MENOPAUSE Fit at 50, strong at 60

Permanent cessation of menstruation resulting from the loss of ovarian follicles (WHO).

DEFINITION

• Effects every woman

• Cessation of menstruation for the past twelve months

• Average Age - 51 years

Need...

Global population of age 60 yrs.

Currently -580 million

• 2020 - One billion• 75% -Elderly• 50% -Postmenopausal women

Premature Menopause:Causes

Primary

Autoimmune disorders

Chromosome anomalies

Enzyme deficiencies

Secondary

Surgical

Infections

Chemotherapy and

radiotherapy

if it occur before the age of 45?

PremenopauseThe time period of endocrine changes before cessation of

menstruation.

Climacteric/ Perimenopause

The period of endocrine changes

surround the menopause is called

Climacteric

PostmenopauseThe time period of endocrine changes After cessation of

menstruation

what is meant by Climacteric?

Actual change around 35 years

sensitive germ cells eleminated

germ cells resistant to

normal gonadotrophins

anovulation and menstrual

irregularity

rise in gonadotrophin levels restores ovulation and

normal menstruation

compensated ovarian failure

Pathophysiology

A time comes when raised gonadotropins level fails to achieve any significant follicular growth and

estrogen produced is not sufficient to cause endometrial growth results in cessation of menstruation and hence

menopause

Pathophysiology

Pathophysiology

Effect Of Menopause

Risk of • Fracture• Heart

Disease

Menopausal Symptoms

Estrogen & Progesterone level

•Short term effects

•Long term effects

Effects of menopause

Short term effects

•Menstrual irregularities•Unintended pregnancy•Hot flushes•Palpitation•Muscle And Joint Pain•Low Backache•Vaginal Dryness•Urinary Leak•Urinary Frequency

•Fatigue•Mood Swings•Depression•Sleeping Problems•Memory Lapse•Decreased Libido•Weight Gain•Dryness Of Skin•Hair Loss

• 75% women• Intense heat (face,forehead,neck,chest,earlobe)• Associated with night sweats,irritability,lethargy,insomnia and

tiredness• More pronounced in premature and surgically induced menopause

Hot flushes

What can you do about Hot flushes

To reduce an attack - Avoid spicy food, coffee, tea, alcohol- Wear loose cotton clothes- Avoid hot water bath just

before sleeping- Medical treatment options

(i) Urinary

• Dysuria• Frequency• Urgency• voiding difficulties

(ii) Genital

• Dyspareunia• Apareunia• genital tract

trauma• loss of libido and • uterovaginal

prolapse

Genitourinary Symptoms

• Anxiety• Irritability• Depression• mood • Fluctuation• inability to concentrate• poor memory• lethargy

Psychological Symptoms

A young women is a gift of nature,An old woman is a work of art.

•Osteoporosis•Heart Disease•Alzeihermen’s Disease

Of Menopause

Of Ageing

• Arthritis• Diabetes• Hypertension• Problems of Hearing, vision

Long term effects

• Average rate of bone loss is 3% per annum• 50% of women by age of 60 years• Bones at high risk of fracture are

• Distal radius,neck of femur,vertebral body• Results in structural deformity, Dowagers hump (fracture of vertebrae T8-L4)

Osteoporosis

Normal bone Osteoporotic bone

Micro-fracture

Leads to fracture

Osteoporosis

AgeIncidence of fracture

> 60 yrs 25 %

> 65 yrs

40 %

> 70 yrs 50 %

Osteoporosis

GETTING SHORTER MAY BE JUST THE BEGINNING

• Bone becomes weak which leads to multiple breaks in the spine

• With gradual accumulation of these breaks people get shorter

• Could lead to a curved back known as “Dowager’s Hump”

A FRACTURE CAN TURN YOUR LIFE INTO ONE OF DISABILITY

Broken hips cause permanent disability

One in four people who suffer a hip fracture due to osteoporosis will die within one year

Predominant factor increasing risk of cardiovascular diseases in post menopausal women is decreased HDL:LDL ratio due to estrogen deficiency

Ischemic Heart Disease

• Incidence 3 times more in women aged 65 yrs or more

• Less common in obese women, because of endogenous estrogen production by adipose tissues

• Prevention by estrogen replacement therapy.

