Cognitive and biological challenges of menopausal women in India

Bishal Patangia *, Anuradha Sathiyaseelan, Soumonetra Chaudhury

Abstract During menopause, women undergo various physical and psychological changes that often create a significant challenge for most women to function in their daily activities. The present study explores the different literature findings on challenges women face during their menopausal stage, primarily cognitive and biological. The present study selected around seventy research papers under the timeline of 2000 to 2021 and collected from various medical journals such as Lancet and Menopause. Women during menopause often face cognitive challenges such as primary memory functioning, attention, and perception, which significantly lead to forgetfulness or dementia. Biologically, women in their menopause could develop hypertension, hair fall, skin loosening, coronary disease, and many more, which could cause significant damage to their daily functioning. The study further explored the condition of Indian women with their menopausal symptoms. Indian women tend to develop more challenges than many other countries due to a lack of medical facilities and poor personal relationships. Due to a lack of awareness and poor public policies, fewer provisions are in force for menopausal women. Moreover, working women tend to experience low self-esteem and poor confidence due to a lack of support and no specific policy for menopause. Necessary interventions such as yoga, psychological interventions, physical support,and awareness programs in general and at the workplace and other public spaces will help ensure a supportive environment for women during menopause.

Keywords: Menopause, cognitive challenges, biological challenges, midlife health, woman

General introduction and statistics from the Indian population

Menopause is one of the significant milestones in women’s life. During this period, women undergo various changes, from biological to psychological. To describe the rapid transition of hormones and their alteration, most healthcare professionals term it“Menopause.” The absence of the menstrual cycle for nearly a year is the completion of the menopausal phase. There are three stages of menopause women need to go through - perimenopause, menopause,and post-menopause. Perimenopause is the period between the onset of menopause and the actual period of menopause. At this stage,the flow of mature eggs starts reducing in women’s ovaries, and fertilization becomes erratic. At the same time, progesterone and oestrogen decline is the primary reason behind the symptoms of menopause [1]. Post-menopause is the final stage of the menopausal transition when the symptoms of menopause diminish or continue for decades or till death and become more adverse. At this stage,women might develop heart disease or Osteoporosis and various other physiological issues. If proper medications are not maintained,the symptoms might be too difficult to manage [2].

Recent findings show that by 2015, around 130 million Indian women had entered the menopausal phase and lived beyond it, transitioning to old age. As globalization, urbanization, and awareness spread among urban dwellers, menopause has become an emerging issue in the Indian population. Women in India remain ignorant about the morbid conditions related to menopausal symptoms due to a lack of information provided to them [3], and a 2017 study conducted on the rural population shows a similar trend which makes it essential and alarming to create more understanding in the rural population [4]. Evidence shows that the mean age range of Indian women retching the onset of menopause at 46.2 years is comparatively lesser than the Western countries, which is 51 years.There also exists a sharp difference among the urban and rural populations concerning economic, social, and marital status in which women enter their menopause [5]. Studies have shown that women above fifty-six have a 4.096 times higher risk of being diagnosed with metabolic syndrome than women under forty years of age[6]. Another study has found that 57 percent of postmenopausal women have a pleasant perception of menopause. However, 69 percent of them complained about a reduction in abilities postmenopause. Studies show that poor estrogen levels could reduce the cognitive ability of post-menopausal women [7]. Twenty percent of women have reported having reduced sexual pleasure after the onset of menopause. 11 percent of women documented having reduced perceptions of femininity, and 16 percent of women stated that there was a reduction in interest in their husbands towards them. About 54 percent of postmenopausal women and 32 percent of premenopausal women had an inactive sex life. The cause of symptomatic vulvovaginal atrophy is due to poor sex drive during the menopausal transition leading to inadequate secretion of sexual hormones, making it difficult for women to function sexually[8]. A study on Indian women reported that 42.47 percent of menopausal women across the country were clinical depression during their perimenopause and postmenopausal [9].

