Aging is a natural biological process that affects all living creatures and in which, over time, predictable physiological changes from cellular to organismic occur.
Each of us feels how the body's vital activity is gradually slowing down and the plasticity of the body is decreasing. Although the rate of aging may depend on heredity, environmental factors, and personal skills of a healthy life, the process itself is inevitable and irreversible.
The impact of aging on sexuality is rooted in both psychological and biological changes. An aging body can be perceived as having beauty and strength if approached with positive psychological attitudes. Today, almost everyone knows that climax means hot flashes, tearfulness, irritability, emotional lability, night sweats, palpitations…
This whole group of disorders occurs when the formation of climax is just beginning. Most often this happens at the age of 45, when a woman simply does not feel well, but according to her gynecological indicators she is healthy.
Later, sexual disorders, urinary incontinence, dry skin and mucous membranes, hair loss develop... Then there is hypertension, atherosclerosis, osteoporosis. And so the state worsens up to a deep memory impairment and even deep mental disorders. But it is true that climax may develop in a slightly different way.
Public opinion also plays an important role, according to which it is often believed that menopause is the end of femininity and the beginning of old age, that is, the time of losses.
Under the influence of such public opinion, the severity of psycho-vegetative manifestations of climacteric-depression, mood swings and sleep disturbances – intensifies.
About ten years before the onset of climax, that is, at the age of 38-40, the transition period begins. And just then a woman should understand that something needs to be done to prevent the onset of early menopause.
The female body is genetically programmed to stop menstruating somewhere in middle age, usually between 45–55 years. This is called menopause, the years before and after onset of menopause are called the climacteric period.
Modification of ovarian function begins before the age of 30 years, the production of hormones is gradually reduced. Premenopause precedes menopause with somatic and psychological changes due to the extinction of ovarian function. Their early detection can prevent the development of severe climacteric syndrome.
Premenopause usually begins after 45 years. At first, its manifestations are insignificant. Both the woman herself and her doctor usually either do not attach importance to them, or associate them with mental overstressing. Hypoestrogenism should be excluded in all women after 45 years who are complaining of fatigue, weakness, irritability.
The most characteristic manifestation of premenopause is menstrual cycle irregularities. During the 4 years preceding menopause, this symptom is noted in 90% of women. Then the irregularity of ovulations and menstrual cycles begins to increase.
Hormonal and metabolic changes occur in premenopause gradually. After an almost 40-year period during which the ovaries secreted sex hormones cyclically, estrogen secretion gradually decreases and becomes monotonous.
In premenopause, the metabolism of sex hormones changes. In postmenopause, the ovaries do not completely lose their endocrine function, they continue to secrete some hormones. If you look at a woman from the point of view of nature, then nature preserves her, because the woman fulfills her main vocation – to bear children.
By the way, it was noticed that if a woman is psychologically oriented toward the family, pays more attention to it in her soul, she gets sick less often. This is the main protection of nature, which is provided by hormones.
Estrogens – hormones of the first phase of the cycle – determine the appearance of a woman, an emotional outburst, brightness and colourfulness of life. Women who do not have enough of them are less emotional, less enjoy life, they have worse skin, hair.
The main task of another hormone – progesterone – is to ensure pregnancy. With its predominance in the body, a woman feels peace, calmness, harmony. Before menopause, usually estrogens still remain, but progesterone is already low.
As a result – emotional outbursts, irritability, emotional imbalance, unbearable character. You just need to timely conduct the therapy, which will help your own ovaries to work another five years. Doctors recommend pregnancy protection for a full year from the last menstruation.
A woman in this period may experience a decrease in breast size, skin structure and color change, the tendency to gain weight, especially on the hips, intensifies. Bone thinning – osteoporosis – is another consequence of changes in the body.
It is observed in women of fragile physique, who lead a sedentary lifestyle. They are prone to fractures of the hips and shoulders, experience chronic back pain due to weakening of the spine.
Menopause is part of the natural aging process, in fact, this is the cessation of menstruation as a result of the extinction of ovarian function. The age of menopause is determined retrospectively, after a year after the last menstruation.
The average age of menopause is 51 years. It is determined by hereditary factors and does not depend on the particularities of nutrition and nationality. Menopause occurs earlier in smokers and nulliparous women.
