Biochemistry of perimenopause and menopause - in-depth study on midlife crisis among rural women in Bengal.

Menopause is defined as one year of amenorrhea after the age is 40 in the two-decade-long menopausal transition as reported by women amid subjective and objective clinical features.[ 1 ] Cessation of menstruation typically occurs by 45–55 years of age, with a mean around 51 years, and is declared as postmenopausal if without menstruation for one year and blood serum levels of follicle-stimulating hormone (FSH) 49 IU/L or more.[ 2 ] Abnormality of reproductive function after menopause in women has been earmarked and correlated with the lowering of levels of estrogen and opting to grow old graciously.[ 3 ] The SWAN study provided strong evidence on reproductive aging and the complex relationship in menopausal transition with incremental cardiovascular risks.[ 4 ] In natural menopause, even after monthly cycles stop, the ovaries maintain the production of minute quantities of estrogen and testosterone to help the continuation of sexual drives.[ 5 ] Menopause happens at earlier ages from premature ovarian failure stemming from stress, irregular eating habits, or exercise, and pathophysiology of co-morbidity and/or their management viz. fibroid, endometriosis, steroids, etc.[ 6 ] Research group reported that the spectrum of metabolic turmoil of menopausal women is also noted in the perimenopausal period[ 7 8 ] even higher in severity than post-menopausal life.[ 9 ] Global focus on research interest on non-invasive markers of menopause is rising due to evolving women empowerment issues and linked hormone replacement therapy.[ 10 11 ] Yet, there is scarce literature from South-East Asian countries on biochemical and pathological profiles of this mid-age crisis around menopause, which are vital for practitioners of primary care and family medicine of India in general and Bengal in particular. In the above scenario, this study attempted to appraise FSH, luteinizing hormone (LH), prolactin (PRL), fasting blood glucose (FBG), Two-hour postprandial glucose (2hr PPBG), glycated hemoglobin (HbA1C), and hemoglobin (Hb) levels around perimenopause and menopause.

This open label analytical cross-sectional non-interventional study on 100 consecutive participants in their perimenopausal ( n = 50) and menopausal ( n = 50) phases of life at the Departments of Biochemistry, and Obstetrics and Gynecology of the tertiary care teaching institute of West Bengal in eastern India during April to September 2024 using pre-tested data collection tool which was prepared with discussion from in-house professional experts. FSH, LH, PRL, FBG, 2hr PPBG, HbA1C, and Hb levels among 50 perimenopausal compared with 50 menopausal women participants. Consecutive perimenopausal and menopausal women attending the outpatient departments without co-morbidities and not seriously ill were recruited. Exclusion Criteria: Having co-morbidities already on interventions, licit and illicit drug users, not on menopausal hormone therapy, suspected pregnancy, and hormonal contraceptive users. FSH, LH, PRL, FBG, 2hr PPBG, HbA1C, Hb levels. Data collection was initiated after the Institute Ethics Committee approved our study. The informed consent process was contemplated with utmost authenticity. Each participant was personally counseled on study objectives and guaranteed that the information would be used exclusively for this study and would not impede management of their issue, irrespective of whether they actively participate or leave this study later on also for any other reason whatever. Written informed consent was taken from each prospective participant in vernacular language without coercion, and they were asked to complete the menopause rating scale if menstruation had stopped for more than the last 12 consecutive months. The principal investigator and the co-investigators ensured privacy during the interview and examination for the collection and documentation of data. Principles of medical ethics and the Helsinki declaration were followed during data gathering, including data sanctity with strict confidentiality. A detailed history taking was done, followed by clinical assessment including vital parameters, anthropometry, and systematic examinations for clinico-physiological changes of menopause with relevant investigations and interventions as part of the investigator’s responsibilities. Cleaning of data followed analysis using Microsoft Excel (Microsoft Corp, Redmond, USA) and Epi Info™ CDC Apache License 2.0 for mean and Student’s t -test to find the statistical correlation with alpha level of five percent accepted as significant. Perimenopause and menopause were defined as per recommendations from the global and Indian experts.