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The impact of Natural and Surgical Menopause in the Indian Population

Authors: 1Sanghamitra Pati, 1Subrata Kumar Palo, 1Bijaya Mishra, 2,3Gayathri Delanerolle, 2,3Peter Phiri

Affiliations:

1ICMR, Regional Medical Research Centre, Bhubaneswar, India

2Southern Health NHS Foundation Trust, Southampton, UK

3Digital Evidence Based Medicine Lab, Oxford, UK

Natural menopause is defined as the complete halt of menstruation for at least one year. Perimenopause, on the other hand, varies in duration and refers to the time of irregular periods leading up to menopause. A woman’s natural age at menopause can be used as a biomarker for predicting future health issues and mortality. Earlier menopause is linked to a higher risk of cardiovascular disease and osteoporosis, but it also reduces the risk of breast cancer. Studies indicate that for each additional year of age at menopause, there is a 2% decrease in age-adjusted mortality and a 5% increase in the risk of uterine/ovarian cancer.

In India, improved medical care and living conditions have led to increased life expectancy, with an estimated 130 million Indian women expected to live beyond menopause by 2015. Therefore, it is essential to study the factors influencing menopausal age in Indian women. However, whilst there is evidence to suggest a variety of health outcomes in natural menopause, there is a lack of comprehensive understanding and evidence on surgical menopause. An observational analysis was conducted using data from Longitudinal Aging Study in India (LASI), 2017–2018. 38,154 women aged > 18 years found the overall prevalence of hysterectomy to be around 11. 3% with higher rates among urban women (14.6% vs. 9.8%) than their rural counterparts and positively correlated with higher education. (12.7%).  

Surgical menopause could be induced by a bilateral oophorectomy, salpingotomy, partial or radical hysterectomy or the use of drugs such as Zoladex or Prostap. The symptoms and complications related to menopause are primarily due to reduced oestrogen levels. These symptoms can vary in severity from one individual to another and may include hot flushes, night sweats, psychological changes like depression and impaired concentration, insomnia, vaginal dryness, and skin changes such as thinning and decreased elasticity. Menopausal women may also experience a decline in sexual function, with the risk of sexual dysfunction increasing as oestrogen levels drop and with the aging process. The sudden cessation of ovarian function through oophorectomy in pre-menopausal women has more severe consequences compared to natural menopause. There is evidence to suggest consequences of surgical menopause may include a higher overall mortality rate (16.8% versus 13.3% in patients with ovarian conservation), increased rates of pulmonary and colorectal cancer, coronary disease, stroke, cognitive impairment, Parkinson’s disease, psychiatric disorders, osteoporosis, and sexual dysfunction. While it was previously believed that the ovary continues to produce some androgens after menopause, recent immunocytochemical evidence suggests that the postmenopausal ovary lacks the necessary steroidogenic enzymes and luteinizing hormone (LH) receptors. Instead, it appears that the primary source of circulating androgens in postmenopausal women is the adrenal gland. Surgically induced menopause, particularly through oophorectomy, has been associated with an increased risk of mortality, as indicated by several authors. A study by Parker et al. aimed to determine the best approach to extend the survival of non-high-risk ovarian cancer patients and examined survival rates over a span of up to 80 years, considering factors like hysterectomy and oophorectomy. Their findings suggest that conserving the ovaries in women under 65 years with a low risk for ovarian cancer offers a long-term survival benefit. Hysterectomy plays a significant role primarily in women who undergo oophorectomy, while it’s less important for patients with ovarian conservation.  Although, some small-scale studies have examined menopausal age and related factors in specific regions of India, there is no comprehensive study covering all regions of the country.

Both early menopause and surgically induced menopause are associated with an elevated risk of cardiovascular disease. The underlying mechanism is believed to involve accelerated atherosclerosis due to increased levels of atherogenic lipoproteins resulting from a hypoestrogenic state. Studies have shown a higher risk of cardiovascular diseases in women who undergo oophorectomy without hormone replacement therapy (HRT). However, the risk is eliminated when HRT is administered. Research by Parker et al. found an increased risk of cardiovascular diseases for women who had oophorectomy, regardless of their age. The risk is particularly elevated in women under 45 years, with the maximum risk observed in those under 50 years who do not receive HRT. Rivera et al. reported that the highest risk for cardiovascular diseases was observed in women under 45 years who underwent oophorectomy without HRT or discontinued HRT. Additionally, Ingelsson et al. demonstrated that hysterectomy with bilateral oophorectomy in women under 50 years increases the risk of cardiovascular diseases by 40%.

Indian women experience menopause and perimenopause at an earlier age compared to women in developed countries. The earlier onset of menopause in Indian women is associated with an increased risk of diseases such as osteoporosis and heart attacks among postmenopausal women. A report from India has estimated that one in three women in midlife has at least two chronic conditions or multimorbidity.  Moreover, women with multimorbidity reported inferior health related quality of life encompassing poor self-rated health, work-limiting health conditions, mobility, and activities of daily living. Thus, the national reproductive health program (RMNCHA+) should start considering women’s health beyond reproductive age and wellness.

There is evidence to suggest a variety of factors may correlate with menopausal age, positive and otherwise. These include;

  • Marital status and menopausal age
  • Education, socioeconomical status and menopause age
  • Psychosocial status and menopause age
  • Body mass index and menopausal age
  • Cardiometabolic status and menopause age
  • Smoking status
  • Alcohol consumption
  • Use of contraception

The decision to undergo elective oophorectomy should be based on a thorough evaluation of the cost-benefit ratio, considering the pros and cons, immediate and long-term risks, and potential complications. To reduce the need for surgical interventions, it’s essential to limit surgical treatment for asymptomatic fibroids, preserve ovaries in low-risk patients, and consider postponing or conservatively managing ovarian cysts. Informed decision-making should involve multidisciplinary pre-operative counselling, where patients can fully understand the risks of early surgically induced menopause. Such counselling should be supplemented by the gynaecologist’s expertise in hormonal and metabolic consequences. Ultimately, the patient should be empowered through adequate menopause health literacy to become the primary decision-maker in these matters. This requires advocacy at multiple levels including professional associations and women’s health organisations.

Discussion
  1. Insightful article on the impact of natural and surgical menopause, especially in the Indian population! I’m curious about the role of lifestyle factors like diet and exercise in mitigating the risks associated with early menopause. Looking forward to more research in this area!

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