The present study is a review article. The study aims to identify cognitive and biological challenges women face during their menopausal stage. It also looked into the condition of Indian women during their menopausal stage and how cultural and personal factors could affect their day-to-day life. The study collected seventy research articles from renowned publishers such as Elsevier, Sage,Springer, Wiley, BMC, and others. Some standard journals used across the paper are Journal of Psychosomatic Obstetrics and Gynecology, Menopause, Lancet, Journal of the North American Menopause Society, Chinese Journal of Clinical Obstetrics and Gynecology, PMC US National Library of Medicine National Institutes of Health, American Journal of Epidemiology, JAMA Psychiatry and Alexandra Journal of Medicine. The timeline for selecting the articles was from 2000 to 2021.

Challenges of cognitive function during menopause

Menopause is a biological milestone for women when there is a change in hormonal levels that often allows the development of various other age-related changes in cognitive function. The decrease in the level of hormones like estradiol and progesterone reduces their protective properties, which results in a reduction in cognitive capabilities. Gonadal and reproductive hormones are responsible for efficient synthesis, enzymatic degradation, and availability of receptors with binding abilities. A study observed a significant connection between aging and the menopausal transition on change in cognitive function during mid-life and beyond. However, few studies on memory alterations could show the association between the transitional period to the postmenopausal state [8]. According to a study, women who have just gone through menopause obtain considerably worse cognitive tests such as driving simulation,reaction time, and a few psychomotor assessments. Reduced gonadal and other reproductive hormones, which generally guard against age-related cognitive impairments, were the cause of the substantial acceleration. However, a recent neuro-imaging study shows that during the transition to menopausal, a difference in brain structure,poor connectivity, and metabolism was identified [10]. Evidence shows that memory complaints during the perimenopausal phase can be due to the complex relationship between mood, memory,and reproductive hormones. Few studies state that some women are specifically vulnerable to developing memory problems and decreases in attentionally mediated cognitive problems [11].

However, cognitive functioning did not change gradually across transitional phases. Studies have shown that a decrease in attention and working memory, verbal learning and memory, and fine motor speed is more significant during the first year after menopause [11].The affected cognitive domains during the menopausal phase are associated with the brain regions, such as the hippocampus and the prefrontal cortex region, which are affected by the effects of estrogen levels. The hippocampus plays a vital role in verbal episodic memory, such as memory encoding and storage, and the prefrontal cortex is responsible for early memory processing, encoding, and working memory[9]. Some contradicting studies show that the impairment in cognitive functioning is not due to the changes brought during the menopausal phase but to normal aging [12].

Memory

Women face several changes in memory function during the menopausal transitional phase. The administration of several memory tests depicts changes in memory function in women across their menopausal transition. A study was conducted on women from all the different stages of menopause to check their memory function.The finding shows high scores for the Symbol Digit Modalities test on all the women. A similar trend in the scores was reported even after repeated test administration. But no improvement was observed in late perimenopausal women.

The administration of the East Boston Memory Test shows that both premenopausal and postmenopausal women show high delayed recall. There were no changes among women in their early or late perimenopausal stage. The test revealed that perimenopausal women show lower cognitive function than premenopausal women throughout their capacity to learn due to reported memory issues.Menopausal-related memory and cognitive difficulties could significantly improve when women move from premenopausal to postmenopausal [13]. Evidence shows that age during surgery and years passed since the surgery could impact short-term memory performance. Women who had undergone menopause surgery at an older age performed better. Such variation between surgical and physiological menopause in terms of short-term memory depicts that surgical menopause impacts short-term verbal memory more than natural menopause and creates more impact in the brain when done prematurely [14]. Verbal memory is one of the significant areas shown to be affected due to reproductive gaining. Another empirical finding has identified that women in their first year of the postmenopausal phase performed relatively worse on verbal learning, verbal memory, and motor functioning than in their later reproductive stages [10].

