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Background reading material by Professor Omar Hasan Kasule for Year 3 Semester 1 Medical PPSD session on 09th August 2008.
1.0 CLIMACTERIC
Climacteric is a period when the woman undergoes endocrine, somatic, and physiological changes as she comes to the end of her reproductive career and prepares to enter middle age. The average age for menopause is 45-55 but may range 40-late 50s. The climacteric may be premature before the age of 40 due to genetic disorders, ovarian auto-antibodies, or loss of ovarian receptors. It may also be induced artificially by surgery or radiation.
The processes leading to the climacteric start even before birth. At 20 weeks of intra-uterine life there are 700 million oogonia. As the ovary ages, these decrease to 700,000 at birth. The decrease increases throughout the rest of life. Ovarian function decreases throughout life but is accelerated in the period immediately before the climacteric. This manifests as missed or irregular menstrual periods that precede complete cessation of menstruation.
Climacteric changes are related to ageing and estrogen depletion. Heredity, nutritional status, and general health also have an impact on onset of the climacteric. The climacteric like early childhood and adolescence is a period of transition and is associated with problems and complications.
2.0 MENOPAUSE
Menopause is permanent cessation of menses and is considered part of the climacteric. The age at menopause has been rising in countries and societies where nutrition and health have been improving. Many women do not enter menopause until they are in their late 40s or early fifties. Khadijah, the first wife of the prophet, gave birth at an advanced age above 40 years.
At menopause the ovarian follicles are depleted. The ovary is no longer able to synthesize sufficient estrogen. As ovarian estrogen production declines, the feedback loop to the pituitary no longer inhibits FSH production. The ageing ovary is no longer capable of responding to the pituitary gonadotropins. High levels of FSH in the blood cause changes in adrenal and thyroid hormones leading to metabolic disturbances.
Among the manifestations of menopause are: vasomotor flushes, headaches, dizziness, osteoporosis, genito-urinary atrophy (vagina, urethra, and bladder), and cardiovascular disorders (MI, CVA). As a result of estrogen deficiency, the uterus becomes smaller. The breasts decrease in size. The vagina becomes dry.
3.0 POST-MENOPAUSE
The postmenopausal syndrome is due to deficiency of estrogen. It is a cause of distress, anxiety, behavioral, and physical disorders.
4.0 PROBLEMS OF THE MENOPAUSE
· Bleeding disorders
· Mood changes
5.0 FIQH / LEGAL RULINGS ABOUT MENOPAUSE
DEFINITION OF MENOPAUSE
Menopause is defined by cessation of the menstrual flow and not by age. Thus early menopause is considered menopause for purposes of the Law.
ARTIFICIAL EARLY MENOPAUSE
A woman can choose to go into early menopause because of the inconvenience of menstruation and childbirth. Early menopause can be induced medically or surgically. Artificial menopause is necessary, dharuurat, if there is serious disease like cancer. Other indications that do not reach the level of dharuurat are prevention of genital tract cancer by surgical removal of the organs that normally become cancerous and shortcutting the problems of the labile transitional period of the menopause.
The harm, dharar, must be considered against the benefit, maslahat, with the understanding that under the Law prevention of harm has precedence over accruing a benefit. In cases of early surgically induced menopause lifetime estrogen replacement therapy, which has complications and side effects, may be necessary.
DELAY OF MENOPAUSE
It is conceivable that with suitable hormonal manipulation, a woman could delay the onset of menopause. This is praiseworthy if the intention is to prolong reproductive life or strengthen marriage. It is offensive if done for purposes of appearing young to the general society. The Law in general is against any deceptions regarding a person's age.
ESTROGEN REPLACEMENT THERAPY
Estrogen replacement therapy (ERT) can alleviate virtually all menopausal symptoms. ERT has serious side effects that have to be considered under the two principles of benefit and harm. HRT is a suspected cause of endometrial carcinoma and breast cancer.