PHYSICAL, PSYCHICAL AND SEXUAL BEHAVIOR CHANGES IN MENOPAUSE IN INSTITUTIONALIZED WOMEN
Received for publication: 3rd of November, 2013
Revised: 20th of November, 2013
SUMMARY: (Hide the summary)
We followed the morpho-functional changes of the organism in 51 women with the age ranging between 50-51 years old, institutionalized in two nursing homes. We established a correlation between these changes and the development of sexual activity, as well as the influence of the menopause and perimenopause on senior women. We performed the anamnesis, the clinical examination, the local gynecological exam, psychological tests and the urinary incontinency test. We made appreciations on the changes at the physiognomy level, the nervous system, the blood pressure values, the presence or absence of the bone arthropathies, muscular hypotrophy, the obesity in different levels and on the changes noticed at the level of the genital system and in sexual behavior. At the same time, we made appreciations on the presence or the absence of the genital prolapse and the stress urinary incontinency. The examinations showed important changes in the women's organism due to the lack of estrogen. These changes were noticed at the level of the cardiovascular system, 43 cases (84.31%) were hypertensive, at the level of osteoarticular system, 26 cases (50.98%), as well as at the level of the genital system (vagina, vulva), 37 cases (72.54%).In all the cases we noticed the complete absence of sexual activity, motivated in 85.7% from cases by the absence of men (the women were in a nursing home) and by the lack of sexual arousal. Urinary stress incontinency was found in 99.96% of cases, from which 62.7% admitted from the beginning the urinary stress incontinency, and 37.26% did not admit to the urinary stress incontinency, but we found slight forms of the latter. The morpho-functional changes in menopause and perimenopause develop a special pathology for senior women which influence the quality of life. Institutionalized women represent a special group due to their social status and to the cultural-educational level which made them call on this form of living their old-age. The found pathology is one that is characteristic for the elderly with some particular features determined by the way of living in nursing homes. Implementing special programs in the nursing homes with socialization programs, as well as applying a hormonal substitution treatment and a gerontologic treatment can lead to delaying the aging phenomenon.
women, sexual habits, menopause.
It is estimated that, for the human species, the information stored in the zygote genome would theoretically satisfy the ontogenetic evolution for a period of approximately 124 years (14). In practice, the proportion of individuals that are over 85 years of age is extremely low, the average life expectancy of men being of 65 years and that of women of 72. After birth, which represents the greatest "shock" a person suffers in their lifetime, transitioning from liquid life to a gas environment, the human organism is permanently heading towards ageing.
The human aim during their lifetime is to maintain a state of health as close to perfect as possible, which, according to the WHO definition encompasses a state of wellness from an organic, functional, socio-economical and sexual point of view. Reaching these parameters to the fullest increases the quality of life.
There are some authors that claim that "old age is ugly", but this can be interpreted with a certain degree of subjectivity, both from an individual point of view as well as from the outside, through the assessment of one person on another. Any one of the modified health parameters can lead to the appearance of pathology associated with senior women, whose effect is a decrease in life expectancy and influencing their quality of life.
Perimenopause and menopause bring about special issues in women, as it is a genuine crisis, the issues arising during this time being existential, psychological, socio-economical or sexual. It is not infrequent for women to consider abandoning or continuing living in this neuro-hormonal storm.
The woman at menopause may choose one of the following options:
- The sizzle, which consists of a positive, optimistic attitude, expressing hope or will to live, benefitting the beauty of life, being sexually active and enjoying her partner. These qualities make it so that the woman ages slowly.
- The fizzle. As opposed to the first option, the women that adopt this negative attitude see menopause with fear, perceiving it as the end of youth and sexuality. These women have a pessimistic psyche, withdrawing from social life and isolating themselves. They age faster, more often than not their appearance being much older than their chronological age. In the case of these women, the physiological modifications that occur during this time, such as hot flashes, cold sweats, breast atrophy, weight gain or excessive weight loss, or any other pathology characteristic of menopause convey the impression of a catastrophe, with significant implications on their quality of life. (5,9)
Ageing is accepted with difficulty. When is one old, the question arises, in your 40s, 50s, 60s, 70s, 80s or 90s? The answer is subjective, being influenced by the age of the person who asks this question. There are people old at 30 and people young and vivacious at 80.