Postmenopause follows menopause and lasts in average a third of a woman's life. For ovaries, this is a period of relative dormancy.
The consequences of hypoestrogenism are very serious, they are similar in importance to health with the consequences of hypothyroidism and adrenal insufficiency.
Despite this, doctors do not pay enough attention to HRT in postmenopause, although it is one of the most important components of the prevention and treatment of a variety of pathologies in older women.
Apparently, this is connected with the fact that the consequences of hypoestrogenism develop slowly (osteoporosis) and are often attributed to aging (cardiovascular diseases).
Progesterone is produced only by the cells of the corpus luteum that forms after ovulation. In premenopause, an increasing part of the menstrual cycles becomes anovulatory.
In some women ovulation occurs, but corpus luteum insufficiency develops, which leads to a decrease in progesterone secretion.
The secretion of estrogen by the ovaries in postmenopause almost stops. Despite this, in all women, estradiol and estrone are determined in the serum.
They are formed in peripheral tissues from androgens secreted by the adrenal glands. Most estrogens are formed from androstenedione, which is secreted mainly by the adrenal glands and, to a lesser extent, by the ovaries.
This occurs primarily in muscle and adipose tissue. In this regard, with obesity, serum estrogen levels increase, which in the absence of progesterone increases the risk of uterine body cancer.
Thin women have lower serum estrogen levels, that is why they have an increased risk of osteoporosis. It is interesting that climacteric syndrome is possible even with high estrogen levels in obese women.
In postmenopause, progesterone secretion ceases. In the childbearing period, progesterone protects the endometrium and mammary glands from estrogen stimulation. It lowers estrogen receptor content in cells.
In premenopause and postmenopause, some women maintain sufficiently high levels of estrogen to stimulate the proliferation of endometrial cells. This, as well as the absence of progesterone secretion, leads to an increased risk of endometrial hyperplasia, cancer of the uterus body and mammary glands.
The psychological consequences associated with aging are usually much more expressed than those associated with the loss of childbearing function. In modern society, youth is valued above maturity, so menopause, as tangible proof of age, causes anxiety and depression in some women.
The psychological consequences largely depend on how much attention a woman pays to her appearance. The rapid aging of the skin, especially in postmenopause, worries many women. The results of numerous studies confirm that age-related skin changes in women are conditioned by hypoestrogenism.
In the climacteric period, many women note anxiety and irritability. These symptoms have even become an integral part of climacteric syndrome. It is generally accepted that they are associated with hypoestrogenism.
Despite this, in none of the conducted studies, the relationship of anxiety with menopause and its disappearance during hormone replacement therapy was not confirmed. Anxiety and irritability are likely conditioned due to various social factors. The doctor should be mindful of these symptoms often encountered in older women and provide appropriate psychological support.
A peculiar restructuring of the system of personality relations associated with climax is noted, even those who were active, energetic, purposeful, hardy, self-confident enough throughout life become worrisome, doubtful about everything at this age.
The system of personality relations is especially significantly changing in the direction of understating one's own abilities, the disappearance of a life perspective associated with an exaggeration of the severity of painful sensations.
At the climacteric age, a woman has many additional psychogenic factors that previously did not cause her concern. These are the so-called conditionally pathogenic mental traumas associated precisely with a change in the personality relationship system.
The manifestations of climax become conditionally pathogenic, such as a change in the appearance (gray hair, a decrease in skin turgor, the appearance of wrinkles, a change in libido), the significance of which increases sharply at this age.
All this happens when adaptation is impaired, when there are traits of rigidity, «getting stuck» at the slightest troubles, which in its turn leads to a kind of «personality narrowing».
Sometimes such a condition, developing in connection with the pathologically ongoing climax, as a personality change, ultimately leads to a kind of «defect», manifested by the pathology of emotions and urges.
At the same time, progressive lethargy, passivity, and indifference to those aspects of life that have recently been of interest, caused an emotional resonance come to the fore.
Psychological conflict is resolved when a person develops a new attitude to the objective situation that gave rise to the conflict, and new motives for activity.
But with a disharmony course of climax, the resolution of conflict situations is difficult due to the inertia of mental processes, «getting stuck» on unpleasant experiences, actualization of old grievances, significantly changing assessments of one’s own capabilities and one’s life prospects.
