Menopause and Beyond: Your Emotional and Physical Health
Hot flashes
Background - importance and magnitude of problem
Diagnostic goals - for overall category
- menopause
- hyperthyroidism/thyrotoxicosis
- anxiety
- panic attacks
- carcinoid syndrome
- pheochromocytoma
- drugs
- diencephalic epilepsy
- tuberculosis
- malaria
Ovarian failure, or menopause is by far the most common cause of hot flashes. Menses have usually stopped by the time hot flashes on menopause occur but occasionally there is some abnormal uterine bleeding still present which may confuse diagnosis. Anxiety or stress is the next most common cause or any stimulus that causes release of the "fight or flight" hormones epinephrine and norepinephrine.
Only 60-85% of menopausal women experience hot flashes and in up to half of these women, hot flashes persist for over five years. For as many as 10%, hot flashes may persist for more than 15 years. The frequency and intensity of hot flashes varies and decreases with increasing age. In spite of the common occurrence of hot flashes, only 20-30% of menopausal women seek treatment specifically for hot flashes relief.
If the hot flashes have just started between the ages or 40-56 (average age 50) and are in association with recently stopping or skipping menses, it can often be presumed that menopause has occurred. If there is any question, a serum follicle-stimulating hormone (FSH) level can be drawn and if it is elevated, it is diagnostic of ovarian failure. Hot flashes due to chronic infections such as tuberculosis or malaria are rare but should be considered along with thyroid, adrenal or carcinoid tumor problems. Medications, foods containing capsaicin (in hot pepper) and other ingested substances can also cause hot flashes but they are usually related in time to the ingestion and not random like menopausal hot flashes.
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Hormone replacement therapy problems
Background - importance and magnitude of problem
Diagnostic goals - for overall category
- irregular uterine bleeding on HRT
- withdrawal bleeding on HRT
- estrogen sensitivity
- progesterone sensitivity
- ERT insensitivity/GI inactivation
- skin sensitivity
- history of estrogen dependent cancer
- fear of carcinogenic effects of estrogens/progestins
Less than 1/3 of menopausal women take hormone replacement therapy (HRT). While some women don't believe the benefits outweigh the risks, many women have side effects from therapy. In this case, the immediate problems outweigh the long-term benefits. Irregular bleeding is by far the most common complication of HRT. Progestin intolerance with moodiness and feeling "poorly" is the next most common problem.
Even though abnormal uterine bleeding is frequently associated with hormone replacement therapy (HRT), is important to make sure there are no mechanical causes of bleeding such as polyps, fibroids or even cancer of the endometrium. (See abnormal bleeding after 40.)
Once mechanical causes have been ruled out, dose adjustment of the hormones can take place. Other HRT problems sometimes have to be solved by trial of different brands and forms of hormonal therapy.
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Fatigue, stress, irritability, PMS
Background - importance and magnitude of problem
Diagnostic goals - for overall category
fatigue
- anemia
- Addison's disease - hypoadrenalism
- chronic fatigue syndrome
- cancer//leukemia
- depression
- diabetes mellitus (uncontrolled)
- hypothyroidism
- hyperthyroidism
- liver disease
- medication induced
- nutritional/caloric deficiency
- sleep loss/deprivation
- stress/anxiety - chronic
stress/irritability
- fear/anger
- caffeine excess
- sleep loss/deprivation
- panic attacks
- agrophobia
premenstrual mood disturbances
- menstrual distress
- anxiety/stress reaction with cyclic exacerbation
- depression with cyclic exacerbation
- premenstrual syndrome (late luteal dysphoric disorder)
Nervous tension is very common in today's complicated society. The lack of adaptation to modern stress is a common cause or contributor to many illnesses. Some stress is beneficial, but if we don't adjust well it can significantly affect our health. Stress is a much more common cause of fatigue than any of the other medical illnesses in this category. It causes a muscle exhaustion from the constant release of epinephrine and norepinephrine. If it is great enough to interfere with sleep, there is an additive effect in causing fatigue.
Mood problems that vary with the menstrual cycle can be very difficult to diagnose. Many women have some degree of menstrual distress due to the normal fluctuation of hormones during a complete menstrual cycle. These hormones often cause physical symptoms such as menstrual cramps, breast soreness, abdominal bloating, headaches and fluid retention. Most of the time these are either minor or tolerable symptoms. When these symptoms begin to interfere with daily work, social or leisure activities, it becomes a significant health problem. If additional problems such as depression or stress or other medical diagnoses are superimposed upon a physiologic menstrual distress, they become worse. Underlying menstrual distress lowers the "thermostat" for other problems but it shouldn't be classified as primarily PMS.
Even though stress is a very common cause of fatigue, it is hazardous to attribute fatigue as due to stress alone. Other medical problems must be looked for. A general blood chemistry and blood count can screen for many of the medical causes. Medications are also common causes. The primary goal even in the face of admitted stress is to rule out the other medical causes.