For women, menopause represents a crossroads in their life, for 50% of these appearing between 42.8 and 48.7 years old (according to Bürger). (17)
According to Utian W.H, for the American Work Shop on Reproductive Aging (16, quoted at 15), the stages of ageing in women start with the transition to menopause, which lasts and average of four years, followed by perimenopause (around menopause), which ends twelve months after the last menstruation, labelling menopause twelve months after the last menstruation and post-menopause, which begins five years after the last menstruation and ends at death.
In the gonadostat of menopausal women, which represents a neurovegetative storm, a series of endocrine changes occur, starting from the decrease of estrogens with influence on the ageing of the "Hypothalamic clock", which results in affecting the woman's hormone capital, to the dissociated increase of gonadotropin hormones and the decrease of sensitivity of the pituitary receptors to estrogens, resulting in a progressive hypoestrogenemia, whose effect is a hypothalamic hypertonia with an increase in the RLH. This accentuates the ageing of the "Hypothalamic clock" and modifies the circadian rhythms. (2,7)
MATERIAL AND METHOD:
We have studied a group of fifty one institutionalized women from two nursing homes, one urban (Timisoara), and another one rural (Comlosu Mare).
The study comprised the performance of the medical history, clinical examination, and local gynecological exam, as well as a series of psychological, stress and urine incontinence tests which we recorded in some sheets that we designed. (1)
The distribution of the study group according to age reveals a Gauss curve between fifty and ninety-one years of age (Table 1., Fig. 1.).
The centralization of data from the sheets calls attention to cardiovascular modifications in forty-three of these cases (84.31%), these suffering from hypertension, all the patients being treated with antihypertensive medication.
Osteoporosis and osteoarthropathies appeared in twenty-six of these case (50.98%), noting that we did not perform bone densitometry on any of the patients, the diagnosis being made by taking into account the medical history and the clinical examination.
In forty-one cases (80.39%) we indicated a muscular hypotrophy with a marked weight loss compared to the maturity period, the patients displaying progressive anorexia soon after entering menopause. In ten of the cases (19.61%) we indicated obesity, with a degree in overweight of I in 20% of the cases (2 cases), II in 50% (5 cases), and III 30% (3 cases).
The talks during the case history and clinical exam highlighted an advanced atherosclerosis and Alzheimer's in only one case (1.9%). The most significant changes once the menopause started occurred in the genital tract. At a breast level, all women studied (100%)have identified changes in the breast shape, 86.3% an increase in volume, 13.7% breast atrophy, and 33.3% depigmentation of the nipple. After the clinical examination, as well as a breast and axilla palpation, we did not find any breast tumors, benign or malignant; nevertheless, we did not perform a screening mammography.
The genital exam (valves and vaginal touch) emphasized severe changes of the genital tract; at a vulva level, the apparition of mucus and labial skin hypertrophy and atrophy, with a reduction of the and fat tissue -the labia becoming more prominent- and with a replacement of elastic fibers with collagen ones. At a vagina level, we marked vaginal atrophy in 40 of the cases (78.4%), but also a vaginal prolapse with cystocele and rectocele. The loss of elasticity of the vagina by reduction of elastic fibers and their replacement with fibrous tissue (3): leukoplakia in 3 cases (5.88%), and kraurosis vulvae in 1 case (1.96%), as well as perineal ruptures and vaginal scars associated to a low vaginal discharge. In 40% of the cases we noted a predominant clitoral hypertrophy in the women that displayed hirsutism. From a point of view of the uterus and cervix progressive with age, we noticed a continuous involution process up to severe atrophy. We have observed genital prolapse in 33 of these cases (88.09%), out of which 23 displayed urinary incontinence (87.6%), although, more often than not, genital prolapse is accompanied by urinary retention. We showed evidence for urinary incontinence in 99.96% of the case, 62.7% out of which admitted to it from the beginning, whereas 37.26% did not admit to it, although these displayed mild and medium forms of urinary incontinence during the provocation tests. (4)
In performing the Drip test, it highlighted bladder instability in 5 cases (9.8%), mixed urinary incontinence in 15 cases (29.4%), and stress urinary incontinence in 31 of the cases (60.78%).
From the vantage point of sexuality at menopause and postmenopause, there is a peculiarity in this study group because all of the women are institutionalized in a nursing home, which signals the complete absence of a developing sexual life, 85.7% motivated by the lack of men, as well as sexual appetite.
