procedure in which the uterus and cervix are removed. The term oophorectomy (or ovariectomy) refers to the removal of the ovaries, either one (unilateral) or both (bilateral). The fallopian tubes also may be removed in a procedure called salpingectomy. Therefore, when the ovaries and the fallopian tubes are removed along with the uterus, the procedure is called hysterectomy with bilateral salpingooophorectomy (BSO).
According to the National Center for Health Statistics, 45.5 percent of all women who undergo a hysterectomy have their ovaries removed at the same time. In some cases, surgery is performed to remove only one ovary; even though the other ovary remains, sudden menopause can occur if the blood flow to the remaining ovary is compromised during surgery.
Commonly cited reasons why hysterectomies are performed include the following:
* Pelvic inflammatory disease (PID)-The phrase pelvic inflammatory disease is a generalized term for an infection in the uterus and/or fallopian tubes and ovaries. It is primarily a result of sexually transmitted disease that has spread into the pelvic region. Signs and symptoms of PID may include abdominal pain, mid- to lower back pain, fever, nausea, vomiting, foul-smelling vaginal discharge, pain or bleeding during or after intercourse, and burning upon urination.
* Endometriosis-This condition occurs when tissue from the endometrium (the lining of the uterus) attaches itself to other organs, usually in the pelvic area. Organs often affected include the fallopian tubes, ovaries, bladder, and bowel. Since the tissue originated inside of the uterus, it responds to the monthly hormonal cycle in the same way the uterus does. It builds and grows, then breaks down and bleeds. The inflammation and internal bleeding can result in the formation of scar tissue and symptoms such as pelvic pain, painful intercourse, heavy menstrual flow, fatigue, painful bowel movements, constipation, and diarrhea. Endometriosis also is a cause of infertility.
* Uterine fibroid tumors-Fibroid tumors, or myomas, are very common and almost always benign (noncancerous). They originate from the muscle tissue of the uterine wall and can grow outward or inward. Small fibroids usually do not create problems, but large ones or clusters of fibroids can cause symptoms, including heavy, prolonged, or irregular menstrual bleeding; abdominal swelling; pelvic or back pain; constipation; and frequent urination.
* Uterine prolapse-When the uterus "drops" from its normal position and protrudes through the vagina, it is said to have prolapsed. The normal uterus is anchored in place by ligaments, muscles, and fascia, but over the years, the uterus may change position. It can drop straight down, or tip forward or backward. Childbirth or obesity may entice the uterus to descend. Symptoms of prolapse may include pressure and heaviness in the vaginal region, a feeling of heaviness in the lower abdomen, lower backaches, and urinary frequency and incontinence.
* Menorrhagia/metrorrhagia-The term menorrhagia refers to excessive or prolonged menstrual bleeding. Metrorrhagia refers to uterine bleeding between periods. A variety of conditions can result in one or both of these problems. Possible causes include fibroids, polyps, ovarian cysts, hyperplasia, birth control pills, hormonal imbalances, stress, or cancer. Menorrhagia and metrorrhagia need to be carefully evaluated.
* Breast cancer-Some forms of breast cancer are estrogen-dependent. This means the hormone estrogen fuels their growth. If this is the case, the ovaries may be removed as part of the cancer treatment. Another breast cancer treatment option is the use of a special medication, such as Tamoxifen, that blocks the estrogen receptors on the cancer cells so they are not responsive to estrogen. Since these medications have become available, oophorectomy is less commonly performed for treatment of breast cancer.
* Uterine, ovarian, and advanced cervical cancer-The extent of treatment for these cancers depends upon the type of tumor and how it is staged. Uterine cancer and ovarian cancer normally necessitate a hysterectomy. However, unless cervical cancer is advanced, it usually can be treated more conservatively.
It is important to note that, with the exception of cancer, hysterectomy is not the treatment of choice for the above conditions.
"I didn't even know I could go through menopause at my age," remarked 28-year-old TINA. Tina is a waitress who struggles with anorexia nervosa. She currently is working with a therapist who specializes in eating disorders, and she is making progress. However, the past decade of starving herself, using diuretics and cathartics, and exercising to excess have taken their toll on her body. She has not had a period in several years.
While she was aware that the cessation of periods, vaginal dryness, hot flashes, and thinking problems were a direct result of the eating disorder, she did not realize that she was menopausal. Tina's sudden menopause was due to ovarian malfunction. Her ovaries simply shut down from malnourishment. As Tina's condition gradually improves, it may be possible for her to regain endocrine function and no longer be menopausal. Only time will tell.
* * *
Besides being surgically induced, sudden menopause also can occur from conditions that inhibit ovarian function. Ovarian damage can result from the following:
* Anorexia nervosa-This is a type of eating disorder that is prevalent in young women. Anorectics have a distorted body image and think they are fat. As a result, they minimize their food intake so that they, in effect, starve themselves. Anorectics become obsessed with weight, food, counting calories, and exercising. Over time, their menstrual cycles cease, a condition called amenorrhea.
