Premenopause: main aspects of aesthetic gynecology

Vladlena Averina, doctor of the highest category, member of EADV, dermatovenerologist, KB "Feofaniya", scientific coordinator of the "Academy of Scientific Beauty" (Ukraine)

During this period, it is important for a woman to realize that “autumn time” is not dangerous, but interesting in its own way. You just need to learn to understand and accept yourself as an adult. According to WHO, in 2015, 46% of all women on the planet reached the age of 40 or more. Accordingly, the relevance of this problem is only gaining momentum.

According to Lydia Dmitrichenko, Ph.D., head of the Kyiv specialized clinical department of gynecology of transitional age, the exact time period for the development of menopause is very difficult to determine: from the moment of its very first signs until its end, an average of 12 years can pass. Much here depends on the conditions and lifestyle, diet, temperament of a woman, her psycho-emotional experiences, and heredity.

Female sex hormones

To make it clear what hormonal changes occur during menopause, we need to talk about the woman’s reproductive system.

A woman’s ovaries produce sex hormones estrogens (estradiol, estrone, estriol) and progesterone, as well as a small amount of male sex hormones, which are necessary not only for the functioning of the female genital organs, but also for maintaining general health. The bulk of androgens are produced by the adrenal glands. Sex hormones, especially estrogens, affect all structures of the body. In addition to the reproductive organs, the targets for female sex hormones are the bladder and urethra, liver, musculoskeletal system, blood vessels, heart muscle, skin, intestines, and brain.

Estradiol

At a young age, there is a certain cyclicity in the production of sex hormones associated with individual phases of the menstrual cycle. In the first phase of the menstrual cycle, estradiol is produced in the ovaries - the most biologically active hormone; it has a protective effect on almost all organs and systems of the female body. This is a hormone due to which a woman has a female figure and a female character, a female voice.

Progesterone

The hormone of the second phase of the menstrual cycle, or pregnancy hormone. The effect of progesterone on the skin: promotes fluid retention in the body, increases the permeability of blood vessels, thereby helping to release the liquid part of the blood into the tissues, as a result of which the hands and feet swell. By the beginning of the critical days, 1⎼1.5 kg of weight accumulates, the face becomes puffy, and bags appear under the eyes. In addition, progesterone worsens the condition of the skin, making it overly stretchy and producing more oil to moisturize and protect it. Also, the chances of inflammatory elements appearing on the skin are much higher in the second phase of the cycle than in the first.

Androgens

Male hormones - androgens ⎼ play a significant role in a woman’s body. Under their influence, a woman becomes more active and self-confident, her sexual desire and performance increase. Androgens act on the skin through special receptors that are located in the epidermis, dermis and hair follicles. They regulate the intensity of cell division, the processes of differentiation, secretion and keratinization.

During perimenopause, the cyclic production of hormones by the ovaries is disrupted, and then their secretion practically stops. The secretion of estradiol decreases especially quickly and significantly within a few months after menopause.

What happens to a woman during menopause?

The climacteric period (or perimenopause) is characterized by such concepts as premenopause, menopause and postmenopause.

Premenopause

The initial period of decreased ovarian function. Their cyclic production of estrogen is disrupted, and the menstrual cycle is disrupted. The secretion of estradiol decreases especially quickly and significantly. The time intervals between menstruation can become shorter (less than 21 days) or longer (more than 35 days) as the number of days of menstruation itself decreases, and the amount of bleeding also changes. This period lasts on average five years - from the onset of irregular menstruation to the last menstrual period. A further decrease in the level of sex hormones leads to an absolute absence of menstruation.

Menopause

This is the last independent menstruation in a woman’s life. This can only be established after a year, since the last menstruation is considered to be menstrual bleeding, after which the next one does not occur for a year.

Postmenopause

A year after the final menstruation, a woman begins postmenopause: the ovaries completely atrophy against the background of general age-related changes in the body. There is not enough estrogen produced, which has a direct impact on the activity of all organs and systems. For some women, the natural course of the menopause is complicated; they should be under the supervision of a gynecologist-endocrinologist.

