Menopause
Definition: permanent cessation of menstruation for 6 – 12 months as a manifestation of climacteric.
Climacteric: transitional phase lasting 2 – 5 years during which the genital
organs involute.
Types:
* Natural (physiological): 45 – 55 years.
* Artificial (induced): which may be
1) Surgical: bilateral oophorectomy.
2) Radiological: complication of radiotherapy for genital cancer.
3) Iatrogenic: GnRH analogue > 6 months → reversible menopausal symptoms.
Abnormalities:
* Premature menopause:
– Def.: menopause < 40 years.
– Aetiology:
a) Constitutional (familial).
b) Chromosomal: mosaic Turner (44 xx /44 xo).
c) Others as irradiation & infections destroying ovary as mumps.
– Investigations: * Serum FSH: > 40 mIU/ mL.
* Ovarian biopsy: atretic follicles.
– Treatment: HRT.
* Delayed menopause:
– Def.: menopause > 55 years.
– Aetiology:
a) Constitutional (familial).
b) Estrogen secreting ovarian tumors.
c) Others as common association with fibroid.
– Complications: high risk of endometrial hyperplasia & carcinoma.
– Treatment: managed as a case of post-menopausal bleeding.
Pathophysiology of menopause:
* Onset: – Usually, preceded by oligohypomenorrhea.
– Sometimes: abrupt or sudden onset.
* Natural sequence of events:
– Intrinsic ovarian failure: atrophy of the follicles leading to ↓↓↓ estrogen
– Pituitary hyperfunction →↑↑FSH & ↑↑ ACTH → hirsutism.
* Physiological changes after menopause:
A. Hormonal changes:
1- Estrogen: marked ↓, the type that persist mainly is estrone (E1).
So, obese females are liable to endometrial hyperplasia & cancer.
(Androstenedione converted in fat cells to estrone).
2- Androgen: mainly androstenedione (mainly from suprarenal cortex).
3- Gonadotrophins (FSH & LH):
– Low estrogen →↑↑ FSH
– Few years’ later ↓FSH & LH due to pituitary exhaustion.
4- Thyroid functions: slight ↓.
B. Genito -urinary changes:
– Atrophy of the ovaries, uterus, cervix, vagina & vulva → senile vaginitis & endometritis.
– Atrophy of ligaments supporting the genital tract predisposes to prolapse.
– Atrophy of the breast.
– Atrophy of UB mucosa.
C. General changes:
– Osteoporosis due to:*↑destruction: leading to loss of bone density.
*↓ ↓ production: due to osteoblastic activity.
– Atherosclerosis & IHD: ↓ ↓ ↑ estrogen leads to HDL & LDL which leads to atherosclerosis.
Clinical picture of post menopausal syndrome:
(Mild in 50% – moderate in 30 % – severe in 20%)
1. Vasomotor symptoms: (the commonest)
a) Hot flushes:
Definition: waves of heat sensation spreading from the chest to the neck & head
repeated several times daily & followed by cold sweat & shivers.
Mechanism: * VD: heat & sweating.
* VC: cold & shivers.
Treatment: estrogen gives good results.
b) Cold sweats.
c) Palpitation.
d) Headache & dizziness.
2. Nervous symptoms:
a) Mood changes: irritability or depression.
b) Sleep changes: insomnia or lethargy.
3. Metabolic:
a) Obesity & baldness.
b) Arthritic pain & bone pain.
4. Sexual: libido usually ↓ (may be ↑ or unchanged).
5. GIT: *flatulence & constipation. *altered appetite.
6. Genitourinary: * dyspareunia & prolapse.
*UTI & urine incontinence.
Management:
* General measures: reassurance that menopause is change of the life & not the end of the life.
* Medical treatment:
a) Non hormonal treatment.
b) HRT.
a) Non hormonal treatment:
1) Sedatives, tranquilizers & antidepressants.
2) Treatment of hot flushes:
– Clonidine (tablet at night): used when estrogen is contraindicated.
– B- blocker: used when estrogen is contraindicated.
3) Treatment of osteoporosis (preventive rather than treatment):
– Exercise. – Calcium: 1 gm /day.
– Fluoride: ↑ bone mass but the formed bone is fragile.
– Biphosphonates:
Action: inhibit osteoclasts leading to ↓ bone resorption.
Drugs: alendronate.
Dose: * 5 mg daily for prevention.