Attention and executive function

Studies have found that estrogen plays a significant role in selectively acting on aspects of memory attention and influencing other beneficial cognitive effects. However, there is little evidence of the long-term effects of reducing estrogen levels in women in their postmenopausal phase. There was also no significant variation in attention and psychomotor performances in women who have undergone surgical or natural physiological menopause; however,there was a substantial reduction in the number of recalled words in women who have experienced surgical contractions [15]. A study shows that women in their first year of the postmenopausal phase perform poorer than women in their late reproductive states on the measure of attention and working memory tasks [10]. However,some contradictory studies depict that the impairments in memory due to menopause were associated with stress and multiple burdens but not the perimenopausal transition. It is due to stress and numerous life roles that result in a lack of attention, concentration,and forgetfulness, and not merely only due to the perimenopause transitional phase [16]. Evidence has shown that the perceived complaints about memory were not related to verbal learning or memory, which relates to working memory and vigilance or complex attention. Memory complaints faced during the menopausal transitional phase depict attention-related cognitive functions.Memory issues have nothing to do with objective verbal memory ability, encoding, or storage. The decreased performance in working memory and attention tasks predicts complaints caused due to memory [17].

A study shows a severe change in attention and executive functioning during the menopausal phases. The dependency of the organizational process on the prefrontal cortex could significantly reduce executive functioning. The estrogen level majorly influences the prefrontal cortex, and the reduction in the estrogen level affects the brain's prefrontal region. Therefore, it is due to the interaction of the estrogen with the neurotransmitters present in the prefrontal cortex that depicts the effects of executive functioning such as working memory and behavioral control during the menopausal transition phase [18].

Cognitive challenges among Indian women

There are very few scientific shreds of evidence on the impact of menopausal transitional phases on women's cognition that focuses on the Indian population. A study conducted by Karishma et al. [19]suggested that the visuospatial abilities decline significantly during menopause. The impairment in visuospatial ability is due to the decline of estrogen in the female body due to menopause, which creates lesions and changes the hippocampus's anatomy, which is in charge of spatial memory. The decrease in estrogen is also responsible for changes in the hippocampal connection with other brain areas like the frontal cortex, which leads to poor performance in memory tasks among women in their menopausal phase. There have also been severe declines in memory, verbal fluency, and language during the menopausal stage. The increase in cortisol that increases the incidence of hot flashes during the menopausal phase also impairs verbal memory, with an increase in endogenous cortisol leading to a delayed performance in memory tasks. Even though it is difficult to differentiate between the effects of chronological aging and reproductive aging, the changes in the hormonal environment due to the onset of menopause cause several impairments in cognitive abilities. During this phase, the most common complaints are issues with recalling, forgetfulness during the perimenopausal phase, and the dependency on memory aids. The study also found that the menopausal transitional phase severely impacts immediate and delayed verbal memory. However, less evidence is available for the decline in attention and orientation in menopausal women [19].The experience of Indian women in their menopausal transitions is quite different from other cultures and variations within society. The difference in livelihood and daily habits makes the symptoms vary across cultures. Menopause among Indian women is often associated with depression leading to cognitive impairment [20]. A comparison study reported that Asian women living in western societies such as the UK and the USA tend to experience major hot flashes and night sweats, impacting a significant change in cognition compared to Asian women living in their own country. One of the reasons behind such differences could be due to social structures existing in different societies like collectivism in India [21] and China [22], whereas individualism in the UK and the USA [23].