Postmenopause lasts on average from 5 to 8 years. During this period, estrone becomes the most important hormone, the level of which does not decrease so sharply. Estrone is a weak, biologically inactive hormone that has virtually no protective effect on target organs. Estrone is no longer formed in the ovaries, but in adipose tissue from the precursors of male sex hormones. Therefore, overweight women have higher levels of androgens and estrone than women with normal body weight. This circumstance in a certain way adversely affects metabolic processes in the body.

Involutive changes in the dermis are expressed in its atrophy, a reduction in the number of mast cells, fibroblasts, collagen, glycosaminoglycans, and a reduction in the number of blood vessels. Estrogens activate the secretion of mucopolysaccharides and hyaluronic acid, flooding the dermis and mucous membranes, promoting their thickening. Estrogens also stimulate collagen synthesis, maintaining skin thickness, promoting vasodilation and enhancing skin vascularization.

Age-related changes in the skin are manifested by an increase in extensibility, viscosity, and loss of elasticity. The skin loses approximately 30% of its collagen in the first five years after menopause. A decrease in skin tone leads to deepening of wrinkles and folds, and the appearance of a network of fine wrinkles. Skin color deteriorates, telangiectasias and uneven pigmentation appear. Violation of the epidermal barrier leads to dry skin.

Menopause: periods

Symptoms that may occur during perimenopause are primarily divided into two groups: autonomic and psychoemotional. Early vegetative and psycho-emotional disorders are called climacteric syndrome (CS) . The first signs of CS:

• hot flashes to the face, upper half of the body;
• sweating;
• increased heart rate;
• dizziness;
• emotional instability;
• fatigue;
• irritability;
• tearfulness;
• sleep disturbance;
• dryness of the vaginal mucosa and skin;
• urinary incontinence;
• change in sexual desire.

Deficiency of sex hormones during the transition period adversely affects the function of the central nervous system. The menopausal period is accompanied by such conditions as nervousness, nervousness, impaired concentration, irritability, difficulty falling asleep, frequent awakenings, depressed mood, a pessimistic assessment of oneself and one’s position in the surrounding reality, inhibition of intellectual and physical activity, decreased motivation, as well as somatic “ masks of anxiety and depression. Late diseases of menopause, developing 5–8 years after menopause, include:

• cardiovascular diseases;
• type 2 diabetes mellitus;
• obesity;
• diseases of the musculoskeletal system;
• Alzheimer's disease.

Rapid weight gain

After menopause it occurs in approximately 60% of women. According to a major international study, Women's Health, in the first three years after menopause, body weight increases on average by 2.5 kg, and after 8 years - by 5.5 kg. During this period, there is a redistribution of adipose tissue in the area of the anterior abdominal wall and a decrease in muscle mass.

Osteoporosis

The concentration of calcium in the blood decreases precisely because of the lack of estrogen, so the body begins to take the necessary mineral from the bones. This process cannot be compensated for by a balanced diet alone, since the body secretes more calcium than it absorbs. Bone density decreases, causing bones to become brittle and more porous. Women with pathological menopause often begin to experience pain in the spine, large and small joints.

Disorders of the genitourinary system

The onset of postmenopause is a difficult ordeal for most women. Among the most common problems bothering postmenopausal women are disorders of the genitourinary system.

Decreased estrogen secretion

Estradiol plays an important role in the processes necessary for the normal functioning of the organs of the urogenital system:

1. Regulates the restoration of the vaginal epithelium, promotes hydration of the mucous membranes.
2. Maintains a sufficient level of lactobacilli as the main representatives of the normal flora of the vagina, increasing local immunity.
3. Improves blood supply to the walls of the vagina, bladder and urethra, thereby increasing their muscle tone, which prevents the prolapse of the vaginal walls and urine retention.