[ 12 13 ] Collection of non-hemolysed blood (10 ml) samples after 8 h fasting were aseptically done from antecubital vein with universal precautions in single needle prick critically abiding “Biomedical waste management” rule. The samples were kept in aliquots at room temperature for 30 min and allowed to clot; then centrifuged at 3000 rpm for 10 min to separate serum. The serum samples were refrigerated in properly labeled aliquots to run in batches later on. Diagnosis of diabetes was based on the WHO cut-off for FPG 126 mg/dl and for 2 hr PPBG 200 mg/dl; 2 hr PPBG blood was taken 2 h after ingestion of 1.75 g/kg body weight (maximum 75 g) of glucose by mouth in 300 mL of water.[ 14 ] FPG and 2 hr PPBG were done using GOD/POD methods following Trinder[ 15 ]; HbA 1 C was done from whole blood by ion-exchange high-performance liquid chromatography by Bio-Rad D10 HbA 1 c program of National Glycohemoglobin Standardization Program.[ 16 ] FSH, LH, and PRL: By eCLIA assay method in Roche Cobas e411.[ 17 ] Hb: By a fully automated Analyzer, Horiba Pentra ES-60, with regular quality control following NABL guidelines, was utilized for estimation of parameters.[ 18 ]

In our study FSH, LH, PRL, FBG, 2hr PPBG, HbA1C and Hb levels among perimenopausal ( n = 50; age: minimum = 41.0, maximum = 49.0, mean = 43.0 ± 3.31) and menopausal ( n = 50; age: minimum = 51.0; maximum = 62; mean = 54.32 ± 2.47) women were compared. FSH: Mean FSH levels were 62.50 ± 8.28 among menopausal women and 20.50 ± 4.91 mIU/mL in the perimenopause group; this difference was highly significant LH: Mean LH levels among menopausal women were 33.84 ± 1.98 in contrast to 5.80 ± 1.82 mIU/mL in perimenopause; this difference was highly significant PRL: The Mean PRL of menopausal and perimenopausal women was 6.36 ± 1.54 and 11.17 ± 2.80 ng/mL, respectively; this difference was highly significant [ Table 1 ]. FSH: Mean FSH levels were 62.50 ± 8.28 among menopausal women and 20.50 ± 4.91 mIU/mL in the perimenopause group; this difference was highly significant LH: Mean LH levels among menopausal women were 33.84 ± 1.98 in contrast to 5.80 ± 1.82 mIU/mL in perimenopause; this difference was highly significant PRL: The Mean PRL of menopausal and perimenopausal women was 6.36 ± 1.54 and 11.17 ± 2.80 ng/mL, respectively; this difference was highly significant [ Table 1 ]. Hormonal profile, glycemic profile, and hemoglobin levels of perimenopausal and menopausal women ( n =100) *Remarks: Significance level accepted at P <0.05; highly significant differences in all parameters. FSH=Follicle-stimulating hormone, LH=Luteinizing hormone, PRL=Prolactin, FBG=Fasting blood glucose, 2 h PPBG=Two-hour postprandial blood glucose, HbA1C=Glycated hemoglobin, Hb=Hemoglobin, SD=Standard deviation FPG: Mean FPG levels were significantly higher at 104.33 ± 4.34 among menopausal women than 94.95 ± 10.83 mg/dL in the perimenopause group 2hr PPG: Mean 2hr PPG level among menopausal women was significantly higher at 138.51 ± 5.72 in contrast to 131.77 ± 8.06 mg/dL of perimenopausal women HbA1C: Mean HbA1C levels of menopausal and perimenopausal women were 7.02 ± 1.01 and 6.21 ± 0.82 percent, respectively; this difference was also highly significant [ Table 1 ]. FPG: Mean FPG levels were significantly higher at 104.33 ± 4.34 among menopausal women than 94.95 ± 10.83 mg/dL in the perimenopause group 2hr PPG: Mean 2hr PPG level among menopausal women was significantly higher at 138.51 ± 5.72 in contrast to 131.77 ± 8.06 mg/dL of perimenopausal women HbA1C: Mean HbA1C levels of menopausal and perimenopausal women were 7.02 ± 1.01 and 6.21 ± 0.82 percent, respectively; this difference was also highly significant [ Table 1 ]. Mean Hb levels of menopausal and perimenopausal women were 13.11 ± 0.97 and 8.65 ± 1.59 gm/L, respectively; this difference was also highly significant [ Table 1 ].