Biological challenges during menopausal transition Diabetes

The menopausal transitional phase, which represents the end of the reproductive phase, also coincides with the mid-life stage of a woman, which leads to an increase in glucose levels and a higher chance of developing diabetes. Studies, however, state that reduction of estrogen and stoppage of bleeding during menopause do not have a significant relationship with the risk of diabetes. Usually, the minor changes in the body could negatively impact glucose metabolism and the increase in androgenic. The higher incidence of diabetes during the menopausal transition also leads to higher chances of developing other comorbid issues, primarily cognitive, cardiovascular, and malignancy diseases [24]. There is also an increase in the possibility of developing type 2 diabetes mellitus during this phase, which is an outcome of ovarian aging. Ovarian aging leads to a decrease in the concentration of endogenous oestrogen, along with changes in body weight, distribution of fatty tissue, energy expenditure,insulin secretion, and its sensitivity, which predisposes to a higher incidence of developing type 2 diabetes mellitus. The treatment of type 2 diabetes mellitus often incorporates hormonal replacement therapy; however, the most suitable treatment is according to the metabolic, cardiovascular, and bone condition factors and the comorbid conditions that exist in post-menopausal women[25]. Evidence has shown that the incidence of type 2 diabetes is higher in postmenopausal as compared to premenopausal women.The higher chance of developing type 2 diabetes is because of the metabolic changes that occur due to changes in hormonal composition and growth in abdominal fat composition. The presence of estrogen before menopause performs the task of masking the genetic predisposition of the developing metabolic risk factor such as insulin resistance against low-density lipoprotein related to the circumstance of type-2 Diabetes mellitus [26]. Some studies have also stated that the changes in body weight during the menopausal phases are not solely due to menopause itself but primarily due to the aging process; however, the alteration in the body composition is exclusively due to the menopausal transition. There still exists ambiguity on the incidence of diabetes due to menopause. The finding shows that postmenopausal hormonal therapy has little to no effect on glycemic control in a menopausal woman diagnosed with diabetes mellitus [27].

Hypertension

Hypertension is defined as a condition when the blood pressure is too high. Blood pressure is the force exerted by circulating blood against the walls of the body’s arteries, the major blood vessels in the body [28]. Hypertension is often misdiagnosed or underdiagnosed in women, mainly post-menopause. The control of blood pressure during the premenopausal phase is primarily due to endogenous estrogens, which maintain vasodilation in the body. After menopause, the reduction of endogenous estrogen accompanied by aging factors leads to a higher increase in the chances of the development of hypertension [29].

In the premenopausal period, the blood pressure in women is relatively lower than in men; however, after menopause, there is a higher chance of developing hypertension in women. Hypertension has been one of the primary reasons for cardiovascular disease in current times. Studies have found that cardiovascular is the leading cause of death in women than men. It is due to the inadequate control of blood pressure in women than in men, even though women conform better to therapy and undergo regular blood pressure assessments than men [30]. During the postmenopausal phase, the deficiency in estrogen that influences the increase in body mass index and endothelial dysfunction is considered the primary reason behind the higher chances of hypertension. The preponderance of postmenopausal hypertension is also due to increased obesity, lack of a healthy lifestyle, and dietary salt [29]. Adopting a healthy diet and lifestyle and endothelial active drugs function as a beneficiary treatment for hypertension during the postmenopausal phase [31].

Gastroenteritis

The timing or age of the onset of menopause is associated with the risk of gastroenteritis in menopausal women [32]. The symptoms range from discomfort in a bowel movement to abdominal pain and bloating, which often causes problems in perimenopausal women.Studies show that the reduction and withdrawal of estrogen and progesterone hormones are the distinguishing factors contributing to menopause, leading to an increase in the incidence of gastroenteritis in menopausal women [33]. Some studies have also found that women with ideal pouches with painful menses have a higher risk of developing gastroenteritis at a later age [34]. Some studies have also found that the incidence of gastroenteritis infections is prevalent in the post-menopausal phase [35].