Vaginal prolapse, or vaginal prolapse, is an abnormal condition in the female reproductive system that mainly occurs in women who have given birth due to weakening of the muscles and ligaments of the pelvic floor. Prolapse of the vaginal walls, if diagnosed early, can be eliminated conservatively; in more advanced and complicated cases, surgical intervention is performed.

The term “ vaginal health” and its definition were proposed by Nathan L. Guerette (President of the Female and Pelvic Medicine Institute of Virginia). This is the absence of sexual dysfunction, mild to moderate urinary incontinence (coughing, sneezing, slight leakage during the day, inability to perform some exercises).

Reasons for decreased vaginal health:

• birth of children (independently through the birth canal);
• cumulative effect of menopause and aging.

According to the International Society for Sexual Medicine, urogenital symptoms of menopause (GSM) are:

• vaginal dryness, burning sensation and irritation of the genital area;
• poor vaginal lubrication, discomfort or pain during sex, decreased sexual function;
• urinary urgency, recurrent UGT infections.

Based on the results of surveys of women, Marco A. Pelosi (Founder of ISCGyn) defined the needs of sexual life at different ages as better sex. At 30⎼40 years old, this is a denser (narrow) vagina, especially after childbirth; the need for correction of visible unaesthetic areas (labia majora). Aesthetics plays an important role here. The needs of better sex over the age of 50 are increased lubrication during sex, absence of pain from stretching the vagina during intercourse, and reduction of the labia minora. In this case, functionality takes precedence over aesthetics.

As a result of these processes, an integrated approach to rejuvenation, slowing down aging through maximum restoration of functions, equalizing the balance, and effectively influencing tissue trophism is required.

Treatment of manifestations of menopausal syndrome

Hormone replacement therapy

The mechanism of action is to replenish the lack of sex hormones in a woman’s body according to the principle of replacement. All drugs contain substances that are analogues of natural female sex hormones, therefore they are easily absorbed by the body and effectively eliminate the symptoms of menopausal syndrome.

Drugs are mainly divided into two large groups:

• containing only estrogens (they are mainly recommended for women after surgery to remove the uterus);
• combination drugs that include two hormones - estrogen and progesterone (progesterone in combination drugs is prescribed to protect the endometrium).

They are produced not only in the form of oral medications, but also in the form of creams, suppositories, and transdermal patches. The main thing in treatment with such hormonal drugs is systematic observation by a doctor every six months and periodic examinations.

According to the results of scientific studies, publications and reports of the Japan Placenta Association, placenta extract has:

• antioxidant effect;
• anti-inflammatory effect;
• restoration of tissue regeneration processes;
• increased activity of cellular and tissue respiration;
• restoration of metabolic processes in cells;
• neurotrophic effect;
• increasing adaptation mechanisms.

In my practice, I use the drug Melsmon; it has direct indications for use in the perimenopausal period to solve the problems described above. As a result of the therapy, the drug prevents metabolic changes that prepare the ground for the development of late complications, and effectively relieves early and mid-term menopausal symptoms (emotional-mental, vasomotor and urogenital). The drug is administered subcutaneously: 1⎼2 ampoules 2 times a week (5 procedures), maintenance course – 1⎼2 ampoules 1 time a week (at least 1 month).

PRP acupuncture

This is a method of introducing platelet-rich plasma into tissues at biologically active points. Stimulation of these points corrects imbalances in the functioning of certain organs, regulates the functioning of the immune system and improves the flow of energy on a general level. Local effects of PRP acupuncture - tonic, improves microcirculation, regenerating, analgesic (in the case of body work). This material was discussed in detail in “Les Nouvelles Esthetiques Ukraine”, No. 4 (98), 2016.

This technique allows treatment to be carried out simultaneously at two levels: local (local treatment, correction of visible changes) and systemic (treatment of the body as a whole, strengthening the immune system and increasing adaptive mechanisms).