The mental state in which a woman comes to the climacteric period of her life affects the nature of its course. Personal disorders, ill health in mental life, life situations that cause neurosis, lead to the pathological development of climax.
Hot flashes are perhaps the most famous manifestation of hypoestrogenism. Patients describe them as a periodic short-term sensation of heat, accompanied by sweating, palpitations, anxiety, sometimes followed by chills. Hot flashes usually last 1–3 minutes and are repeated 5–10 times a day.
In severe cases, patients report up to 30 hot flashes per day. With natural menopause, hot flashes occur in about half of women, with artificial menopause – much more often. In most cases, the hot flashes slightly disturb health.
Hot flashes are explained by a significant increase in the frequency and amplitude of gonadoliberin secretion. It is possible that increased secretion of gonadoliberin does not cause hot flashes, but is only one of the symptoms of dysfunction of the central nervous system, leading to disorders of thermoregulation.
Relax your face. To find out the location of your future wrinkles, look at your mother... give risk areas more care. Double your attention if you have dry or sensitive skin: it gets old faster. Thorough cleansing and skin care, a minimum of cigarettes and the open sun, balanced nutrition, a sufficient amount of liquid.
Almost a third of a woman’s life passes under the sign of climacteric. In recent years, it has been convincingly shown that it is possible to significantly improve the quality of life during climacteric using hormone replacement therapy (HRT), which can cure climacteric syndrome, reduce cardiovascular pathology, osteoporosis and urinary incontinence by 40–50%.
HRT quickly eliminates hot flashes in most women. Some of them, especially those who have undergone bilateral ovariectomy, require high doses of estrogen. In mild cases, in the absence of other indications for HRT (for example, osteoporosis), treatment is not prescribed. Without treatment, hot flashes pass through 3–5 years.
The epithelium of the vagina, urethra and base of the bladder is estrogen-dependent. 4–5 years after menopause, approximately 30% of women who do not receive hormone replacement therapy develop its atrophy.
Atrophic vaginitis is manifested by dryness in the vagina, dyspareunia, and recurrent bacterial and fungal vaginitis. All these symptoms completely disappear against the background of hormone replacement therapy.
Atrophic urethritis and cystitis are manifested by frequent and painful urination, peremptory desires to urinate, stress urinary incontinence, and recurrent urinary tract infections. Atrophy of the epithelium and shortening of the urethra due to hypoestrogenism contribute to urinary incontinence. HRT is effective in 50% of postmenopausal patients with stress urinary incontinence.
Women in climacteric period often notice impaired concentration of attention and short-term memory. Previously, these symptoms were explained by aging or sleep disturbances caused by hot flashes. Now it has now been shown that they may be conditioned by hypoestrogenism. Hormone replacement therapy improves the central nervous system functions and the psychological state of postmenopausal women.
One of the most interesting areas of future research is determination of the role of HRT in the prevention and treatment of Alzheimer's disease. There is evidence that estrogens reduce the risk of this disease, although the role of hypoestrogenism in the pathogenesis of Alzheimer's disease has not yet been proven .
Cardiovascular diseases have many predisposing factors, the most important of which remains age. With age, the risk of cardiovascular disease increases in both men and women. The risk of death from coronary heart disease in women of childbearing age is 3 times less than in men. In postmenopause, it rises sharply. Previously, an increase in the frequency of cardiovascular diseases in postmenopause was explained only by age.
At present, it has been shown that hypoestrogenism plays an important role in their development. This is one of the most easily eliminated risk factors for atherosclerosis. In postmenopausal women receiving estrogen, the risk of myocardial infarction and stroke is reduced by more than 2 times. A doctor who observes a postmenopausal woman should tell her about cardiovascular diseases and the possibilities for their prevention. This is especially important if for some reason she refuses HRT.
In addition to hypoestrogenism, it is necessary to strive to eliminate other risk factors for atherosclerosis. Perhaps the most significant of these are arterial hypertension and smoking. So, arterial hypertension increases the risk of myocardial infarction and stroke by 10 times, and smoking by at least 3 times. Other risk factors include diabetes mellitus, hyperlipidemia, and a sedentary lifestyle.