The investigators of this current study explored hormonal, biochemical, and pathological profiles with correlation to the clinico-physiology of perimenopausal and menopausal women from the hinterland of rural Bengal and found interdependence among these variables. The decade-long journey of normal physiological reproductive lives of womenfolk from menarche to menopause shows wide levels of inconsistency of age distribution at both ends, narrower in the beginning and wider at termination. The secular trend of mean menarcheal ages in Indian women hovers around a narrow range, 12.5–15.2 chronological age.[ 19 ] Usually, cessation of menstruation occurs between 45 and 55 years of age, with a mean of 51 years.[ 2 ] The concept of perimenopause is relatively new, derived from the classical definition of menopause as one year of amenorrhea after age 40.[ 1 ] WHO identified perimenopausal phase from period before to first year of post-menopause; irregular and sparse periods at this phase makes it difficult to find a firm end date; majority have mild negative symptoms, 1:5 moderate to severe; indirectly linked to higher cardiovascular risk due to narrow vessels from atherosclerosis stemming from gradual decline of the levels of estrogen during this phase of life.[ 20 ] Our study noted that the menopausal women mean FSH, LH, FBG, 2hr PPBG, HbA1C, and Hb, and higher PRL as lower than in the perimenopausal group. Stem cell study reports pointed to the important fact that there is up-regulation in cells and tissues of reproductive, central nervous, and hematopoietic systems by the sex hormones in the dimorphic mammals.[ 21 ] Researchers noted that during the transition from perimenopause to menopause, pituitary secretion of LH and FSH consistently increases to stimulate aging ovaries to produce more estrogen analogues. Researchers in this field felt that the menopausal symptoms are alleviated and prevented as a compensatory mechanism that results from the free fall of estrogen levels from the dwindling of ovarian functions.[ 22 ] In our study mean FSH levels were significantly higher after menopause. The textbook mentions comparable FSH levels in menopausal women of more than 40 mIU/mL.[ 1 ] During the transition from perimenopause to menopause ovaries reduce the production of estrogen. Estrogen deficiency at perimenopause carries over to menopause, leading to an array of psycho-somatic changes and impairments of cognition at menopause. Further, with the lowering of the levels of circulating 17β-estradiol, FSH rises to compensate.[ 23 ] Mean LH levels among menopausal women were also significantly higher at 33.84 ± 1.98 mIU/mL in our study. Standard classroom teachings, however, documented still higher LH levels of menopausal women between 50 and 100 mIU/mL.[ 1 ] The mean PRL level of menopausal women was significantly lower at 6.36 ± 1.54 ng/mL compared to perimenopausal participants in our study. Literature supports the PRL level in postmenopausal women at 3–15 ng/mL.[ 24 ] There is a physiologic decline of PRL levels during menopause. Hyperprolactinemia, reported after menopause, is commonly associated with macroadenomas; may remain unrecognized and delayed for a long period; requires greater clinical effort in diagnosis due to atypical clinical features.[ 25 26 ] In our study mean FPG levels were significantly higher among the menopausal women group. Literature supports that premenopausal women exhibit high insulin sensitivity to minimize type 2 diabetes; this effect disappears after menopause, with upset of glucose homeostasis.[ 27 ] The mean 2hr PPG level among menopausal women was significantly higher among our study participants. In a study on American Indian women, menopausal estrogen therapy had positive effects on FBG but not on glucose tolerance; however, evidence showed that longer estrogen therapies may increase the risk of diabetes.[ 28 ] The mean HbA1C of menopausal women was significantly higher in our study than perimenopausal group. Saudi research group working on menopause concluded that HbA1C levels should be taken at lower values before menopause during the process of screening, diagnosis, and intervention of adult diabetic women.[ 29 ] Perimenopausal women are relatively iron deficient due to regular menstrual blood loss. As HbA1C is affected by the lifespan of red blood cells (RBC) and its indices, its level may vary in anemic women independently of plasma glucose variations. This should be considered while interpreting HbA1C in pre-menopausal women with a history of co-morbidity of diabetes.[ 30 ] The mean Hb level of menopausal women was significantly higher in our study. Literature reported higher values of Hb, RBC count, hematocrit, and mean corpuscular volume in menopausal women; notably gradual increase from 40 years (perimenopausal) to 65 years in Hb levels.