The major challenge in diagnosing PMS is to make sure there is not a coexistent problem that is merely superimposed upon physiologic menstrual distress. True PMS has a two week or more relatively symptom free period followed by a 7-14 day symptom period immediately preceding the menses. The hallmark of PMS diagnosis is a menstrual calendar in which symptom intensity is tracked on a daily basis throughout the entire month. This calendar is extremely helpful to make sure there is not another underlying problem the entire month which is just exacerbated in the premenstrual phase. If there is a chronic problem present, therapy must first be directed toward it rather than proceeding with PMS treatment.
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Sexual feeling dysfunction
Background - importance and magnitude of problem
Diagnostic goals - for overall category
- decreased sex drive (libido)
- anorgasmia/decreased sexual response
- personal sexual abuse
male dysfunction-
- primary
- secondary
- transitory
impotence
- premature ejaculation
- ejaculatory incompetence
- male/female
- female/male
- lesbian/gay
- bisexual
-
In some large surveys, almost 50% of couples experience some form of sexual dysfunction. Disorders of arousal or desire are the most common complaints among women. Males also have problems, especially ejaculation problems. In addition, there is a wide variation of what is normal in sexual behavior so that it is difficult to extrapolate to all couples what is normal or what is a problem. Suffice it to say that if one member of a couple perceives that something is a problem, then both partners must be involved in the treatment.
Sexual questions or concerns are a sensitive area for most people. It takes a very knowledgeable physician or counsellor to treat these problems.
Decreased sexual arousal or response, including anorgasmia, is a frequent concern in women. While current or past anger at a partner is a common cause for this, other etiologies should be considered. Medications such as antihypertensives affect the male sexual response frequently. They can also affect the female sexual response and any chronic medication should strongly be considered as an etiology.
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Sexual, physical, emotional abuse and rape
interpersonal
Background - importance and magnitude of problem
Diagnostic goals - for overall category
- Rape/sexual assault
- sexual abuse/incest
- physical abuse
- emotional abuse
Rape is an underreported crime but estimated to represent at least 10-20% of all violent crime. By definition it is the penetration of any object or body part into the vagina, oral cavity or anus without the consent of the victim. Under the age of 18, any such penetration even with consent is statutory rape. It is a violent crime and can affect women as well as men.
One source estimates almost 40% of women under age 18 have on some occasion been sexually abused by family members or someone outside the family. While sometimes not as violent as the more isolated instance of forcible rape, it nevertheless is a form of chronic rape that can inflict severe, lifetime psychological damage.
Physical or verbal abuse may also occur in up to 50% of households today in varying degrees. A battered woman is defined as "any female over 16 years of age with evidence of physical abuse on at least one occasion at the hands of an intimate male partner."
Most women undergoing any of these forms of abuse are reluctant to bring these episodes to anyones attention. Indirect evidence should raise suspicions. Common signs and symptoms in abused women include headaches, chest, back or pelvic pain, insomnia, choking sensation, hyperventilation, gastrointestinal symptoms, shyness, fright or embarassment, and alcohol abuse among others.
Possible signs of sexual abuse or incest among young girls may include: recurrent sexually transmitted diseases, alcohol or substance abuse, poor school peformance and truancy, runaways, recurrent urinary tract infections, perineal warts, recurrent abortions or pregnancies and psychosomatic disorders. When these signs are encountered. One should always provide the opportunity for the woman to acknowledge these problems in a non- threatening, confidential environment. Proper diagnosis can save a woman's life.
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Alcohol, substance, cigarette, food abuse
intrapersonal
Background - importance and magnitude of problem
Diagnostic goals - for overall category
- alcohol abuse
- marijuana abuse
- drug/substance abuse
- tobacco/cigarette abuse
- food abuse
Any form of abuse is a reflection of nervous tension. Alcohol is one of the leading substances abused just behind tobacco abuse. Over 80 million Americans drink but only one in fifteen, 6-7%, become alcoholics. While the abuser's life problems are just as valid as anyone else's problems, the abuser is incabable of facing those problems with something that gives an "escape" feeling.
Addiction of any type should be identified because it often complicates other medical problems. Treating these health problems is likely to be unsucessful if the abuse problem is unknown. Addictions are not untreatable but they do take considerable effort, detoxification programs and continued medical supervision.
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Gynecologic emotional reactions
Background - importance and magnitude of problem
Diagnostic goals - for overall category
- chronic pain
- infertility
- surgery
- cancer
- adolescence
- sexually transmitted diseases
- marital problems
- climacteric/post menopause
Many health problems or physiologic states can produce adjustment or situational problems. They can produce or aggravate neuroses, panic attacks, psychoses, depression or just extreme stress.
It is important to understand the common stages of feeling progression. With cancer there is a well-described sequence of anger, depression, denial, bargaining and acceptance. A person might spend any amount of time in any of the stages and might sucessfully pass through all of them or stall at any stage. The primary goal is to separate the triggering situation from the specific emotional response.
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