The impact of Natural and Surgical Menopause in the Sri Lankan Population

Authors: Nirmala Rathnayake¹, Gayathri Delanerolle^{2, 3}, Peter Phiri^{2, 3}, Tharanga Mudalige¹, Thamudi Sundarapperuma¹, Lanka Dassanayake⁴

¹Department of Nursing, Faculty of Allied Health Sciences, University of Ruhuna, Sri Lanka

²Southern Health NHS Foundation Trust, Southampton, UK

³Digital Evidence Based Medicine Lab, Oxford, UK

⁴Department of Gynaecology and Obstetrics, Faculty of Medicine, University of Ruhuna, Sri Lanka

Menopause is largely considered as a natural biological phenomenon that occurs in every woman as a result of the age-related decline in primordial ovarian follicles. Menopause is the phase in a woman’s life when menstrual periods permanently cease. According to the World Health Organization, natural menopause is officially recognized as the absence of menstrual periods for a continuous 12-month period, and when no other biological or physiological cause can be identified for this absence. It marks the permanent cessation of menstruation and is officially recognized when there is a 12-month period without an active menstrual cycle, without any other identifiable cause. Menopause and the accompanying physiological changes can have a detrimental effect on women’s overall health, quality of life, and general well-being during middle age. The lack of ovarian hormones in women can lead to emotional difficulties, especially in those with unstable psychological conditions and elevated levels of anxiety, negatively affecting their quality of life. This is often accompanied by increased depression due to declining oestrogen levels and their impact on neurotransmitters. It will also negatively affect women’s social and intimate relationships,  occupational productivity, and  routine family responsibilities.. Further, these negative effects of menopause would have an impact on country’s economy due to loss of productivity and high heath care expenditure. Since

Hysterectomy, the surgical removal of the uterus, is a common procedure used to address gynaecological issues such as endometriosis, fibroids,  adenomyosis, and uterine prolapse, often in women near or after menopause. Population-based research on hysterectomy has primarily concentrated on high-income countries, leaving a gap in our knowledge regarding the frequency, contributing factors, and long-term health consequences of hysterectomy in low and middle-income nations. This indicates a need for more comprehensive research in these settings to better understand the impact of this surgical procedure on women’s health. The prevalence of hysterectomy varies among high-income countries, with some reporting a decline due to advancements in alternative treatments. However, in Sri Lanka, it is estimated a third of women have a hysterectomy during the course of their life.

Hysterectomy can lead to surgical menopause if the ovaries are removed, or it may still affect ovarian function when the uterus alone is removed. A 2022 systematic review of 29 studies revealed that hysterectomy, with or without oophorectomy (ovary removal), is associated with chronic diseases in women. These risks include an increased likelihood of cardiovascular events, cancers, depression, metabolic disorders, and dementia. Women who have removed their ovaries,  even face higher risks due to the loss of oestrogen. Surprisingly, recent cohort studies suggest that hysterectomy with ovarian preservation is linked to a higher risk of cardiovascular disease, metabolic disorders, and all-cause mortality for women who undergo the procedure before age 50 without hormonal therapy. Moreover, the abrupt discontinuation of ovarian function (by oophorectomy) in premenopausal women is associated with more severe consequences than natural menopause, such as increased overall mortality rate (16.8% versus 13.3% in patients with ovarian conservation), and increased rates of pulmonary and colorectal cancer, coronary disease, stroke, cognitive impairment, Parkinson’s disease, psychiatric disorders, osteoporosis and sexual dysfunction. This highlights that the widespread use of hysterectomy is a crucial concern for women’s health, reflecting issues of unequal access to healthcare services and raising concerns about the long-term consequences for women’s well-being throughout their lives especially after menopause in a low middle-income country like Sri Lanka.

Current international guidelines advise use of Menopausal Hormone Therapy (MHT) for women under menopause either naturally or surgically under age of 45 years those do not contraindicated to address menopausal symptoms. Despite advancements in therapeutic approaches for psychiatric issues related to surgical menopause, there remains a shortage of effective treatments for menopausal symptoms. Some traditional treatments are only partially effective and can have side effects, limiting their use in sensitive individuals. Consequently, alternative therapies based on lifestyle changes and stress reduction techniques have been explored. Many of the interventions focus on non-invasive alternatives to alleviate menopausal symptoms. Studies  highlight the use of Hormone Replacement Therapy (HRT) too as a standard treatment to alleviate post-menopausal symptoms, but notes its limitations and potential side effects. Specific approach such as Cognitive Behaviour Therapy (CBT), is also can be considered highly effective in addressing these symptoms, offering structured, short-term treatment to help individuals manage their thoughts, emotions, and beliefs. CBT has gained popularity among clinicians and the general public in recent years. Its short-term and structured nature makes it suitable for empirical investigation, and it has amassed a substantial body of research. CBT practices aim to make individuals more rational, help them gain control over their thoughts, change self-beliefs, and promote calmness and relaxation.

In developed countries, menopausal women seek medical attention early when they perceive health problems attributed to menopause. However, women in low and middle income countries such as Sri Lanka, most women do not perceive the need to prevent or detect such health problems early, probably due to the lack of knowledge, socio-cultural stigma and negative attitude. A study has revealed that women in Sri Lanka manage menopausal problem mainly on their own as they viewed the menopause as a natural stage of aging risking unnecessary suffering and failure to detect preventable complications. Moreover, their health seeking behaviours subside with the recent economic crisis, shortage of effective treatments for menopausal symptoms due to the cut down of supply of HRT like medicine, inability to afford for purchasing the HRT. Poor health seeking behaviours of postmenopausal women that inherited from the socio-cultural barriers are also seriously affect on poor status of health and wellbeing of postmenopausal women.

The average age of a women attaining menopause in Sri Lanka has been found to be between 49 and 51 years. In Sri Lanka, nearly one fourth of women over 50 years (Department of Census and Statistics, 2014), are postmenopausal. This number is expected to increase with the increase of life expectancy and overall health of women due to the advancement of health technology and inventions. Further, documented evidence of attaining menopause surgically is and its impact on health is not yet understood systematically. However, understanding the background and considering the female life expectancy in Sri Lanka which is 78 years, a woman has to spend an approximately three decades in their life in postmenopausal period.

 In the Sri Lankan context, postmenopausal women are facing an ever increasing burden of family responsibilities; as caregivers to the young and old, bread winners, preparing for retirement and contributors to the welfare of the communities in which they live. Therefore, empowering of these women achieved menopause either by naturally or surgically through improved awareness, creating social support network, exploration of alternative therapies like lifestyle changes and stress reduction techniques would be effective to enhance the overall health and wellbeing.