An Overview of the Menopausal Transition

The United States population is just over 336 million, according to the U.S. Census Bureau. The population includes approximately 168 million women. Women in America manage a series of reproductive health matters throughout their lives, including menopause.

Menopause is a transitional period in a person’s life. It begins roughly one year after a woman’s final period. Many of the symptoms associated with menopause actually occur in the weeks, months, and even years leading up to the last period. This time is alternatively referred to as menopausal transition or perimenopause. Physical signs of perimenopause include hot flashes, experienced as a rush of warmth in the upper body, and various changes to a woman’s monthly cycles.

Women may experience menopausal transition and menopause at various points in their lives. Individuals may begin the transition as young as 45, while other women do not experience symptoms until closer to 60. Similarly, the transitional period can vary considerably in terms of length. Perimenopause is a multi-year process, lasting anywhere from seven to 14 years.

A few common factors may prolong a person’s transitional phase. Tobacco use, for example, is associated with extended menopausal transitions. Menopausal transition tends to last longer for women who begin their transitions later in life. Race and ethnicity may also have an impact: Healthline reports that menopausal transition symptoms are more frequent and more severe among Black and Hispanic women.

Each individual has their own unique experience with menopause. This is partly because the menopausal transition involves constant changes to the body’s estrogen and progesterone levels, sometimes resulting in unpredictable periods of normalcy and symptoms, which can range in severity.

The symptoms of menopausal transition and menopause are extensive, impacting countless body functions. During menopause, a woman’s body begins to absorb and convert energy in different ways, particularly regarding fat cells. For some women, this makes it easier to gain weight. In addition to changes in body shape and function, perimenopause is closely linked to bone and heart health.

Because of the diversity of symptoms and the wide range of time during which the menopausal transition can begin, some women may be unsure about whether they are experiencing the start of menopause. Women should discuss concerns with their physician, who can perform follicle-stimulating hormone and estradiol blood tests to determine whether the transition has started.

Physicians can provide patients with invaluable insight into their menopausal journey. For instance, some individuals may be unaware of when or how menopause begins. Without a blood test for confirmation, a woman may be under the impression that she started menopause years ago, yet in reality is still in menopausal transition. One of the primary concerns here is that women can get pregnant throughout perimenopause, including the 12 months following a woman’s last period. Failure to continue observing established family planning practices can result in late-life pregnancies, which are associated with several health risks for both mother and child.

Physicians can also guide patients through medical scenarios that can trigger menopause. These scenarios include surgical procedures such as hysterectomies or the removal of the ovaries. Individuals should continue working with health providers as they age out of menopause, as postmenopausal women are susceptible to certain health conditions, such as osteoporosis and heart disease. Basic health tips during this time include staying physically active and maintaining a healthy diet.

Common Pregnancy Complications

The fertility rate in the United States was 56.3 per 1,000 women from the ages of 15 to 44 in 2021, according to women and babies’ health organization March of Dimes. There were 3.66 million live births in the US that year. From 2019 to 2021, 52 percent of live births were White, with the majority of mothers from 20 to 39 years old. Every year, 60,000 or more women experience some kind of pregnancy or delivery complication. These complications can range considerably in terms of severity.

A pregnancy complication can be defined as any mental or physical condition that negatively impacts the health of the child or mother during or after the pregnancy. The many unique causes behind pregnancy complications can begin at any point, including before a woman becomes pregnant and after a successful delivery.

There are many ways for an expecting mother to mitigate their chances of developing a health complication linked to their pregnancy. Some complications result from unhealthy lifestyle choices such as using tobacco products, drinking excessive amounts of alcohol, and eating an unhealthy diet. A poor diet can lead to obesity, which can cause numerous pregnancy complications.

In the US, maternal obesity ranks as one of the most commonly observed pregnancy risk factors. Women living with obesity carry a higher risk of many complications impacting both mother and child, including miscarriage, preeclampsia, and venous thromboembolism. Women with obesity are also more likely to require induced labor and cesarean section procedures and to experience complications while on anesthesia. Obesity can further impact a mother’s ability to initiate and maintain breastfeeding. Regarding the child’s health, common complications range from various congenital anomalies to neonatal death.

Obesity is often associated with diabetes, another potential risk factor when it comes to pregnancy complications. Women can reduce their chances of developing type 2 diabetes by eating healthy foods and exercising regularly, but nearly 1.5 million Americans live with type 1 diabetes, the causes of which remain unclear to medical professionals. Both type 1 and type 2 diabetes result in high blood sugar levels, which increase the risk of birth defects, preterm births, and stillbirths.

In addition to eating a proper diet, individuals can decrease their risk of birth complications by following preconception healthcare standards. Preconception is a comprehensive field of healthcare that helps women prepare for a healthy pregnancy, though the tenets of preconception health can benefit all women. Aspects of preconception health range from learning about common environmental contaminants to researching relevant family health history.

Preconception healthcare transitions into prenatal care after a woman becomes pregnant. During this time, families and healthcare providers must discuss any health conditions or medications the mother is taking that may impact the child’s health. Other important elements of prenatal care include screening and diagnostic testing for both genetic and anatomic abnormalities.

Health providers continue to support mothers through postpartum care. Various health risks can arise following a normal pregnancy and delivery, such as postnatal depression. More than 10 percent of mothers experience depression within 12 months of giving birth. Any woman who has given birth within the last 12 months and believes they are experiencing physical or psychological symptoms should discuss their concerns with a healthcare provider.