It has long been known that menopause, natural or artificial, leads to osteoporosis. Osteoporosis is a decrease in density and remodeling of bone tissue. For convenience, some authors suggest calling osteoporosis such a decrease in bone density in which fractures occur, or their risk is very high.
Unfortunately, the degree of loss of the compact and spongy substance of the bone in most cases remains unknown until a fracture occurs. The number of elderly women with fractures of the radius bone, femoral bone neck and compression fractures of the vertebrae with osteoporosis is high. With an enlargement in average life expectancy, it, apparently, will only increase.
Despite the fact that the speed of bone resorption increases already in premenopause, the highest frequency of fractures due to osteoporosis is observed several decades after menopause. The risk of femoral bone neck fracture in women older than 80 years is 30%. About 20% of them die within 3 months after a fracture from complications of prolonged immobilization. It is extremely difficult to treat osteoporosis already at the stage of fractures.
Osteoporosis risk factors
In order to prevent complications of the climacteric period, hormone replacement therapy is most effective. Climacteric syndrome, most often observed in the premenopausal period, is characterized by vegetative-vascular, neurological and metabolic manifestations.
Hot flashes, instability of mood, tendency to depression are characteristic, hypertension is often aggravated, diabetes mellitus type 2 progresses, exacerbations of peptic ulcer disease, lung pathology occur. The hypotrophic processes of the vaginal mucosa, urethra and bladder gradually progress.
The conditions for frequent urinary and vaginal infections are created, sexual life is disturbed. Atherosclerosis progresses, the risk of myocardial infarction and strokes increases. In late menopause, due to progressive osteoporosis, bone fractures occur, especially fractures of the spine and femoral neck.
HRT is effective in climacteric syndrome in 80–90% of cases; it halves the risk of myocardial infarction and stroke and increases life expectancy even in those patients who have narrowed coronary arteries bore by angiography. Estrogens prevent the formation of atherosclerotic plaques. Estrogens, which are part of combined HRT preparations, reduce bone tissue loss and partially restore it, preventing osteoporosis and fractures.
HRT also has a negative effect. Estrogens increase the risk of hyperplasia and cancer of the uterus body [8,10], but the simultaneous prescribing of progestogens prevents these diseases .
According to the literature, a clear picture of the risk of breast cancer cannot be made; many authors in randomized researches showed no increased risk, but in other researches it increased . In recent years, the beneficial effect of HRT in relation to Alzheimer's disease has been shown .
Despite the clear advantages of HRT, it is not widespread. Only about 30% of postmenopausal women intake estrogens . This can be explained due to the large number of women with relative contraindications and limitations for HRT.
In adulthood, many women have uterine fibroids, endometriosis, hyperplastic processes of the reproductive organs, fibrocystic mastopathy, etc. All this forces us to look for alternative methods of treatment for climacteric disorders (physical activity, limiting or stopping smoking, reducing the consumption of coffee, sugar, salt, a balanced diet).
Long-term medical observations have demonstrated the high efficiency of a balanced diet and the use of multivitamin, mineral complexes, as well as medicinal plants.
Climactoplan is a complex preparation of natural origin. The plant components of the preparation affect thermoregulation, normalizing the processes of inhibition in the central nervous system; reduce the frequency of sweating assaults, hot flashes, headaches (including migraines); relieve feelings of tightness, internal anxiety, help with insomnia. The preparation is taken until complete resorption in the oral cavity half an hour before or one hour after eating 1–2 tablets 3 times a day.
There are no contraindications to the use of the drug, no side effects have been identified.
Climadinon is also a plant-based drug. Tablets of 0.02 g of 60 pieces per pack. Drops for oral administration – 50 ml in a flacon.
Selective estrogen-receptor modulators are a new direction in the treatment of climacteric. Raloxifene stimulates estrogen receptors, while also possessing antiestrogenic properties.
The drug was synthesized for the treatment of breast cancer, it is part of the tamoxifen group. Raloxifene prevents the development of osteoporosis, reduces the risk of stroke and myocardial infarction, and does not increase the risk of breast cancer.
For HRT conjugated estrogens, estradiol valerate, estriol succinate are used.
