Download MENOPAUSE

MENOPAUSE
Dr. Ahmed jasim
Ass.Prof.
MBChB-DOG-FICMS
COSULTANT OF GYN. & OBST.
OBJECTIVES
Definition
 Etiology/Endocrinology
 Epidemiology
 Clinical Manifestations
 Diagnosis
 Therapies
 Prolog Questions
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DEF.
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permanent cessation of normal menstruation
in women .
The diagnosis can only be made retrospectively
after a minimum 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.
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Stages of Reproductive Aging Workshop (STRAW) Staging
System 2001
Menopausal transition: a) Variation in menstrual cycle ( > 7 d
different from normal) and ≥2 skipped cycles and >=60 d
amenorrhea; b)  FSH
Perimenopause: Starts at the time of the menopausal
transition ( see above) and ends 12 months after last
menstrual period
Menopause: 12 months of amenorrhea after final menses
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
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TYPE OF MENOPAUSE
1. Physiologic Menopause.
 2. premature Menopause.
 3. Artificial (therapeutic) Menopause
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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.
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TYPE OF MENOPAUSE
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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.
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PATHOPHYSIOLOGY
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(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.
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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.
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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
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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
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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
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CONSEQUENCES OF MENOPAUSE
IMMEDIATE
 INTERMEDIATE
 LONG TERM
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IMMEDIATE
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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.
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INSOMNIA, ANXIETY, IRRITABILITY
POOR CONCENTRATION
MOOD DISTURBANCES
REDUCTION IN SEXUALITY AND LIBIDO
MEMORY LOSS
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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
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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, premenopausal amenorrhea, smoking, premature
ovarian failure
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Cardiovascular
 Protective effect of oestrogen—
increase in HDL
decrease in LDL
NO mediated vasodilatation
antioxidant effect
direct effect on aorta decreasing atheroma
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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.
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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.
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Causes alzheimers disease, dementia.
(intervenes at the level of amyloid precursor
protein).
DIAGNOSIS
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1. Characteristic history of hot flushes and night
sweats with prolonged periods of amenorrhoea.
Measurement of plasma hormone level is not
necessary.
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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.
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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.
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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.
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Pharmacological Management
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 Hormon Replacement Therapy (HRT).
 alternative treatment
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7/7/2017
HRT REGIMENS
Oral formulations- cyclic or
continuous
 Vaginal preparations
 Patches
 Injectable forms
 Low dose oral contraceptives
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HORMONE REPLACEMENT THERAPY (HRT)
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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.
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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.
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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.
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B. relative contraindications of HRT:
 seizure disorders.
 high serum triglyceride.
 current gall bladder disease.
 migraine headache.
 uterine Fibroids.
 endometriosis.
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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
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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.
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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.
Thank
you