Coronary artery disease

One of the significant causes of death in women is heart-related diseases. Coronary Artery Disease (CAD) is the most common cause of death globally, with one out of every five deaths [36]. Studies have found that out of 54 percent of total deaths and 39 percent of disability in women globally, 70 percent of the death toll is due to cardiovascular diseases. Studies state that after menopause,women often lose their female advantage or increase their chances of developing any heart disease. The incidence of coronary heart disease, hypertension, and cardiovascular diseases increases after menopause and continues to hike till the postmenopausal phase [26].The increase in lipid profiles in menopausal women is considered one of the leading factors for the development of coronary heart disease. Changes in lipid profile involve a massive increase in serum lipids and lipoproteins, which indicates the heightened risk of coronary heart disease. Due to the lack of an increase in lipids, there is a rare chance of developing coronary heart disease before menopause [37]. Some studies also found a decrease in serum estradiol and inhibin A and B after natural and surgical menopause and an increase in follicle-stimulating hormones. Leptin concentrations, serum asymmetric dimethylarginine, and total and low-density lipoprotein cholesterol were high in postmenopausal women compared to premenopausal women. In the menopausal transition phase, studies have also found a significant increase in serum homocysteine concentration. These changes in serum and hormones were the major contributors to coronary heart disease.Studies did not find any association with the prevalence of coronary heart disease caused due to surgical or natural menopause. However,the same investigation shows that surgical and natural menopause negatively affect the risk of coronary heart disease [38]. The rapid increase in the lipid after the final menstruation could increase the chances of Coronary heart disease in the menopausal woman, and a proper check of the lipid profile in a perimenopausal woman can function as a preventive tool for coronary heart disease in menopausal women [39].

Rheumatic illness

Rheumatic illnesses are musculoskeletal diseases consisting of several illnesses related to the joints of our bodies. Rheumatic illnesses are common among women as compared to men, whether autoimmune or common osteoarthritis. The age at which the woman has undergone her menopause could determine the risk and course of rheumatic illness. The prevalence of Osteoporosis, one of the rheumatic illnesses, increases during menopause. A rheumatic study shows that cyclophosphamide induces early menopause, and there is a reduction in ovarian reserve in women with rheumatic diseases.Systemic Lupus Erythematosus, an inflammatory rheumatic disease,is ten times more common in women, with its onset during their menopausal transitional age. A study shows that the course of systemic lupus erythematosus is also affected by menopause. Postmenopausal Systemic Lupus Erythematosus patients are more vulnerable to developing vertebral compression fractures than women in their premenopausal stage. Menopause also increases the vulnerability toward osteoporosis and fragility fracture. The onset of systemic lupus erythematosus in menopausal women was during their post-menopausal years. However, the onset of rheumatoid arthritis is comparatively later in menopausal women than the onset of systemic Lupus Erythematosus. The beginning of menopause before age 45 is related to mild levels of rheumatoid arthritis.

Premature onset of menopause leads to the prevalence of Rheumatoid Arthritis in the post-menopausal phase, which creates an ambiguity in understanding the relationship between menopause and Rheumatoid Arthritis. The preponderance of osteoarthritis has also increased in the postmenopausal stage. These are mainly because of the reduction of estrogen after the beginning of menopause, as joint tissues consist of estrogen receptors. Estrogen plays a chondroprotective role during glycosaminoglycan synthesis,a crucial aspect of the connective tissue. Inhibiting the production of cyclooxygenase 2-mRNA in bovine articular chondrocytes serves as a preventive function against reactive oxygen, which frequently causes induced chondrocyte injury. Studies have revealed that premenopausal women with osteoarthritis had lower levels of free estradiol and total 2-hydroxy ketone in their blood, while postmenopausal women had higher levels of 2-hydroxy estradiol.These changes in the enzymes and hormones cause a higher vulnerability of developing a rheumatoid illness. However, the role of estrogen after menopause in impacting the rheumatic illness is still unclear [40].

