Impact of Surgical and Natural Menopause in the Malaysian Population

Authors: Teck-Hock Toh^1,2, Lee Jeffrey Soon-Yit¹, Gayathri Delanerolle^3,4, Peter Phiri^3,4, Lee Kimmy Kim-Yen⁵, Xiu-Sing Wong⁶, Kamilah Dahian¹, Siti Nurul Aiman¹, Nurul Amalina Jaafar¹

Affiliations:

¹ Clinical Research Centre, Sibu Hospital, Ministry of Health Malaysia, Sibu, Sarawak, Malaysia

² SEGi University, Kota Damansara, Selangor, Malaysia

³ Southern Health NHS Foundation Trust, Southampton, United Kingdom

⁴ Digital Evidence Based Medicine Lab, Oxford, United Kingdom

⁵ Sibujaya Health Clinic, Ministry of Health Malaysia, Sibu, Sarawak, Malaysia

⁶ Department of Obstetrics & Gynaecology, Sibu Hospital, Ministry of Health Malaysia, Sibu, Sarawak, Malaysia

Menopause is a biological process that impacts all middle-aged women. The mean menopausal age among Malaysian women is reported as 50.7 years.. Epidemiological studies on menopausal symptoms have shown varying prevalence rates in different populations. Studies among Caucasians have reported a higher prevalence of menopausal symptoms, ranging from 40-60%, while in Asian populations, the prevalence has been lower, ranging from 10-40%. Asian women have shown a higher prevalence of musculoskeletal issues such as muscular aches and fatigue, while symptoms like hot flushes, night sweats, mood swings, and psychological symptoms, though present, are less severe in comparison to Caucasian women. Similar findings were reported within the Asian Menopause Survey that showed a very high percentage of women (over 90%) experienced various menopausal symptoms. The most common symptoms included joint and muscular discomfort (73.3%), followed by fatigue. Vasomotor symptoms, particularly hot flushes described as sudden intense heat in the face, neck, and chest, often accompanied by skin flushing, were experienced by 55% of women, slightly higher than previously reported rates (ranging from 17% to 53%). Notably, Asian women tended to have more musculoskeletal symptoms than Western women who experienced more vasomotor symptoms. The cultural and physiological factors contributing to these differences remain unexplained. Additionally, studies have reported on vaginal dryness resulting from long-term estrogen deficiency in the genital tract approximately around 40.3% of women, and 34.1% experienced sexual problems. Many studies did not delve into the underlying factors contributing to these sexual problems, including dyspareunia, poor lubrication, loss of sexual desire, and the spouse’s health status and aging. Reduced libido was often not openly discussed, likely due to embarrassment. Some studies also reported bladder symptoms such as dysuria, recurrent urinary tract infections, and bladder irritability were also observed, affecting approximately quarter of women. These symptoms are known consequences of long-term hypoestrogenism. The naturalistic perception of menopause among Malaysian women may partly explain their tolerance of the symptoms.  Dyspareunia and urinary incontinence were evidently regarded as embarrassing complaints, around 80 % of the women did not seek medical advice.

Early menopause could incur due to premature ovarian failure. In addition, surgical procedures such as a radical hysterectomy or oophorectomy due to conditions such as Endometriosis, pelvic inflammatory disease, uterine prolapse, gynecological cancers or recurrent fibroids may cause early menopause.  This is commonly termed surgical or medical menopause and is characterized by the sudden discontinuation of ovarian function. Surgical menopause increases the risk of ischemic heart disease, substantial reduction in libido and vascular compliance, hormonal imbalance, cognitive impairment and osteoporosis. In 2018, the European Society for Medical Oncology, Gynecological Oncology, and Radiotherapy (ESMO-ESGO-ESTRO) issued guidelines to prevent unintended or deliberate outcomes following surgical menopause. These guidelines offer recommendations for making decisions regarding oophorectomy.

