**2. Social, psychological and biological characteristics of women in menopause**

#### **2.1. Hormonal profile, signs and symptoms**

Menopause is the permanent cessation of menorrhagia, due to ovarian dysfunction, which marks the end of the reproductive stage in a woman's life and is characterized by low levels of estradiol and high concentrations of follicle-stimulating hormone and luteinizing hormone, although other complex changes have also been reported in systems such as immunological and nervous among others [1]. Hormonal changes begin about 3 years before menopause and continue for a similar period after menopause; in addition, there are metabolic disorders that induce characteristic signs and symptoms such as vasomotor and psychological, whose duration ranges from 3 months to 5 years after menopause [2]. Central obesity, dyslipidemia, sleep disorders, and high blood pressure, among others, are also identified [3–5].

Several symptoms have already been described widely; so here, only some will be described that require special mention given the complexity to diagnose or study them, or those of the major importance, or they have recent advances.

**1. Introduction**

58 Reflections on Bioethics

The study of menopause and the medical care of women at this stage require a multidisciplinary approach, given that the signs and symptoms observed are multiple. Therefore, obtaining reliable data depends on the researcher's training, the experience and specialty of the medical treatment, the instruments used to obtain the information, and the degree of

The objective of clinical research is to obtain knowledge to incorporate it systematically in health policies. Specifically, research on women's health began in 1990, when the Office of Research on Women's Health (ORWH) promoted policies and funded research considering the influence of sex and gender on health. After, in 1991, the Women's Health Initiative (WHI) announced, under which menopause was studied to understand the treatment of cardiovascular diseases, cancer, and osteoporosis. In addition to promoting research in women's health methodologically, technically, and more recently, ethical aspects have been analyzed, in order to protect the patient's safety, in the social, psychological, and biological spheres. With respect to medical care, the influence of the sex of treating doctor or nurse has been studied, but no differences were observed; on the contrary, there was only predisposition to give preferential treatment to a family member, when in a hypothetical situation, the life was in high risk. Despite the fact that each gender is characterized by a type of ethical reasoning, is based on caring/protection for women and justice for men. Finally, for the study and medical attention of women, various surveys have been developed, with the aim to evaluate a specific sign or symptom. This fact highlights the importance of studying and attending multidisciplinary to

The application of ethical norms for the investigation and medical attention of women requires that doctors and nurses from their professional formation have to approach to this concept. So also, the political authorities and administrators of economic funds must know

Menopause is the permanent cessation of menorrhagia, due to ovarian dysfunction, which marks the end of the reproductive stage in a woman's life and is characterized by low levels of estradiol and high concentrations of follicle-stimulating hormone and luteinizing hormone, although other complex changes have also been reported in systems such as immunological and nervous among others [1]. Hormonal changes begin about 3 years before menopause and continue for a similar period after menopause; in addition, there are metabolic disorders that induce characteristic signs and symptoms such as vasomotor and psychological, whose duration ranges from 3 months to 5 years after menopause [2]. Central obesity, dyslipidemia, sleep

**2. Social, psychological and biological characteristics of women in** 

disorders, and high blood pressure, among others, are also identified [3–5].

safety and security that the patient has both in the researcher and in the doctor.

women, given the complexity and diversity of the signs and symptoms.

the transcendence of ethics in their fields of action.

**2.1. Hormonal profile, signs and symptoms**

**menopause**

Sexual dysfunction: In general, menopause is usually perceived as a stage of decline, because signs and symptoms are accentuated with aging. One of the symptoms that usually cause embarrassment in female patient is the sexual dysfunction, which has a final result, the reduction of sexual desire [6]. The events that lead to this can be pathophysiological such as vulvar and vaginal atrophy and lubrication reduction or psychological, due to women who present low self-esteem. Sexual function in this stage is influenced by several factors, such as previous sexual activity, co-morbidities, cultural environment, mental illness, and ethnic origin; for example, the prevalence of sexual desire reduction has been described in 47, 54, 42, and 24% in English, Italian, French, and German menopausal women, respectively. It has also been pointed out that black and Latina women had greater sexual desire than white and Asian women at this stage. Although even women from the same country, but of different ethnic groups, tend to have a different prevalence of sexual dysfunction, as shown in a study carried out in ethnic groups from Iran, that study showed that the prevalence of sexual dysfunction was 75.3 in Arabs, 86.1 in Lors, and 83.2% in Persians [7]. Undoubtedly, the evaluation of the sexual function requires an ethical management by the treating medical personnel, since it must auscultate and interrogate the patient, without the woman feeling uncomfortable.