Obstetric Hemorrhage Causes and Treatments

Obstetric hemorrhages are the most prevalent cause of maternal death. Losing a certain amount of blood after giving birth is expected, with 500 milliliters of blood loss typically accompanying vaginal birth and 1,000 milliliters common after c-section. Obstetric hemorrhages involve a much greater amount of lost blood, which can send the body into shock as blood pressure drops dramatically. If untreated, it may cause death. Affecting between one and five percent of women who give birth, the condition typically occurs within a day after delivery but can take place as far out as 12 weeks.

Among the causes of obstetric hemorrhages is antepartum bleeding, which involves placenta previa or placental abruption. The latter occurs when the placenta separates from the uterus’ inner wall before birth. Placental abruption not only cuts off nutrient and oxygen supply to the baby, often necessitating early delivery but results in heavy bleeding.

The placenta usually attaches to the top or side of the uterus’ inner wall. When placenta previa occurs, the placenta attaches lower down in the uterus, with a portion of the placental tissue covering the cervix. As a result, heavy bleeding may occur when giving birth or after delivery.

Obstetric hemorrhages often take the form of postpartum hemorrhage (PPH), and this commonly has to do with uterine contractions. Following birth, the uterus contracts, pushing the placenta, which supplies the baby with oxygen and food, out. The contractions place compressive pressure on the bleeding vessels, where the placenta is attached to the uterus. In cases where the contractions don’t have enough strength (uterine atony), the blood vessels bleed freely, and hemorrhage results. Alternatively, bleeding may continue if small pieces of placenta remain attached to the uterus.

Another risk factor for PPH is an overdistended uterus, an excessive uterus enlargement related to a large infant (above 8.8 pounds), or excessive amniotic fluid. Having more than one baby, such as twins or triplets, is also a risk factor. Overdistention of the uterus is an issue, and more than one placenta also increases bleeding risks. Preeclampsia or gestational hypertension, related to high blood pressure during pregnancy, can also cause excess bleeding. Infection, prolonged labor, and the use of drugs to induce labor are also PPH risk factors.

Less common conditions, such as blood clotting disorders and tears in uterine blood vessels or cervix or vaginal tissues, may also be involved. Placenta accreta, occurring once in every 2,500 births, involves the placenta being attached abnormally to the uterus inside and is most common when the placenta attaches over a past cesarean scar. With Placenta increta, placental tissues invade the uterine muscle, while placenta percreta involves placental tissues passing through the uterine muscle, potentially causing a rupture.

Treatment of postpartum hemorrhage centers on finding the source of the bleeding and treating it as fast as possible. Uterine contractions may be simulated either through medication or manual massage, and placental pieces removed from the uterus if necessary. A Foley catheter or Bakri balloon can also compress bleeding within the uterus. In cases where diagnostics such as ultrasound are insufficient, laparotomy surgery may be performed. This involves opening the abdomen and seeking the cause of bleeding.

A last resort measure involves a hysterectomy or removing the uterus surgically. In addition, IV fluids and blood and blood products may be rapidly deployed to prevent shock, with the patient receiving oxygen through a mask.

Cervical Cancer – Causes, Diagnosis, and Prevention

Cervical cancer centers on the uterus’ narrow lower end, which connects to the birth canal (vagina). Typically developing slowly, cervical cancer begins in the cells of the cervix. Cell changes are known as dysplasia, with abnormal cells gradually populating the cervical tissue. Not removing or eliminating such cells may spread into deeper portions of the cervix and surrounding tissue.

The cervix has two major parts, with the ectocervix being the outer portion viewable through a gynecologic exam. This is made up of squamous cells, or thin, flat cells. By contrast, the inner endocervix is made up of glandular cells that are column-shaped and produce mucus, and it is this part that connects the vagina with the uterus. Also known as the transformation zone, the squamocolumnar junction forms the border between the endocervix and ectocervix, and most cervical cancers start here.

Around 90 percent of cervical cancers are covered with cell carcinomas, forming within the ectocervix, with most of the remainder known as cervical adenocarcinomas and developing in the endocervix’s glandular cells. In cases of adenosquamous carcinoma (or mixed carcinoma), cervical cancer features both types of cells, and in extremely rare cases, it can develop in other cervical cells.

Preventing cervical cancer starts with administering human papillomavirus (HPV) vaccine, which addresses the HPV types responsible for vaginal, vulvar, and cervical cancers. This FDA-approved vaccine, Gardasil, is administered as early as age nine but is most common in the preteen years of 11 to 12. For those who start before age 15, a two-dose schedule is recommended at six to 12-month intervals. For those to begin after turning 15, a three-shot series is recommended.

If not vaccinated, the HPV vaccine is advisable for all women up to age 26. While some adult women, from age 27 through 45, take the vaccine, its benefits diminish, as a majority of women have already had some exposure to HPV by their late 20s.

Among the steps women can take to minimize HPV risks are delaying sexual intercourse until the late teens (or later), practicing safe sex, and limiting the number of sexual partners. Smoking cessation may also have a positive effect in preventing the disease.

There are three basic tests and procedures that screen for cervical cancer. The HPV test involves removing a sample of cells from the cervix, which are examined for the human papillomavirus linked with the cancer. Often combined with the former procedure, the Pap test involves examining the same sample for cell changes that can potentially develop into cancers.

Finally, visual inspection with acetic acid (VIA) involves applying diluted white vinegar to the cervix. Typically employed in places with limited medical options, this helps identify abnormalities as they turn white with exposure to vinegar.

Treating cervical cancer often involves removing cancerous tissue surgically, with chemotherapy and radiation used in conjunction to shrink or eliminate the tumor. A paper published in Gynecologic Oncology in 2023 points to the immunotherapy drug pembrolizumab, in conjunction with chemotherapy, as an effective way of reducing mortality risks among patients who have metastatic or recurrent cervical cancer. This approach harnesses the immune system’s natural cancer-fighting properties and thus is better tolerated, with fewer side effects, among many patients.