The emotional and psychological effects of surgical menopause highlight that the absence of ovarian hormones can lead to emotional instability, especially in women with pre-existing psychiatric issues and severe anxiety. Depression is noted to increase due to declining estrogen levels and their impact on neurotransmitters. HRT is considered the standard treatment for mitigating post-menopausal symptoms, but it may have side effects and limitations. There have been significant advancements in therapeutic approaches for managing psychiatric symptoms associated with surgical menopause, but there is still a shortage of highly effective treatments. As a result, alternative therapies, such as lifestyle changes and stress reduction techniques, are explored.

Women undergoing natural and surgical menopause are susceptible to cognitive impairment and psychiatric issues such as anxiety and depression. Cognitive Behavioral Therapy (CBT) is highlighted as a comprehensive and effective approach for managing these conditions. CBT is highlighted as a beneficial method for addressing these symptoms, particularly for post-surgical menopause patients. CBT is described as a structured, short-term approach that helps individuals become more rational, gain control over their thoughts, modify self-beliefs, and promote relaxation.

Memory complaints and difficulty concentrating are commonly reported during the menopause transition, with up to 70% of women experiencing these issues in combination with other menopausal symptoms. These cognitive problems, often referred to as “brain fog,” can significantly impact daily life and work. Research has shown that subjective cognitive complaints are supported by objective cognitive measurements, highlighting their real impact on daily functioning. Subjective cognitive problems during menopause can be influenced by various factors, including lifestyle (e.g., diet and exercise), psychosocial factors (e.g., anxiety, depression, and attitudes toward menopause), and menopausal symptoms (e.g., hot flashes, night sweats, and sleep disturbances). Despite the widespread use of the term “brain fog,” there is no standardized measurement for menopausal-related brain fog. While some studies have used unstandardized questionnaires to assess memory and attention issues associated with brain fog, the development of a validated and standardized questionnaire specific to menopausal-related brain fog is deemed necessary. Perimenopausal women commonly report cognitive symptoms related to lexical or verbal information retrieval. For example, approximately half of peri-menopausal women experience the phenomenon of “tip of the tongue,” where they struggle to recall words or phrases once or more daily. Notably, there were no significant differences in these verbal retrieval-related issues between pre- and early postmenopausal groups, suggesting that the menopausal transition may particularly affect verbal memory and retrieval. This observation aligns with the established connection between subjective memory complaints and objective verbal recall based on cross-sectional data. Additionally, research has shown decreased immediate and delayed verbal recall associated with hormonal changes, such as dehydroepiandrosterone sulphate, during the menopausal transition in longitudinal studies. Another longitudinal study examining verbal episodic memory found an inverse association between follicle-stimulating hormone and luteinizing hormone levels and memory performance in menopausal women. The absence of significantly higher scores on the Attentional factor subscale in the perimenopausal group contradicts the findings of prior research, indicating reduced attention and concentration abilities, both objectively and subjectively.

Numerous clinical and non-clinical management strategies exist to alleviate post-menopausal symptoms and enhance the quality of life during this phase. These strategies encompass lifestyle changes, hormonal treatments, non-hormonal treatments, as well as complementary therapies involving traditional herbs and natural products. However, there is a lack of research on the treatment-seeking behavior of menopausal women, especially in Malaysia. Additionally, as more information on the safety and effectiveness of HRT becomes available, this treatment may be more acceptable among post-menopausal women. The clinical practice guidelines (CPG) within Malaysia suggest bringing about awareness, preventative strategies, early diagnoses and improved overall management to support women’s transition through some of the challenging circumstances that could reduce their overall quality of life. Of course, HRT remains a good option to manage menopausal symptoms, although the uptake of this could vary largely across the principalities of Malaysia.

While many studies have described the physical and psychological effects of menopause, there is a paucity of studies looking at menopause from the social dimension. It is important to realize that peri-menopausal women are also the matriarchs of their families, leaders of their organizations and part of a social clique. How do menopausal symptoms affect their family dynamics, work, and social performance? How do they address the issues, especially in a more conservative community where topics like menopause are not openly discussed? These are the important questions that need answers to make us realize that menopause is a complex phenomenon not just confined to hot flashes and brain fog; it might also affect the woman’s social life and the people surrounding it.