Menopause - An uncomplicated metabolic change

By Umangi de Mel

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“Recently there has been a lot of clinical and media interest about menopause related health issues. Especially now that the life expectancy of Sri Lankan women have gone up to 70 years, they live 25 to 30 years after menopause,” says Kapila Ranasinghe, Consultant Psychiatrist.

However, he points out that each woman takes it differently, “A large number of women who have completed having families welcome it, while some take it negatively as they feel that they’ve lost fertility.

Whatever it is, they feel that it’s definitely an entrance into a new phase of life. Because the woman experiences new changes both biologically and psychologically while entering a different social group”.

What is menopause?

“The word is used to mark the cessation of menstruation which is on since puberty.

The important biological change that takes place during menopause is that the ovary stops production of oestrogen, which brings certain changes to the whole body and brain.

But most of the acute changes are seen during peri-menopause and not after. This is due to rapid reduction of circulation of oestrogen in the blood.

Usual symptoms are:

* Hot flushes

* Tiresomeness

* Unnecessary worrying

* Sleep disturbances.

These are more like anxiety symptoms that usually differ from person to person or culture to culture. While hot flushes and cessation of menstruation occur universally the rest of the symptoms depend on one’s cultural background, social activities, and other concerns.”

He also points out that if someone perceives it negatively and start worrying about ageing, they start developing emotional issues. “They will feel down for sometime. If the particular woman is concerned about how they should face it, she should go to a counsellor, gynaecologist or a psychiatrist.

However, the reduction in the oestrogen levels can affect the vaginal lubrication, causing atrophy of vaginal tissues. If this happens, sexual intercourse can become unpleasant and even painful.

This can be treated by gynaecologists by prescribing vaginal creams and other applications which will restore the sexual life of the individual and the partner.

Sometimes these sexual problems are associated with other systematic changes like hot flushes or changes in blood pressure.

Oestrogen hormone replacement can be considered under the supervision of an experienced doctor. Hormone replacement is helpful to reduce ageing that is associated with the rapid reduction of oestrogen levels in the body. It improves the mineralisation of the bones, muscle mass, the skin and the texture.

There are claims that hormone replacement improves psychological and cognitive functions. However, there is no evidence to support this. In fact, there are case reports of cognitive functions worsening after hormonal replacement.

Improvement of general well-being of a person is likely to improve the mental well-being of that person. At the same time, one must be careful as it makes her vulnerable to various other medical problems and side effects.

Also, it is known that hormonal replacement increases the risk of breast cancer, uterine cancer and the risk of blood clot related disorders called ‘Thromboembolism.’ Thus recent research warns against the hormone replacement therapy.

At the moment, medical professionals don’t advocate hormonal replacement as the first choice to counter balance medical and psychological symptoms seen after menopause.”

Dr. Ranasinghe shows that the present tendency is to use nutritional diets, exercises and other lifestyle measures to counter balance problems seen in menopause.

“It’s common practice for doctors and other healthcare service providers to prescribe nutritionally balanced, high fibre diets for this age group. It’s advisable to take green vegetables and fruits with lots of minerals and vitamins.

Also it’s very important to cut down the amount of fat and carbohydrates taken by the woman to reduce the unnecessary fat distribution. High calcium and minerals help to restore bones and muscle mass. This should be supplemented with regular cardio-vascular exercises and regular walking. (30-45 minutes).

If someone is interested in learning more about ‘Menopause’, there are many books and even the internet comes in handy.

Nutritional and exercise tips can be taken from a dietician.

If the psychological and physical problems keep increasing, the person should go to a doctor.

The tendency’s that problems encountered in the menopausal period is best managed mainly using non hormone based treatment. They’re well recognised as effective approaches to management in problems during or after menopause without putting the person in danger of developing other illnesses.”

Diagnosis and treatment of ectopic pregnancy

Dr. Vijith Vidyabhushana

Consultant Obstetrician and Gynaecologist, Colombo, South Teaching Hospital, Kalubowila.

Cont. from last week....

Your risk of getting an ectopic pregnancy and the signs and sypmtomps and effects were discussed last week.

How is it diagnosed?

It is important that ectopic pregnancy is diagnosed as early as possible to avoid complications. If it isn’t treated quickly, there may be severe internal bleeding leading to shock, and in a very small number of cases, death of the mother. Therefore if the patient has

collapsed or if there is evidence of internal bleeding the patient will be rushed to the theatre for surgery following a clinical diagnosis without further investigations which can delay treatment. However, only a minority of patients present in this way. If an ectopic pregnancy is suspected, the woman should attend the hospital.