* Chemotherapy-This generally refers to the medications that are used to treat cancer. A combination of agents often is given. Some of these medications can render the ovaries inactive, causing menstruation to cease.
* Radiation treatment-This involves the use of radioactive substances to destroy cancer cells. Radiation can be administered externally or internally to a localized region. Radiation that is directed toward the pelvic region can damage the ovaries and cause the menstrual cycle to stop.
* Medications-Certain medications also can cause ovarian shutdown. In fact, some medicines are given for just that purpose. For example, Lupron, which is used to treat endometriosis, works by blocking ovarian function.
In some of these cases, the sudden menopause may be temporary and reversible. In others, it is permanent.
Whether sudden menopause follows surgery or ovarian damage, the body may react to the resulting drastic hormonal changes by manifesting symptoms such as hot flashes, night sweats, vaginal dryness, decreased libido, memory loss, and mood changes. In order to comprehend how a woman's body reacts once the ovaries are removed or damaged, it is important to understand how the female reproductive system normally functions.
The Menstrual Cycle
A common misconception that exists about a woman's monthly cycle is that it begins and ends in the uterus. Although a great deal of activity occurs in this region, the entire process is orchestrated by the brain.
Located within the brain is a structure called the hypothalamus. It communicates intimately with the pituitary gland, which sits below it, to regulate the endocrine system. The endocrine system consists of specific glands that secrete hormones to activate bodily functions. Some of these hormonal responsibilities include growth and development, fertility and reproduction, metabolism, fluid and electrolyte balance, and stress response.
The hypothalamus produces a variety of releasing hormones that, in turn, cause the pituitary gland to produce a variety of stimulating hormones. These stimulating hormones go directly to the target organs and initiate action. It is important to keep in mind that, although a single organ may be primarily responsible for specific functions, the endocrine system utilizes a team approach. The hormones all work together.
One example of the endocrine system at work is the functioning of the adrenal glands. After corticotropin-releasing factor (CRF) is secreted from the hypothalamus, it travels to the pituitary gland, which then secretes adrenocorticotropic hormone (ACTH).
The target organs for ACTH are the adrenal glands. These small glands are located on the upper portion of the kidneys and are responsible for the production of many hormones. These hormones include mineralocorticoids, which regulate sodium, potassium, and fluid levels; glucocorticoids, which influence metabolism, response to stress, emotional well-being, and the anti-inflammatory response; androgens, which commonly are referred to as the male hormones (predominantly testosterone) and which govern functions such as libido and the development of armpit and pubic hair; and catecholamines, such as epinephrine and norepinephrine, which function to elicit the "fight or flight" response.
A similar hormonal symphony occurs in the thyroid gland. Once again, the process begins with the hypothalamus, which produces thyrotropin-releasing hormone (TRH). TRH travels to the pituitary gland and causes it to produce thyroid-stimulating hormone (TSH). TSH travels through the bloodstream to the thyroid gland, where thyroid hormones and calcitonin are produced. Thyroid hormones govern metabolism, and calcitonin helps to regulate calcium absorption.
As these examples illustrate, the hypothalamus and the pituitary gland secrete a host of hormones that carry out life-sustaining functions. These hormones coexist in harmony, and a change in one of them can upset the delicate balance within the body.
The ovaries are also under the influence of the pituitary gland. They, too, respond to the directions given to them by the brain.
Like the thyroid and adrenal glands, the ovaries communicate with the brain. Gonadotropin-releasing hormone (GnRH) is secreted from the hypothalamus and travels to the pituitary gland. The pituitary gland produces follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which prepare the reproductive system for a potential pregnancy (See Figure 1.1). This occurs approximately on a monthly basis.
FSH starts the cyclical process by stimulating the ova (eggs) within the ovaries to grow and to produce estrogen. Estrogen then begins to encourage the cells of the endometrium (uterine lining) to proliferate and thicken, and to create an environment conducive to nourishing a fetus. As the estrogen level peaks, LH springs into action and entices one of the eggs to mature and burst forth from the follicle that houses it and to begin its journey through the fallopian tubes to the uterus. This process is called ovulation.
Not only is ovulation necessary for conception to occur, but once ovulation has occurred, the corpus luteum (empty follicle) begins producing progesterone. Progesterone is called the "hormone of pregnancy" and is vital for maintaining a pregnancy. If the ovum does not meet the sperm, the level of progesterone begins to drop off, and the lining of the uterus is shed.
The day menstrual bleeding begins is considered the first day of your period. Based upon a 28-day cycle, days 1 through 14 are called the follicular phase. During that time, only estrogen is produced. Days 15 through 28 make up the luteal phase of the cycle, during which both estrogen and progesterone are present. Small amounts of testosterone are produced by the ovaries throughout the entire menstrual cycle.
Periodically interrupted by pregnancy, the body continues with this rhythmic cycle throughout a woman's life. Menopause, whether gradual or sudden, completes this chapter in a woman's life.
Excerpted from Sudden Menopause by Debbie DeAngelo Copyright © 2001 by Debbie DeAngelo. Excerpted by permission.
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