[ 31 ] While menarche ushers in passionate rights and responsibilities of motherhood, menopause represents the permanent loss of fertility, occurring spontaneously (natural menopause) or surgically from a spectrum of pathophysiologies. The clinical features of menopause, from decreased ovarian secretion of estrogen, vary qualitatively depending on threshold levels of individual tolerance; most commonly reported are hot flush, night sweat, dryness of vagina, itching, thinning and decreased elasticity of skin, depression, and impaired concentration.[ 32 33 ] An Indian study highlighted that longer expectations of life expectancy and earlier ages of menopause demand more research on menopausal quality of life for rural womenfolk and dedicated national health programs to deliver primary health care services.[ 34 ] Another Indian study stressed that the primary care physicians should have good knowledge of community needs for the critical role to manage psychosomatic issues in and around menopause.[ 35 ] To sum up, menopause is self-diagnosed and self-reported most of the time as a natural process without major psycho-somatic issues, as the majority accepts this mid-life issue graciously. Its patho-physiology usually begins around the age of 40 with ushering in the phase of perimenopause ending around age of 60, with a median age of 51, with a healthy lifestyle without major intervention. This novel study on the hormonal profile, glycemic profile, and Hb levels in menopause was compared with a perimenopausal group of participants in this study conducted in a peripheral government medical college within the hinterland of the western part of rural West Bengal in eastern India. An attempt was made to discuss an array of data in and around menopause, depending on the age and presence of co-morbidities that increase morbidity, disability, and mortality risks. We had limitations in our study. Firstly, as a cross-sectional study, we were unable to find the grassroots risk factors and risk correlates of their reported issues of menopause. Secondly, this was a single-centre study in a peripheral medical college with the hinterland of a mainly rural population. Lastly, as a self-funded intramural project, the sample size was small with limited external validity and could not be extended to all the variables related to menopausal transition. We are yet to find plenty of publications on basic and translational researches from Indian on the Biochemical profiles of perimenopause menopause. In futuristic vision we will focus on other clinic-physiological parameter of menopause. We will follow comparable global literatures to find feasibilities and applicability in our set up of research following Good Clinical Practice.

In our study, there was an attempt by the investigators to develop a mitigation plan for women from this region of rural Bengal. The baseline mean FSH, LH, PRL, FBG, 2hr PPBG, HbA1C, Hb levels were explored in perimenopausal and menopausal women. In the menopausal group, mean FSH, LH, FBG, 2hr PPBG, HbA1C, and Hb levels were higher than perimenopausal women participants. However, the mean PRL level in the menopausal women was lower compared to women in the perimenopausal group. All this information will unquestionably help primary care and family medicine practitioners of low- and middle-income countries (LMICs) like India while managing menopausal crisis, especially among disadvantaged and rural women. The finding of our study suggests a dire necessity to establish an Indian standard of perimenopausal and menopausal biomarkers as a nationally representative data source to champion women’s empowerment. Further initiate standard office procedure by updating the clinical practice guideline to assess subtle changes of paramount importance in women from 40 to 60 years of age. Screening of functional status and metabolic transition in basic biochemical and pathological profiles periodically in perimenopausal phases passing through their post-menopausal lives can limit morbidity, disability, and mortality risks. We need to find suitable point-of-care, user-friendly, and cost-effective biomarkers for the prognosis of perimenopausal transition that contribute to alleviating health risks of menopause, especially in the practices of primary care and family medicine among the rural marginalized populations of the LMICs. Menopause is the predictable end of the reproductive phase of life in every woman. There is a spectrum of unpleasant clinical features depending on threshold values of perception to acceptance of this closing stage at midlife during perimenopausal transition. All levels of stakeholders need to understand the primary care needs of half of the world’s population. Family health practitioners should initiate the development of a systems approach to generate standard office procedures regarding clinical case management of this transition to improve the quality of life. There are no conflicts of interest.