The first test would be a ‘pregnancy test’ to confirm that she is pregnant. It is important to understand the basis and how the pregnancy test is done as it is an important test in view of diagnosing an ectopic pregnancy.

The developing pregnancy tissue starts to produce pregnancy hormone (human chorionic gonadotrophin - hCG) which is thought to sustain pregnancy. This hormone appears in mother’s blood and filtered through kidneys in to mother’s urine.

Sensitive blood tests done on mother’s blood can detect hCG as it is produced. Much more of this hormone is necessary for the urine test to become positive. So the urine pregnancy test will become positive later as levels rise. Usually, currently available urine pregnancy test kits can detect a pregnancy as early as a day or two after missing a period.

(Blood preg. test +ve above 10 international units per litre of hCG and urine +ve above 25iu/l)

If the patient has not collapsed, an Ultrasound scan will be done following a positive pregnancy test. If the scan shows an empty uterus but the pregnancy test is positive, an ectopic pregnancy is likely although the pregnancy may be early or a miscarriage might have occurred.

The best ultrasound scan is done with a modern intravaginal probe( transvaginal scan- TVS) but it is not always possible to see an ectopic on scan.

If the woman is well and not in severe pain, she may be investigated with a blood hormone test done repeatedly over two days to ascertain whether there is an ectopic or not.

If the pregnancy is inside the womb the pregnancy hormone levels in blood would be doubled in 48 hours. If there is a rise of this hormone which is less than expected, it is more in favour of diagnosis of an ectopic pregnancy.

If there is a high index of suspicion or the woman develops worsening signs, a laparoscopy (keyhole surgery) to inspect the tubes is done and if an ectopic pregnancy is found it can be removed laparoscopically.

If the diagnosis is obvious, however, abdominal surgery to remove the ectopic pregnancy is more likely and blood transfusions may be required to replace lost blood.

What are the treatment options?

Frequently ectopic pregnancies can be treated with planned but urgent surgery. Occasionally sudden emergency treatment is needed.

Therefore the best treatment option for most ectopic pregnancies involves urgent planned surgery to remove the growing embryo. The embryo cannot be saved or it cannot be put back in to the womb if it has begun to grow outside the womb.

The operation is usually done by laparoscopic (keyhole) surgery involving a small incisions in the abdomen.

Keyhole surgery has fewer risks of surgical complications than open surgery, such as blood loss, but open surgery has slightly better results. Your doctor will discuss these options with you, deciding what is best based on your current condition and history. Immediate emergency surgery is required if the fallopian tube has split and there is heavy bleeding which is life-threatening.

According to medical evidence, it is always better to remove the whole Fallopian tube with the ectopic pregnancy as it will prevent recurrence of another ectopic pregnancy in the tube which had been scarred and damaged due to this ectopic pregnancy.

A damaged fallopian tube will be repaired only if other tube is also damaged or if it does not look normal. You still have a good chance of having future normal pregnancies even if you have one fallopian tube.

If an ectopic pregnancy is diagnosed early in the presence of few symptoms, it can sometimes be treated with a drug called methotrexate instead of surgery. This drug kills the cells of the growing embryo, but has side effects such as abdominal pain in many women. You will also need to be closely monitored with regular blood tests for the following few weeks.

Traditionally methotrexate has been given by an injection into the muscles or directly into the fallopian tube, but recent evidence suggests that an oral tablet form (taken by mouth) may be more effective. As it involves longer hospital stay and serial blood tests which are relatively expensive this kind of management is not commonly done in our country.

Sometimes a ‘wait and see’ approach is used, for ectopic pregnancies that are diagnosed early, or for pregnancies where it has not been confirmed where the embro is (because it cannot be found on a transvaginal ultrasound).

This can be an alternative to surgery because many ectopic pregnancies will miscarry naturally. However, this is not advised often, because there is still a risk that the fallopian tube will rupture and cause internal bleeding.

Complications

All ectopic pregnancies should be diagnosed as early as possible to avoid complications. If it is not treated at the appropriate time, there may be severe internal bleeding leading to shock and collapse, and in a very small number of cases, death of the mother. Some parents will feel depressed or sad if they have an ectopic pregnancy, as they would for a miscarriage caused by other factors.

They may also be worried about their future changes of having a normal pregnancy. Women with only one fallopian tube still have a good chance of having a normal future pregnancy.

