Download MENOPAUSE Dr. Ahmed jasim نسائيه Objectives Definition

 MENOPAUSE
Dr. Ahmed jasim
‫نسائيه‬
 Objectives
 Definition
 Etiology/Endocrinology
 Epidemiology
 Clinical Manifestations
 Diagnosis
 Therapies
 Prolog Questions
 Def.
• permanent cessation of normal menstruation in women .
• The diagnosis can only be made retrospectively after a
of 1 year’s amenorrhoea.
• The climacteric and perimenopausal are the periods of waning
ovarian function.
• the mean age of menopause is 51 with a normal range from
45-56.
 Stages of Reproductive Aging Workshop (STRAW) Staging
System 2001
1) Menopausal transition: a) Variation in menstrual cycle ( > 7 d
different from normal) and ≥2 skipped cycles and >=60 d
amenorrhea; b)
FSH
2) Perimenopause: Starts at the time of the menopausal
transition ( see above) and ends 12 months after last menstrual
period
3) Menopause: 12 months of amenorrhea after final menses
4) Postmenopause: Stage 1 is the first 5 years after menopause –
women have bone loss and hot flashes. Stage 2 is 5 yrs after
the last menstrual period until death.
 Perimenopause(climacteric)
 Perimenopause is a transition rather than an event
 It is the period of time surrounding menopause when ovarian
function is declining, but has not stopped
 Onset of perimenopause is usually 3-5 years before the periods
stop
 Perimenopause and menopause may last 2-10 years
 Type of menopause
 1. Physiologic Menopause.
 2. premature Menopause.
 3. Artificial (therapeutic) Menopause
 Type of menopause
 1. Physiologic Menopause.
 Spontaneous progressive decline of ovaries function at age of
40-50, resulting in infrequent ovulation and menses and cease
completely by the age of 45 – 56.
 Type of menopause
 2. premature Menopause.
 Spontaneous permanent cessation of menses before the age of
40. It occurs in about 5% of menstruating women. premature
ovarian failure can be caused by:

1. genetic and cytogeneic abnormalities.

2. enzymatic defects.

3. physical insults.

4. autoimmune disturbances.

5. abnormal gonadotrophin structure or function.

6. idiopathic.
 Type of menopause
 3. Artificial (therapeutic) Menopause
 1. removal of both ovaries (castration) by surgical operation .
 2. Irradiation therapy or chemotherapy.
 3. pseudomenopause which is occurred during the use of
gonadotrophin- releasing hormone agonists in the treatment of
endometriosis or fibroid.