* 10 mg daily for treatment.
– Raloxifene: selective estrogenic effect on the bone.
– Tibolone (livial): selective estrogenic effect on the bone.
b) Hormonal replacement therapy (HRT):
♦ Indications:
1) Post-menopausal women.
2) Gonadal dysgenesis.
3) Cases of intersex.
♦ Contraindications:
1) Cancer breast & family history of cancer breast.
2) Endometrial hyperplasia & carcinoma.
3) Undiagnosed genital bleeding.
4) Active thromboembolism.
5) Liver diseases (acute & chronic).
6) Gall bladder diseases.
♦ Benefits of HRT:
1) Relief of vasomotor symptoms.
2) Prophylaxis against osteoporosis.
3) Decrease risk of IHD.
♦ Complications:↑ incidence of:
1) Endometrial hyperplasia & cancer if estrogen is used alone.
2) Cancer breast.
3) Thromboembolism.
4) Alteration of liver functions.
♦ Precautions:
1) Before treatment : exclude any contraindications.
2) During treatment :
– HRT should be for at least 2 years to avoid recurrence of symptoms.
– For bone protection, long period is needed.
– Follow up for any complications.
♦ Regimens:
1) Estrogen only: (hysterectomized women only)
* Oral: – Conjugated estrogen (premarin 0.625 mg /day).
– Unconjugated estrogen: ethinyl estradiol.
* Non- oral: – Vaginal cream & ointment.
– IM injection monthly.
– Transdermal patch & gel (estraderm): twice weekly.
– Percutaneous implant.
– Nasal spray.
2) Phytoestrogens (klimadynon):
– Derived from plants.
– Have mild estrogenic activity.
– Have fewer side effects.
3) Estrogen & progesterone:
* Oral : cycloprogenova.
* Non-oral: skin patch.
N.B.: Estrogen is given continuously &
Progesterone is given intermittently (10 – 14 days /month).
4) Estrogen & androgen:
– Advantages: control hot flushes & anabolic effect.
– Disadvantages: virilization.
5) Tibolone(livial):
– Progesterone, estrogenic & androgenic effect.
– Very recent non-bleeding drug.
6) Calcitonin: for established osteoporosis.
♦ Follow up & monitoring:
1) After 2 months: * to check control of symptoms & side effects.
* To measure BP & weight.
2) After 6 months: * deal with any problem.
* Check amount of uterine bleeding (acceptable or not).
3) Then every 6 months: to check BP, weight, breast & legs.
4) Every year, this woman should do lipogram, mammogram & cervical smear.
Special notes:
♦ SERM (selective estrogen receptor modulator):
– Drugs: * 1st generation: tamoxifen & clomiphene citrate.
* 2nd generation: raloxifene.
– Advantages: * Mild estrogenic activity.
* Anti-estrogenic effect on breast & endometrium.
Menopause – Symptoms and tips
In this animation you will learn more about the menopause. Why do women face menopause? What are typical symptoms and complications? Finally, you will get some tips to relieve the complaints and hormone replacement treatment is described.
Menopause
Menopause by Osmosis
What is menopause? Menopause refers to the natural halting of the monthly menstrual cycles because of the depletion of ovarian follicles. It’s usually considered that a woman has entered menopause when more than 1 year has passed since her last menstrual period.
SEMINAR ON MENOPAUSE
Menopause is the end of menstruation .The word menopause came from the Greek word ` mens ’ meaning “monthly’’ and ` pausis ’ meaning “cessation ‘’. Menopause is a part of a women’s natural ageing process when her ovaries produce lower level of the estrogen and progesterone and when she no longer able to become pregnant .
Menopause overview by Associate Prof Dr Hanifullah Khan
Overview of menopause, the issues related to this subject and clinical implications for the student. Objectives! to understand this condition & terminology! physiology of menopause! problems linked with menopause! clinical scenarios
Menopause Resident Lecturer: Abigail Polintan, MD Consultant Facilitator: Divina Rojas, MD, FPOGS
Menopause • Defined by the WHO as the permanent cessation of menstruation resulting from loss of ovarian follicular activity • Determined retrospectively from the date of the last menstrual period, after 12 months of amenorrhea, with no other attributable cause
Perimenopause • Menopausal transition • Includes the years prior to menopause that encompasses the change from normal ovulatory cycles to cessation of menses • Hallmark: Skipped periods, or longer duration between periods (40-60 days)