Warning note to women

Common complaints which a gynaecologist encounters in daily practice include menstrual problems, vaginal discharge, infertility, premenstrual tension and lower abdominal and lower back ache. Sometimes, gynaecologists also come across very specific complaints like precocious puberty, failure of onset of menstruation and premature menopause. However, a symptom, which is rarely mentioned in textbooks and which may confuse the gynaecologist, is continued menstruation, or in other words failure to attain menopause even at the age of about 51.

Puberty and menopause are important milestones in a woman’s life and should happen at specific time periods. And if they happen too early or late, it not only causes a lot of mental distress, but is also harmful to the reproductive and physical health of the woman.

Premature menopause is more the commonly encountered problem and it has an adverse impact on the woman's heart and bones. Late menopause is, comparatively, a rarely encountered problem, and longer functioning of the ovaries may actually benefit the woman's heart and bones.
Western literature states that the mean age for menopause to occur is 50-51 years. Menopause occurring before 35 years is premature and occurring after 56 years is late menopause.

However, Indian women attain menopause in the mid-forties, probably due to poorer build and nutrition. Genetic factors may also play a role. Women with chronic ailments or a history of receiving chemotherapy and radiotherapy also attain menopause earlier than usual.

Women who have undergone hysterectomy and/or removal of both ovaries attain surgical menopause.  Menstrual pattern changes in most women as they approach menopause. Cycles become more frequent or infrequent, bleeding becomes scanty or excessive. Gynaecological cancer should always be ruled out in any middle aged woman with irregular bleeding. Vaginal bleeding after menopause, and after coitus, no matter however small in amount, are very ominous symptoms, and one shouldn't delay medical intervention to rule out the possibility of cancer.
The trouble therefore is when a woman reports continued menses beyond the age of 51 years, having a menstrual pattern not different from the one she has been having for the preceding few years.

Understanding the risks
Menstrual cycles in older women tend to be anovulatory, which means there is no release of 'egg' (therefore, older women also face the problem of infertility). Such cycles increase the risk of endometrial cancer (cancer of the lining of the uterus, which is the commonest gynaecological cancer in the west and the second commonest gynaecological cancer in India after cervical cancer). Obviously, if menses continues well beyond the age of 51, the woman has a higher risk of endometrial cancer, due to longer exposure to anovulatory cycles. The risk is increased if the woman is a diabetic and obese. Late menopause also poses a slightly increased risk for breast cancer. Therefore, all women with continuing menses beyond 51 years should be made aware of the potential risks.

Necessary tests
A pap test (a compulsory investigation which should be done in all women at regular intervals after marriage/sexual debut) and a gynaecological examination should be done. Self examination of the breast at regular intervals should be practiced by all women. Colposcopy (examination using a low power microscope to look for any abnormal area before it becomes visible to the naked eye) should be done when a pap test is found abnormal. Pap test and colposcopy are simple tests consuming only a few minutes, not costing more than a few hundred rupees in most centres in India.
A pelvic ultrasound scan and examination under anaesthesia with curettage may be advised by the doctor if any pelvic/ovarian mass or an increased endometrial thickness is found on ultrasound scan. Though majority of the women will probably have no abnormality, an opportunity must not be lost to detect possibility of early cancer and to impart awareness.