 pathophysiology
 (1) Menstrual Cycle Alterations
 Around 40 years, the number of ovarian follicles becomes
substantially depleted and subtle changes occur in the
frequency and length of menstrual cycles.
 The first endocrine change is a fall in inhibin production by the
ovary (inhibin inhibit production of FSH) so the plasma FSH
concentration begins to rise above the premenopausal limit
then associated with rise in LH values above premenopausal
limit. the high FSH greater than 30 iu/L is diagnostic of
menopause.
 a significant amount of postmenopausal androgen production is
stimulated by FSH and LH from ovarian stroma.
androstenedione converted to oestrone (weaker oestrogen than
oestradiol) in adipose tissue. menstruation stops due to a lack
of cyclical oestrogen and progesterone (the endometrium does
not proliferate to be ready for shedding).
 it is the lack of oestrogen that causes the majority of symptoms
and pathology of the menopause.
 the cessation of cyclic bleeding takes many forms. the
menstrual cycle may stop abruptly or may cease after a
prolonged stage of oligomenorrhoea.
 factors affect the age at which the menopause occurs including;
 smoking (may occur up to 2 years earlier).
 low socioeconomic status.
 age at menarche.
 parity.
 ethnicity.
 previous oral contraceptive use.
 family history.
 Clinical Manifestations
 Irregular bleeding patterns- if heavy bleeding should perform
endometrial surveillance given period of unopposed estrogen
exposure
 Hot flashes- Etiology unknown. Thermoregulatory dysfunction.
Self limited to 1-5 yrs. Variable among cultures – 75% US women
complain of hot flashes, 20% seek therapy.
 Sleep disturbance – Hot flashes can arouse from sleep and
primary sleep disorders more common
 Clinical Manifestations-2
 Vaginal dryness – Estrogen deficiency leads to thinning of
epithelium - > vaginal atrophy ( loss of rugae, pale, pH inc to >
6.0)
 Sexual dysfunction – decrease in blood flow to vagina/vulva ->
decreased lubrication; dyspareunia
 Urinary sx – low estrogen results in atrophy of urethral epithelium
and predispose to stress/urge urinary incontinence
 Clinical Manifestations -3
 Depression – Overall studies support an association between
menopause and mood changes such as irritability/nervousness;
controversial if related to true depression
 Bone loss – secondary to estrogen def
 Breast pain – Common in early menopausal transition
 Skin changes – estrogen def -> reduced collagen content of the
skin/bones
 CONSEQUENCES OF MENOPAUSE
 IMMEDIATE
 INTERMEDIATE
 LONG TERM
 IMMEDIATE
 HOT FLUSHES---
Thought to arise due to loss of oestrogenic induced opioid
activity in the hypothalamus.
NA and serotonin mediate this activity.
Obese women are protected due to large amounts of
oestrone and low SHBG.
 INSOMNIA, ANXIETY, IRRITABILITY
 POOR CONCENTRATION
 MOOD DISTURBANCES
 REDUCTION IN SEXUALITY AND LIBIDO
 MEMORY LOSS
 INTERMEDIATE CONSEQUENCES
Oestrogen deficiency leads to rapid loss of collagen
dyspareunia and vaginal bleeding
urethral syndrome(dysuria, urgency and frequency)
increased bruising
generalized aches and pains
 Long term health problems
 Osteoporosis, cardiovascular disease and dementia are three
long-term health problems which have been linked to the
menopause.
 Osteoporosis
Disorder of bone matrix resulting in reduction in bone
strength to the extent that there is increased risk of fractures.
Women lose 50% of their skeleton by the age of 70 years,
but men only lose 25% by the age of 90 years.
Predisposing factorsgenetic predisposition, use of corticosteroids, pre-menopausal
amenorrhea, smoking, premature ovarian failure
 Cardiovascular
 Protective effect of oestrogen—
increase in HDL
decrease in LDL
NO mediated vasodilatation
antioxidant effect
direct effect on aorta decreasing atheroma
 Risk factors include high BMI and a decrease in oestradiol
levels.
 Women with day3FSH > 7 IU/ml compared to those with day3
FSH < 7 IU/ ml were found to have higher lipid levels.
 CNS
Oestrogen has a direct effect on the vasculature of the CNS and
promotes neuronal growth and neurotransmission. Also
improves cerebral perfusion and cognition in women.
 Causes alzheimers disease, dementia. (intervenes at the level
of amyloid precursor protein).
 diagnosis
 1. Characteristic history of hot flushes and night sweats with
prolonged periods of amenorrhoea. Measurement of plasma
hormone level is not necessary.
 2. Measurement of plasma hormone levels in patients with
classical symptoms are unnecessary, expensive, time consuming
and of little clinical significance
 An FSH level of >30 IU/L is regarded as being diagnostic of the
menopause in most cases.
 After the diagnosis has been established, investigations should
be no more than the annual screening which is normally
applicable to middle-aged women and must be carried out
before commencing HRT include:
 assessment of weight.
 blood pressure.
 routine cervical cytology.
 Fasting lipid profile estimation may be useful in women with risk
factors.
 Mammography.
 Routine breast palpation and pelvic examination is unnecessary;
these need only be performed if clinically indicated.
 treatment
 Non-Pharmacological Management;
 healthy diet, exercising regularly, maintaining a healthy body
weight, not smoking, and Avoidance or reduction of intake of
caffeine may be useful in relieving mild menopausal symptoms.
 Pharmacological Management
 includes:
 Hormon Replacement Therapy (HRT).
 alternative treatment
 HRT Regimens
 Oral formulations- cyclic or continuous
 Vaginal preparations
 Patches
 Injectable forms
 Low dose oral contraceptives
 Hormone Replacement Therapy (HRT)
 Oestrogens
 use only natural oestrogens and avoid synthetic oestrogen. it can
be given by oral route (conjugated equine ostrogens, 0.625mg
(Premarin), transdermal patches, local vaginal application.
 Topical oestrogen therapy is effective for moderate to severe
vaginal symptoms for a short course (few weeks) and can be
repeated if necessary.
 Oestrogen given systemically in the perimenopausal and
postmenopausal period, and effective in treating vasomotor
symptoms.
 In hysterectomised women estrogen should be given unopposed
by progesterone.
 oestrogen and progesterone
 for all women who have intact uterus (not doing hysterectomy), a
progesterone should be added for at least 10 days each month
to prevent endometriual hyperplasia and carcinoma.
 Combined oestrogen and progestogen can be given as a
sequential (cyclical) or continuous regimen.
 tibolone
 has oestrogenic, progestogenic and androgenic properties. it is
effective in treating hot flushes and will prevent osteoporosis.
 testosterone use for those women with loss of libido.
 Contraindications of HRT
 A. absolute contraindication of HRT:
 venous thromboembolism (VTE) .
 a history of, or at high risk of CVD,
 breast cancer.
 recent history of endometrial carcinoma.
 undiagnosed vaginal bleeding.
 hepatic disese.
 B. relative contraindications of HRT:
 seizure disorders.
 high serum triglyceride.
 current gall bladder disease.
 migraine headache.
 uterine Fibroids.
 endometriosis.
 side effects of HRT
 1. endometrial carcinoma. this risk reduced by adding
progesterone.
 2. increase incidence of benign breast disease and breast
cancer
 3. uterine bleeding.
 4. mild gastrointestinal symptoms.
 5. weight gain
 6. Oestrogenic side effects, including bloating, breast tenderness
, leg gramps, headach and nausea.
 7. Progestogenic side effects, including fluid retention, breast
tenderness, headaches and mood swings.
 *the side-effects can be reduced by reducing the dose, changing
the HRT type or route of administration.
 Alternative treatment
 norethisterone 5mg daily effective in reducing hot flushes.
 *medroxy progesterone acetate daily.
 propranolol have been used in treatment of hot flushes.
 * clonidine have been used in treatment of hot flushes.
 *selective oestrogen receptor modulators are effective in
prevention of bone loss.
 *naturally occurring oestrogen such as phytoestrogens occur in
cereals, legumes and vegetables so diet rich with this estrogens
has fewer menopausal symptoms.