Skin disease and loosening

The acceleration of physiological aging characterizes menopause.There are several dermatological diseases whose risks are heightened in women as they transition towards their menopausal phase. There is an increase in gingival inflammation and periodontitis during the menopausal transition. Periodontitis is due to a reduction in the alveolar bone density, often leading to weak teeth. There has also been an increase in oral discomfort during the menopausal phase characterized by pain, burning sensation, dryness, and different sensations of taste. A cluster of cutaneous conditions was associated with menopause. For instance, vulvovaginal infections are prevalent during the menopausal phase, which causes extreme itching and pain in the vulva region. Women could experience discomfort and poor quality of life due to atrophic vulvovaginitis. The presence of atrophic vulvovaginitis is due to hypo-oestrogenism. It causes atrophy in the vagina and vulva vestibule, which can be easily irritated and leads to the vulnerability to secondary infections.Vulvovaginal candidiasis is another skin disease that causes distress in menopausal women. The oestrogen creates a favorable environment for the enriched concentration of glycogen in the vaginal epithelial cells, which provides carbohydrates necessary for candidal growth. After the onset of menopause, there results in oestrogen deficiency. There was a decrease in the incident rate of the infection. However, recent studies show that there is still a high prevalence of infection in post-menopausal women [41].

Menopause also leads to several changes at the cellular level,including a reduction in cell division, cellular atrophy, tissue repair capacity, and degenerative changes in elastic connective tissue.The loosening of facial skin could be due to a decline in collagen content, skin thickness, and elasticity. Studies have found that almost thirty percent of collagen loss the initial five years after the onset of menopause, which majorly results in the loosening of skin[42]. Hypoestrogenic conditions could affect the dermal cellular metabolism causing collagen composition, glycosaminoglycans, and water concentration. Such changes, in turn, change the functional compatibility of the skin. The reduction in collagen leads to a decrease in elasticity and skin strength. The changes in hydrophilic glycosaminoglycans also lead to decreasing water concentration,affecting the skin turgor. Skin texture and composition changes often lead to wrinkles, skin loosening, and sagginess. Several structural residents are affected by menopause. There has also been a decrease in blood flow velocity during the postmenopausal phase [43].

Hair fall

The menopausal phases are the formation of facial hirsutism and the gradual thinning of public and axillary hair. Testosterone works on the skin after its conversion to DHT by an enzyme called 5-α-reductase, which is also responsible for transforming fine vellus hairs into terminal hair. The recession of frontal and frontoparietal hairlines for 13 percent of premenopausal women and 37 percent of post-menopausal women. The thinning of hair can also be due to female androgenetic alopecia in postmenopausal women. The presence of frontal fibrosing alopecia in postmenopausal women is marked by recession in the frontotemporal and parietal hair margins related to scarring. The medication given to menopausal women also results in hair fall, especially androgen supplementation. The side effects of the supplementation could lead to cutaneous changes that often lead to hair fall. Some of its side effects are hirsutism, acne,and seborrhea [44].

Biological challenges among Indian women

Evidence states that women in their menopausal phase undergo muscle and joint aches with feelings of tiredness, lower back pain, and sleeping issues. There is also an increase in complaints in the physical domains during the menopausal phase in Indian women [45]. The finding shows an increase in metabolic syndrome in postmenopausal women in India. Metabolic syndrome is a collective risk factor that raises cardiovascular disease and diabetes vulnerability. Postmenopausal women have higher systolic blood pressure, pulse rate, and total cholesterol levels than premenopausal women. Metabolic Syndromes are prevalent in 44 percent of premenopausal and 56 percent of postmenopausal women [7].Other physical challenges included diminished visual acuity among menopausal women in India [46]. Studies have also reported an increase in cardiovascular disease in the postmenopausal phase among women belonging to the age group of forty-fifty-five years.The risk of cardiovascular disease is associated with central obesity,an abnormal lipid profile, and the postmenopausal transitional phase.There has also been a 35-40 percent increase in osteopenia, and 8-30 percent of women are diagnosed with Osteoporosis in India. Due to the reduced intake of calcium, lack of exercise, and lack of exposure to sunlight in urban women. There is also a higher incidence of stroke among menopausal women in India due to the higher rate of hypertension prevailing among the population [47]. Studies show that Indian women reach their menopause at 42 years compared to the western population at 51 years. The findings also show a different level of work intensity across the various regions within India that influence the onset of menopause and biological changes at much early age compared to most developed countries [48].