In the USA conjugated estrogens are more commonly used, in European countries – estradiol valerate. The listed estrogens do not have a clear effect on the liver, coagulation factors, carbohydrate metabolism, etc. Mandatory is the cyclic addition of progestogens to estrogens within 10–14 days, which allows to avoid endometrial hyperplasia.
Natural estrogens, depending on the route of administration, are divided into 2 groups: for peroral or parenteral use.
With parenteral administration, the primary metabolism of estrogen in the liver is excluded, as a result, lower doses of the preparation are required to achieve a therapeutic effect in comparison with peroral preparations. With the parenteral use of natural estrogens, various methods of administration are used: intramuscular, cutaneous, percutaneous and subcutaneous. The use of ointments, suppositories, tablets with estriol allows to achieve a local effect in case of urogenital disorders.
Widespread in the world have got drugs containing estrogen and progestin. These include monophasic, two-phase and three-phase types of preparations. Kliogest is a monophasic preparation, 1 tablet of which contains 1 mg of estradiol and 2 mg of norethisterone acetate.
The two-phase type drugs supplied to the Russian pharmaceutical market currently include:
Three-phase preparations for HRT are presented by Trisequens and Trisequens-forte. Active substances: estradiol and norethisterone acetate.
Monocomponent preparations for peroral administration include: Proginova–21 (a calendar package 21 dragees of 2 mg of estradiol valerate and Estrofem (tablets of 2 mg of estradiol, 28 pieces).
All of the above drugs suggest bloody spotting that resembles menstruation. This fact confuses many menopausal women. In recent years, Femoston and Livial continuous preparations have been introduced in the country, with the use of which spotting either does not occur at all, or ceases after 3–4 months of administration.
Thus, being a normal phenomenon, climacteric lays the foundation for many pathological conditions. The most noticeable change in climacteric is the extinction of ovarian function. Decreased estrogen level contributes to aging. That is why the effect of hormone replacement therapy on the female body is so actively studied. It would be naive to believe that all the troubles of aging can be eliminated by hormonal means. But it should be recognized as unreasonable to abandon the great possibilities of hormone therapy to preserve the health of women in climacteric.
The global female population is not only growing, but also «turning gray». About 10% of it today are women in climacteric. Each year, 25 million are added to their number, and by 2020, this figure is predicted to increase to 47 million . In connection with the increase in life expectancy in modern society, there is growing interest in the health problems of women in the older age group.
Climacteric in literal translation from Greek means «step» or «grade», that is, the transitional stage from puberty of a woman to old age. At this time, against the background of general biological aging of the body, a gradual involution of the ovarian parenchyma occurs, which leads to a decrease in their production of sex hormones (estrogen, progesterone, androgen). A decrease in the secretion and release of hormones into the blood during menopause is accompanied by a wide range of complications – from discomfort (vasomotor and emotional-mental) to disorders that potentially make threat for life (cardiovascular diseases and osteoporosis). Symptoms of climax and the long-term effects of menopause significantly worsen the health and well-being of women, reducing quality of their life.
The gynecologist who observes women in the climacteric period has two main tasks: the treatment of existing climacteric disorders and the prevention of long-term complications of menopause. Currently, hormone replacement therapy (HRT) is widely prescribed for patients to arrest menopausal symptoms, urogenital disorders, in order to prevent bone tissue mass loss and the development of osteoporosis, metabolic and other disorders, for example, Alzheimer's disease.
The idea of hormone replacement therapy – to fill the lack of endogenous hormones by introducing them from the outside – is simple, and its concept appeared a long time ago. About a hundred years ago, hormone replacement therapy was first introduced into medical practice. In 1896, doctor Mond's first publication on the use of homogenized bovine ovarian extract for treating women after a hysterectomy appeared in the medical journal «Munchner Medizinische Wochenschrift». Almost at the same time, a month later, doctor F. Mainzer published the results of his experiments of using a powder of bovine ovary extract to treat women after ovariectomy. In 1926, the first estrogenic preparation was synthesized by E. Laqueur. The idea of estrogen treatment of climacteric syndrome came in 1932 to Geist and Spielmann.