In general, the change in sexuality during premenopause is due to a decline in sexual intercourse, a decline in sexual pleasure, an increase in the frequency of dyspareunia of 15% (according to Lauman) (13), as well as local pain 17% (according to Graziottin) (8). The etiology of the loss of sexuality at menopause may be attributed to the loss of the sexual cycle, loss of breast firmness, excess of weight (obesity), embarrassment and shame because of appearance, associated pathology (stress urinary incontinence, primary arterial hypertension, cardiomyopathy), neurologic conditions, depression (acknowledged or not), sexual dysfunction, stress, fatigue, smoking, using drugs with side effects on the libido and a declared aversion toward sexual life.
Unfortunately, as none of the women from the study group had a sexual life at the moment they were institutionalized, we were not able to collect enough statistical data as to the etiology of sexual dysfunction.
- Morpho-functional changes of the organism in menopausal women due to the lack of estrogens are significant and self-evident in the case of institutionalized women.
- The systematic application of a hormone replacement treatment in these women may reduce the incidence of both these changes, as well as the pathology at menopause.
- Institutionalized women represent a special group with a special social status. The found pathology is one that is characteristic for the elderly with some particular features determined by the way of living in nursing homes.
- Implementing special programs in the nursing homes with socialization programs, as well as applying a hormonal substitution treatment and a gerontologic treatment can lead to delaying the aging phenomenon
- Anastasiu D. - Investigatii moderne si tratamentul pe cale vaginala a afectiunilor ginecologice. Teza doctorat UMF "Victor Babes" Timisoara 1999
- Anastasiu D. , Gluhovschi A., Anastasiu Diana Maria, Iordache Olivera - Modificarile morfofunctionale in climacterium la femeile institutionalizate. Vol. Conf. Nat. Soc. Ginec.- Endocrin. Madeira 2008 pag 13.
- Anastasiu D. Dema Alice, Dorneanu F. Gluhovschi A. Dumitrascu D. - Modificari histologice vaginale in menopauza. Vol. Conf. Nat. Soc. Ginec. Endocrin. Madeira 2008 pag 29
- Anastasiu D. , Craina M., Gluhovschi A., Dorneanu F., Anastasiu Diana Maria - Aspecte privind incidenta incontinentei urinare in menopauza Vol. Conf. Nat. Soc. Ginec.- Endocrin. Madeira 2008 pag 48
- Galaseanu Corina - Efectul terapiei de substitutie asupra disfunctiei sexuale la femeia in menopauza Vol. Conf. Nat. Soc. Ginec.- Endocrin. Madeira 2008 pag 16-19
- Mandru Ungureanu M. - Sex si sexualitate, Ed. Med. SA Bucuresti 1994
- Munteanu I. - Ginecologie , Lito UMF "Victor Babes" Timisoara 1999 pag 94-100
- Graziottin A., Koochaki P.E. - Hipoactive sexual desire in menopausal women in Europa. Women's Health and Menopause. Abstracts book 2004 pag 45
- Giblin J.L. - Sex and menopause - The sizzleand the Fizzle. Sexuality Reproduction & Menopause 2005, 3, pag 72-77
- Sarrel P.M. - Sexuality and menopause. Obstet. Gynecol. 1990, 7, pag 265-305 Sexuality
- Sarrel P.M. - Sexual dysfunction: treat or refer. Obstet. Gynecol 2005, 106, pag 834-839
- Slibel M.M. - Sex and menopause : From red hot to hot mame. Sexuality reproduction & menopause 2005, 3,pag43-44
- Lauman E.O., Paik A., Rosen R.C. - Sexual dysfunction in the United States : Prevalence and predictors. Journal American Medical Association, 1991, 281, pag 537-544
- Braila M.B., Anca Daniela Braila, Gilda Cazacu, Grigorie T., Verginia Semen Maria - Carenta estrogenica - "Varf de lance" in discordanta dintre "varsta biologic programata" si "varsta cronologic realizata" in viata femeii. Vol. Conf. Nat. Soc. Ginec.- Endocrin. Madeira 2008 pag 20-22
- Rusu Manuela - Imbatranirea urogenitala la meonpauza. O veche problema medicala reactualizata. Vol. Conf. Nat. Soc. Ginec.- Endocrin. Madeira 2008 pag 22-29
- Utian W.H. - Sematics, menopause-related terminology, and the STRAW reproductive aging staging system. Menopause, 8,(6) pag 398-401
- Burger H.G., Dudley E.C., Hopper J.L., si altii - The endocrinology of the menopause transition: a cross-sectional study of a population-based sample. J.Clin.Endocrinol.Metab., 1995, 80, pag 3537-3545.