Need for interventions during menopause

With enough change or modification to the way of living, women could identify an improvement in their menopausal symptoms.Several intervention programs could help women develop a positive attitude towards the transitional period and reduce the severity of the menopausal symptoms [49]. An Indian study revealed that 87 percent of women attain their menopause naturally, and 13 percent had to take the artificial way of reaching menopause, such as the surgical method [50]. This conjecture creates a significant shift in the psychological aspect of the woman’s life. The same study shows that implementing intervention programs among menopausal women in groups such as yoga and other awareness programs could help reduce the severity of the symptoms. However, various interventions are equally relevant in providing psychological and physical support during the menopausal onset.

Under the beliefs that prevail among women, the interventions classified into two aspects are: psychological and physiological.Some significant psychological interventions are cognitive behavioral therapy, behavioral-based therapy, mindfulness-oriented therapy, and yoga. Physiological interventions are hormonal replacement therapy, estrogen replacement therapy, and psychiatric medications.

Cognitive-behavioral therapy and behavioral-based therapy

Cognitive Behavioral Therapy (CBT) is one of the practical nonmedical approaches that help in reducing the severity of menopausal symptoms. The British Menopause Society states that providing cognitive behavioral therapy to menopausal women can help reduce anxiety, depression, mood issues, hot flush, night sweats,and sleep problems [51]. Using cognitive behavioral therapy and behavioral therapy specifically targeting hot-flush were found to show a significant impact in making the depression and anxiety symptom levels from severe to mild [52]. A recent study on working menopausal women with breast cancer states that using targeted cognitive behavioral therapy could reduce the chances of being diagnosed with depression and anxiety, reduce vasomotor symptoms,and improve sleep quality and overall quality of life [53]. A further study focusing strongly on breast cancer women in their menopause revealed that cognitive-behavioral therapy help in developing a positive attitude towards their symptoms and improvises their sleep and mood issues [54]. Group Cognitive-behavioral Therapy shows a positive association among postmenopausal women in reducing insomnia. Women undergoing cognitive behavioral therapy showed an improved trend in insomnia during the entire process. CBT shows a positive outcome in cognitive functions and improves physiological symptoms women face during their menopause[52].

Mindfulness and yoga

As the entire menopausal transition is implanted with various psychological issues such as stress, anxiety, poor sleep quality,concentration, and many others, mindfulness tends to positively impact the cognitive function of menopausal women and enhance physiological conditions [55]. A mindful living could help develop a more vital self-awareness and stay constant in dealing with fluctuating moods [56]. Evidence shows that mindfulness reduces stress, vasomotor symptoms, and psychosocial conditions with enhanced healthy sexual life [57]. Practicing mindfulness acts as a self-learning strategy that help reduce stress and improves the process of self-acceptance and coping with the change during the menopausal transition. Mindfulness-based Stress reduction, also known as MBSR, uses the idea of meditation and yoga, which help the bodily change somatically. Such practice was found helpful in improvement in the quality of life of peri and postmenopausal women. It influences or helps develop positive feelings and sensations that develop a nonreactive awareness and a sense of acceptance towards the changes, both physically and psychologically[58].

Yoga as an alternative strategy could help in managing menopausal symptoms. Evidence has shown that practicing Hatha yoga could reduce the severity of the symptoms. Menopausal women practicing yoga found that their hormonal levels such as cortisol, progesterone, FSH, LH, and estradiol were reduced, which helps women enhance their menopausal transition compared to those not practicing yoga [59]. Practicing yoga could reduce the risk of insomnia and the aversive nature of vasomotor symptoms [60].