Since the skin and muscle tissue are estrogen-dependent, postmenopausal women often experience atrophy, dry skin, appearing of wrinkles, mainly due to decreased collagen, and loss of muscle mass. The positive effect of HRT on the skin gives a cosmetic effect that improves the well-being of a woman and increases her self-esteem . Estrogen deficiency also significantly affects the genitourinary system: the vaginal epithelium becomes thinner, its blood supply and elasticity decrease, causing vaginal dryness, pain during sexual intercourse and, as a result, extinction of the emotional side of sex life, and a decrease in sexual desire. Disorders in the urogenital tract are observed in more than 50% of postmenopausal women.
Atrophy of the epithelium and connective tissue of the bladder and urethra causes pain during urination, nocturia, urinary incontinence, leading to repeated infections of the urinary tract. The effect of HRT on urinary incontinence and other symptoms of the urinary system has been clearly proven up to date . Treatment with 17b-estradiol in combination with dydrogesterone has a positive effect on urinary incontinence and nocturia, as well as on vaginal epithelium, reduces urogenital symptoms and improves sex life.
Weight gain is an important risk factor for cardiovascular disease. With the onset of menopause in women, new fat deposits appear or redistribution of adipose tissue by the type of abdominal obesity occurs . HRT slows down or even stops (depending on the treatment regimen) this increase. As shown by preliminary results of a clinical study conducted by De Jonge co-authored , while taking 17b-estradiol in combination with dydrogesterone (monophasic mode), fat gain does not occur, the average weight indicator remains stable during the year of therapy.
Women are usually brought up in the belief that having menstruation means being a woman, i.e. be fertile, feminine and sexually active. Therefore, for many women menopause is the loss of an important component of their female nature. They appear to be victims of any of the myths associated with this topic: that this is the beginning of the end of life, that sexual attractiveness and excitability worsen after menopause, and that the purpose and meaning of being a woman (i.e., the ability to reproduce) is lost. It is indicated that a woman may experience a decrease in sexual desire. In many ways, how a woman’s life will change depends on her attitude to menopause and to herself.
The sexual value system, cultural affiliation, social environment, general health, fantasies and expectations associated with menopause play a role. It is critical for woman to receive accurate information and emotional support throughout the transition period. A woman needs to be able to discuss her fears, doubts and concerns in order to understand that menopause is a natural stage of human development.
The hormone concentration in the body decreases very gradually in the fourth decade of life, and by the age of 75, the level of testosterone drops to about 90%. The optimality of the sexual function of men may depend on the presence of minimal amounts of free testosterone in the body. The introduction of additional testosterone can increase sexual interest and potency. Since usually men do not have any noticeable decrease in hormone levels, as well as in reproductive abilities, they also have nothing like menopause. Men often experience a period of stress, although it is less predictable and its symptoms are more diverse. The male transition period is characterized by increased anxiety, depression, insomnia, hypochondria, loss of appetite or chronic fatigue.
This period in life is usually marked by great changes and the implementation of plans. In a society oriented toward youth cult, it is especially difficult for men to put up with their aging. Men with wives and children also share the problems associated with the menopause of the spouse and the start of independent life for children. In families where the man is primarily a breadwinner, he may feel tired from the multiyear family caregiving responsibility burden. Middle age may turn out to be a time to achieve a stable career position, and the possibilities for further changes are already much limited. Physical changes and exertion caused by stress can cause changes in sexual interest and behavior, causing even more anxiety and frustration. Stress is intensified by strained relationships in marriage or with grown-up children.
Aging and female sexual reactions
Menopause results in a woman and brings unpleasant sensations:
– the inner layer of the vagina becomes thinner, which can lead to a decrease in the amount of vaginal lubrication, and as a result – sensations of itching or burning after sexual intercourse, caused by irritation of the vaginal mucosa
– uterine cramps during and after orgasm
– there is a slight decrease in her ability to experience orgasm and a general alleviation of the usual physiological reactions during sexual arousal
– increasing the time required to moisturize the vagina and the appearance of other early signs of sexual arousal
– increasing the duration of stimulation necessary to achieve an orgasm, and reducing associated muscle contractions
How sexual a man remains depends on physiological, social, psychological factors. As the natural slowdown process is underway, some men begin to feel insecure about their sexual abilities. They may be afraid of sexual failure, which usually means all sorts of problems with erection. Having survived even a single case of non-occurrence of an erection, some men stop engaging in sexual intercourse. They may suggest that aging