Impact stages:

• immediate stimulation of biologically active points using a needle;
• prolongation of action due to growth factors;
• general restorative, immunostimulating effect, tonic effect.

Course: 3⎼5⎼7 procedures 1 time in 3⎼4 weeks, 1⎼2 times a year.

Complex therapy options:

• 1st option: 2 ml of placental preparation subcutaneously into reflex points of the lumbosacral zone, after 40 minutes ⎼ PRP locally;
• 2nd option: 1 ml of placental preparation + 4 ml of PRP locally, 1 ml of placental preparation subcutaneously to the point under the navel.

Injection local correction

General principles of correction:

• increased tone and elasticity;
• improvement of microcirculation;
• eliminating dryness;
• replenishment of soft tissue volume;
• alignment of relief and color;
• restoration of libido;
• elimination of pain during sexual intercourse.

Indications:

• vaginal dryness, burning sensation and irritation of the genital area (PRP, injection boosters, carboxytherapy, Gynodek
• stress urinary incontinence (BoNT-A, PRP, fillers);
• decreased tone of the vaginal walls (Kegel exercises, lasers, threads, PRP);
• laxity and sagging of the labia (threads, fillers, autofat, PRP, surgery, carboxytherapy, boosters);
• decreased sensitivity during sexual intercourse (strengthening the G-spot, PRP, placental preparations).

Here it is necessary to understand that we are talking about restoring not function, but sensation. Therefore, one method may not be enough, and it is impossible to predict the duration of the effect. Next time, a different approach will often be needed.

For anti-age mesotherapy , active regenerating and stimulating cocktails and boosters are used to improve the quality of the skin. The synthetic and proliferative work of fibroblasts is stimulated, the number of collagen and elastin fibers and matrix increases, and microcirculation improves. The drugs are administered papularly. Course: 4⎼6 procedures, 1 time per week, or according to the scheme.

The main indication for botulinum toxin administration is stress urinary incontinence.

PRP can be administered locally (deeply, along the entire length of the needle, into the labia majora, papularly into the vaginal mucosa). I recommend using a ready-made combination of PRP + HA. Treatment can be supplemented with paravertebral injection of pure PRP. Protocol: in 1 procedure, 4⎼8 ml of PRP is injected locally and throughout the body with a 30 G ⎼ 13 mm needle. The course consists of 2⎼4 procedures (depending on indications and initial condition), carried out once every 3⎼4 weeks.

For the correction of the labia majora, preference is given to natural biodegradable fillers based on hyaluronic acid with high viscoelastic properties. The volume is filled with a 22 G ⎼ 70 mm cannula (1⎼2 ml of the drug on each side). It is preferable to work with a cannula, since it is a less traumatic and more “large-scale” method. It is also necessary to examine the posterior wall of the vaginal opening for an episiotomy scar. The correction is carried out by introducing filler into the scar with a bolus of 0.3⎼0.5 ml of NA, creating a soft frame.

The existence of the G-spot is controversial. From the point of view of evidence-based medicine, neither a cluster of nerve endings nor any specific cells were found in the intended location (anterior vaginal wall ⎼ 2⎼5 cm deep along the midline). But, according to the results of introducing fillers from 0.5 to 1 ml as a bolus into this area, most women note increased arousal and sensitivity during sexual intercourse. Again, this is not about function, but about sensation. Therefore everything is relative.

Express correction (in one procedure):

1. I use Teosyal Deep Line, 22 G ⎼ 70 mm cannula (filling the labia majora).
2. Threads 29 G ⎼ 40 mm.
3. PRP (at the places where the threads are inserted, into the vaginal mucosa).
4. Vaginal gel based on hyaluronic acid and decamethoxin to complete the procedure.

The selection of regimens and doses for each patient must be individual. Dosage, frequency of administration and course duration depend on the severity of the changes, age and physical condition of the patient.

First published in Les Nouvelles Esthetiques 2017/№6