Hormonal replacement therapy

From a physiological point of view, the transition of menopause led to a fall in the estrogen level, which significantly requires medical support in regulating hormones. One of the effective interventions that help improve menopausal symptoms is hormonal replacement therapy (HRT), also known as menopause hormone therapy or estrogen replacement therapy [61]. In the perimenopausal stage,there is a high possibility that women might get migraine due to the fluctuation of estrogen hormone. Evidence shows that maintaining a proper estrogen level through replacement therapy can relieve vasomotor symptoms. However, there could be side effects of hormonal therapy. But the study suggests that using transdermal estrogen could reduce the chances of unwanted risks. An alternative approach of non-hormonal could be using escitalopram and venlafaxine, which were found effective. However, due to a lack of evidence, there are still areas that need to explore [62]. There is a high chance that menopausal women would develop sleepdisordered breathing due to lower hormonal levels. Evidence shows that hormonal therapy was associated with treating sleep-disordered breathing. However, due to poor literature connection, it can be hard to understand the relevance of using HRT to treat sleep-disordered breathing [63].

Psychiatric medication

Due to the deficiency of estrogen hormones during menopausal symptoms, women are vulnerable to psychological disorders.Evidence shows that the symptoms may be psychotic or affective;antipsychotic medications are the compelling physiological approach to address menopausal symptoms. Psychosis women with postpartum or menopausal women tend to improve their mental issues using raloxifene, a selective estrogen receptor modulator, and antipsychotics. The medication tends to improve the symptoms both psychologically and physiologically. However, there is still a lack of literature on oxytocin usage, which can be significantly valuable in treating menopausal symptoms [64]. Further, a study shows that antidepressants reduce menopausal symptoms before and after the transitional period whereas, if women had a break in the medication,there is a higher health risk that could be very aversive [65].

Other alternative therapies and interventions

Several traditional remedies across various cultures, such as Reiki in Japanese tradition, Ayurveda in India, and Moxibustion and Auricular Point Techniques, were still prevalent in Chinese Tradition. In Japanese tradition, Reiki, or energy healing, is considered an alternative medication that could emotionally help pain or any physiological issues. A Canadian study on menopausal interventions states that implementing Reiki therapy was effective and beneficial in improvising the menopausal symptoms. However,there is not much scientific evidence, so conducting studies to understand this therapy in various menopausal women could help improve the women's health condition in an alternative way [66].Ayurveda is the ancient medicinal culture in Indian society. It uses various herbal medicines that can significantly help improve menopausal symptoms without any side-effect. A study shows that adding ayurvedic medication has considerably reduced menopausal symptoms such as hot flush and night sweat compared with the placebo group. Ayurvedic medication such as Tinospora Cardifolia,Withania Somnifera, and several other herbs could help reduce the aversive effect of the symptoms within twelve weeks [67].In the Chinese tradition, various techniques help improve the health condition of menopausal women. Moxibustion, just like acupuncture, uses small herbal leaves and burns them on the skin so that the body receives the heat. While compared with non-users,moxibustion lowers both the intensity and frequency of menopausal hot flashes [68]. Auricular Point Application or ear acupuncture is another alternative therapy significantly effective when combined with other medications. A study shows that Auricular therapy used among menopausal women could help reduce the vigor of symptoms such as day-night hot flashes, especially among women who refused to continue the Hormonal treatment [69].

With the advancement of psychological research, several non-invasive alternatives are significantly effective compared to traditional interventions. Hormonal therapy is the first intervention but is very invasive. It increases the risk of venous thromboembolism and stroke, a higher chance of breast cancer,and fundamental issues such as nausea and migraines [70]. Several emerging interventions are still in process to make the menopausal transition heath-friendly and less invasive. A recent study states that acupuncture tends to have a much better and more effective approach to reducing menopausal symptoms [71]. Similarly, in the last two decades, mindfulness-oriented therapy has also emerged as a significant intervention that has helped women reduce the severity of menopausal symptoms. There is a need for awareness creation among women living in urban and rural as they are still many women not aware of interventions that could help them improve their physiological and psychological quality of living.