Osteoporosis: It is another important health problem in women postmenopausal, which usually occurs in the late phase but goes unnoticed because it is not painful or by patient's ignorance. This pathology results from the decrease in estrogen production, reduced calcium resorption, increased urinary excretion, reduced vitamin D synthesis, as well as less formation of its active metabolites, decrease in the number of vitamin D receptors. The analysis of the quality of life of women with osteopenia or osteoporosis is important, as it can guide pharmacological and non-pharmacological strategies [8].

Obstructive sleep apnea: It is neither a symptom usually asked by doctors nor does the patient report having more episodes in this stage. However, clinical research found a higher prevalence after menopause, and even more, it has been proposed that it predisposes to enuresis, coronary risk, and cardiovascular disease. Enuresis, occurs during the apnea as a result of a negative pressure against the glottis, which causes cardiac distension and greater release of the atrial natriuretic peptide, which finally results in an increased urinary volume and, consequently, enuresis [9]. Then, the knowledge factors to obstructive sleep apnea can also control the enuresis, improve the quality of sleep, and reduce cardiac risk, the mood, and, in general, the well-being. Common risk factors for obstructive sleep apnea and enuresis have been reported, such as obesity, snoring, restless sleep, sleep fragmentation, daytime somnolence, and hypertension; this has not been found in postmenopausal women (**Figure 1**) [10].

#### **2.2. Influential factors in the symptomatology**

As already mentioned, there are several condition factors of the presence and intensity of a certain symptom of menopause and therefore the type of treatment that they will receive to control

**Figure 1.** Interrelationship between signs and symptoms with diseases observed during menopause and its stages.

them. Several studies indicate that among these factors are the psychological, cultural, and family factors, additionally to events that usually occur around the age of menopause [11].

**2.3. Advantages of menopause**

health centers that can be accessed.

them [7].

Many clinical research and medical care to postmenopausal patients has been focuses to treat diseases, uncomfortable symptoms, or family problems; without consider the advantages that menopause has; in example, there is no possibility of becoming pregnant, so, the women can enjoy their sexuality. Also, women can do activities that satisfy

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**Figure 2.** Factors and events that influence the presentation of symptoms during menopause.

The menopause is an opportunity to empower women. To achieve the above, it is necessary that the woman is better informed of physical and psychological changes she will undergo, of family and medical needs, as well as of the strategies she can carry out for her self-care [15]. Because approximately half of the world's population is woman, and the life expectancy is greater than that of man, it can be intuited that women spend two thirds of their lives in postmenopausal, so their functional status must be preserved, since it will impact on the family, society, and itself. It is important to recognize those factors that hinder empowerment, for example, co-morbidities present before menopause, marital status, family network, and

Currently, campaigns have been implemented to prevent and treat osteoporosis: follow a healthy diet and promote moderate physical activity, stress management, interpersonal relationships, and group education, which will improve the quality of life. If menopause is accepted with the inherent changes, it will bring the woman to face this stage better; in contrast,

Personality is part of the human being and is defined as the series of features or characteristics that induce the behavior of a person, in turn, allowing us to intuit the way of acting in a given situation. The personality is defined by traits such as neurosis, extroversion, openness to new experiences, kindness, and scrupulousness. The identification of this traits could guide the pharmacological and non-pharmacological strategies to reduce the anxiety and to improve the self-esteem and, with that, the self-care of the patient [12]. Of the different personality traits, the one that has been most related to the presence of vasomotor symptoms is the neurosis, since it predisposes anxiety, stress, hostility, impulsivity, low self-esteem, and depression, which in turn conditions feelings such as sadness, anger, and guilt. Although results of clinical studies in postmenopausal women are contradictory, for example, it has been reported that neurosis and anxiety are associated with physical symptoms; in contrast, in others, no correlation has been found with the number of hot flushes [13].

Another aspect that is not usually considered in the consultation is the possibility that the woman suffers some type of mistreatment (sexual, economical, or physical) which has been proven to diminish physical capacity functioning (**Figure 2**) [14].