Your chances will depend very much on your individual case but approximately 65% of women will become pregnant again within 18 months of having an ectopic pregnancy.However approximately 10-15% of women will have another ectopic pregnancy.

What about future pregnancies?

There is a good chance of getting another pregnancy inside the womb in 85 out of 100 patients who get ectopic pregnancies . But there is a 10 to 15 fold rise of the risk of getting an ectopic pregnancy again, compared to some one who has not had an ectopic who has a risk of about 1%.

What should I do in future pregnancies?

As there is a higher risk of recurrence of an ectopic pregnancy, you have to get a urine pregnancy test done as soon as you think that you are pregnant.

If it is positive you have to see your Gynaecologist as soon as you can to get a transvaginal Ultrasound scan done to see if the pregnancy is in the right place. An internal scan(TVS) as early as 4 weeks would reveal this.

Breastfeeding ‘helps to boost IQ’

More evidence is being put forward that breastfed babies eventually become more intelligent than those who are fed with formula milk.

Canada’s McGill University found breastfed babies ended up performing better in IQ tests by the age of six.

But the researchers were unsure whether it was related to the breast milk itself or the bond from breastfeeding.

The study of nearly 14,000 children is the latest in a series of reports to have found such a positive link.

However, one problem has been that some of the research has struggled to identify whether the findings were related to the fact that mothers from more affluent backgrounds were more likely to breastfeed and it was factors related to the family circumstances that was really influencing intelligence.

But the latest study attempted to take this into account by following the progress of children born in hospitals in Belarus, some of which ran breastfeeding promotion schemes to boost rates across all groups.

They found that those who breastfed exclusively for the first three months - with many also continuing to 12 months - scored an average of 5.9 points higher on IQ tests in childhood.

Teachers also rated these children significantly higher academically than control children in both reading and writing, the Archives of General Psychiatry reported.

Lead researcher Professor Michael Kramer said: “Long-term, exclusive breastfeeding appears to improve children’s cognitive development.”

But he added: “Even though the treatment difference appears causal, it remains unclear whether the observed cognitive benefits of breastfeeding are due to some constituents of breast milk or are related to the physical and social interactions inherent in breastfeeding.”

Changes

Fatty acids found in breast milk are thought to boost intelligence, but the report said the physical and emotional aspect of breastfeeding may lead to permanent changes to brain development.

The researchers also suggested breastfeeding may increase verbal interaction between mother and child, which in turn could aid their development.

Nonetheless Professor Kramer said more efforts should be made to promote breastfeeding. In England, the government recommends mothers breastfeed exclusively for the first six months. But research shows while three quarters start off breastfeeding, just one in four are still doing it by six months.

Rosie Dodds, of the National Childbirth Trust, said: “This research certainly increases the evidence about the impact of breastfeeding. “And I think what we now need is more effort put into supporting it.”

Baby bottle chemical label call

More information should be given to parents about a controversial chemical found in most plastic baby bottles, the National Childbirth Trust has said. American scientists last month raised concerns about Bisphenol A, or BPA, which they say could cause behavioural changes and the early onset of puberty.

Some US retailers are to stop selling the bottles, while Canada wants a ban. The National Childbirth Trust wants all UK bottles clearly labelled, but the government says they are safe to use.

In April, the National Toxicology Program, part of the US National Institutes of Health, found that, based on animal experiments, exposure to low-levels of BPA “can cause changes in behaviour and the brain, prostate gland, mammary gland and the age at which females attain puberty”.

Situation ‘concerning’

In the US, major chain stores, including Wal-Mart - the word’s largest retailer - say they are now going to stop selling bottles made with the chemical.

In the UK, Wal-Mart subsidiary Asda is producing its own BPA-free range. BPA is widely used in reusable plastic products to prevent them from shattering.

The National Childbirth Trust wants bottles containing BPA to be clearly labelled. Belinda Phipps, the charity’s chief executive, said the lack of awareness was “concerning”.

“As a first step, it is important that bottles and other items that might reach a baby’s mouth are labelled in a standard and easy-to-understand way. This will help to remove the risk of Bisphenol A contamination.”

The charity advised parents not to pour boiling water directly into a bottle, as this could cause more of the chemical to be released. It also said scratched and damaged bottles should be discarded. The Food Standards Agency and the manufacturers say the amount of the chemical in such products is well below levels considered harmful and the bottles are completely safe to use.

BBC