**Figure 2.** Factors and events that influence the presentation of symptoms during menopause.

#### **2.3. Advantages of menopause**

them. Several studies indicate that among these factors are the psychological, cultural, and fam-

**Figure 1.** Interrelationship between signs and symptoms with diseases observed during menopause and its stages.

Personality is part of the human being and is defined as the series of features or characteristics that induce the behavior of a person, in turn, allowing us to intuit the way of acting in a given situation. The personality is defined by traits such as neurosis, extroversion, openness to new experiences, kindness, and scrupulousness. The identification of this traits could guide the pharmacological and non-pharmacological strategies to reduce the anxiety and to improve the self-esteem and, with that, the self-care of the patient [12]. Of the different personality traits, the one that has been most related to the presence of vasomotor symptoms is the neurosis, since it predisposes anxiety, stress, hostility, impulsivity, low self-esteem, and depression, which in turn conditions feelings such as sadness, anger, and guilt. Although results of clinical studies in postmenopausal women are contradictory, for example, it has been reported that neurosis and anxiety are associated with physical symptoms; in contrast, in others, no

Another aspect that is not usually considered in the consultation is the possibility that the woman suffers some type of mistreatment (sexual, economical, or physical) which has been

ily factors, additionally to events that usually occur around the age of menopause [11].

correlation has been found with the number of hot flushes [13].

60 Reflections on Bioethics

proven to diminish physical capacity functioning (**Figure 2**) [14].

Many clinical research and medical care to postmenopausal patients has been focuses to treat diseases, uncomfortable symptoms, or family problems; without consider the advantages that menopause has; in example, there is no possibility of becoming pregnant, so, the women can enjoy their sexuality. Also, women can do activities that satisfy them [7].

The menopause is an opportunity to empower women. To achieve the above, it is necessary that the woman is better informed of physical and psychological changes she will undergo, of family and medical needs, as well as of the strategies she can carry out for her self-care [15]. Because approximately half of the world's population is woman, and the life expectancy is greater than that of man, it can be intuited that women spend two thirds of their lives in postmenopausal, so their functional status must be preserved, since it will impact on the family, society, and itself. It is important to recognize those factors that hinder empowerment, for example, co-morbidities present before menopause, marital status, family network, and health centers that can be accessed.

Currently, campaigns have been implemented to prevent and treat osteoporosis: follow a healthy diet and promote moderate physical activity, stress management, interpersonal relationships, and group education, which will improve the quality of life. If menopause is accepted with the inherent changes, it will bring the woman to face this stage better; in contrast, it has been reported that women who do not accept this stage have more severe symptoms. In targeted studies, women in menopause have expressed that they need to be informed of this stage through different means [16].

after a training program. A study in pediatric residents indicated that they needed ethical

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Several studies indicate that (1) medical women trained in ethics perceive more benefits than men and (2) student women focused more on psychosocial aspects and men were based on the rights of the patients. This shows that women are more based on abstract and personal principles, while men focused on responsibility, authority, and control. It is necessary to make a systematic analysis by the specialty and educational level, considering areas of special interest such as the role of bioethics and the conceptualization of justice, obtaining the informed consent of the patient or from a legal representative, facing the rejection of the signature of the said document, as well as obtaining it from people who speak different languages and care for special people or with a certain degree of vulnerability. Recognizing the training needs of the different specialties and taking into account the evolution of bioethics, better-oriented ethics

A survey at the School of Medicine of the University of New Mexico to better understand these problems was conducted. The hypotheses were that (1) medical students and residents would support the need for more curricular attention to the principles of bioethics, the issues of informed consent, and the special needs of the population; (2) women would more strongly support these curricular needs; (3) residents of psychiatry would more strongly support curricular needs than other residents; and (4) there would be a greater perceived need in these curricular domains of

Among the diseases that affect menopausal women, there are some that are deserved to be explained with ethical focus, for example, osteoporosis, periodontal disease, and vaginal

Osteoporosis is a disease that occurs in women in late postmenopausal; in fact, according to the National Osteoporosis Foundation, every second, a woman suffers a fracture due to osteoporosis, and even the risk for this disease is higher than for other gynecological cancers. Therefore, studies have been developed that measure the quality of life of these patients, who are determined by their degree of functionality. This has been confirmed in women with osteopenia and osteoporosis; since they have limited physical activity, they have altered the

There are many approaches that have been given for the prevention, treatment, and study of osteoporosis. Primary prevention means promoting habits that encourage the formation of good quality bones; also, at this stage, the primary detection is carried out, and the modifiable risk factors are identified, or they can be reduced or eliminated. Secondary prevention implies the opportune diagnosis and its pharmacological and non-pharmacological treatment, before

Vaginal symptoms: Like the vasomotor symptoms, the vaginal symptoms are frequent. The clinical evaluation of these manifestations is not easy, and validated questionnaires are required that can be understood and answered by the same patient, as well as being able to be

ethics among apprentices who were in more advanced stages of training (**Table 1**) [21].

physical position, suffering, and pain, with mental and emotional alterations [22].

a fracture occurs. Tertiary prevention is directed to limit the damage by osteoporosis.

training, especially to make the decision to give or take life support [20].

programs can be designed.

symptoms.

**3.2. Diseases and ethical considerations**