Alzheimer’s disease

• Like decrease in bone mass skin thickness also declines after menopause

• Skin collagen declines by 30 % in first 10 yrs after menopause

• Collagen restored to premenopausal levels within 6 months of initial hormone replacement therapy.

Skin

• Patients in premature menopause fails to have more children

• Reproduction with ovum donation remains only option.

Infertility

DIFFERENTIAL DAIGNOSIS

(1) Premenstrual syndrome

(2) Endogenous depression

(3) Hyperthyroidism

(4) Pheochromocytoma

• Gonadotrophin assessment

• FSH level > 15 iu/ml suggest perimenopause and

• FSH level > 40 iu/ml confirms menopause

Investigations

Hormonal Non Hormonal Add on

•Estrogen •Tibolone •SERMS

Raloxifine

• Bisphosphonate

Alendronate

Risedronate

•Others

• Calcium

• Vit D

Analog•Alfacalcidol

Treatments Therapy

(i) Tibolone

• Non hormonal steroid with oestrogenic, progestogenic and androgenic properties.• Dose is 2.5 mg/day• Reduces hot flushes, sleeplessness and improves mood and libido• Increases bone density by 8 % after 2 years use• Side effect is irregular bleeding

Non Hormonal therapy

(ii) Calcitonin

(iii) BisphosphonatesSodium etidronate and clonronate have beneficial effect on bone mass

(iv) ExerciseDecreases incidence of osteoporosis,ischemic heart disease and depression(v) Calcium Supplements

Calcium alone no effect on osteoporosisCalcium + estrogen = beneficial effects in lower doses

(vi) Hypnotics,Sedatives,Tranquilizers

Non Hormonal therapy

• Indications

(1) Women distressed with perimenopausal symptoms(2) Women at increased risk of osteoporosis(3) Women who wants to take it by choice The risks of HRT must be explained and follow up ensured in such patients.

Harmone Replacement therapy

Before prescribing HRT,benefits and risks associated with it should be discussed in detail

Blood pressure,weight is recordedBreasts examined for any lumpPelvic examination for any massCervical smear is carried outIn some cases pretreatment mammography

is indicated

Pre treatment evaluation

Blood sugar estimationRenal and liver function testsLipid profilePelvic ultrasonographyEndometrial samplingBone densitometryInvestigations not mandatory but indicated

in selective patients

Optional Investigations

(A) Short period of time3 months to one yearFor perimenopausal symptoms

(B) Long period of time5 to 10 yrsPrevention of cardiac diseases and osteoporosis

Patients taking HRT should have checkups at regular intervals for benefits and side effects of drug

Treatment duration and follow up

(i) Oestrogen alone In patients where hysterectomy has been performedNatural oestrogens are prefered over synthetic,coz synthetic

oestrogen are metabollized 100-1000 times more than natural oestrogen,hence chances of side effects (hypertension and thromboembolism) is high

Natural oestrogens include17 beta oestradiol oestriolOestrone conjugated equine estrogen

Estrogen and progestogen combination To eliminate the risk of endometrial hyperplasia and carcinoma

in women with intact uterus progestogens along with estrogens are given which causes regular endometrial shedding at menstruation

Types of Harmones

• Progestogens alone

Indicated in patients cannot tolerate estrogen/contraindicated

Controls hot flushes and prevent bone loss

Have no cardio protective role as it causes reduction of HDL

Types of Harmones

(i) Absolute

•History of breast cancer

(ii) Relative•Hypertension•Diabetes•Endometriosis•Fibroids•History of thromboembolism

Contraindications of HRT

• (i) return of menstruation in postmenopausal women

• (ii) premenstrual syndrome like symptoms (bloating,fluid retention,mastalgia,headache,depressn)

• (iii) disturbance in lipid profile (reduced HDL:LDL)

(a) Progestogen

related

• (i) risk of thromboembolism(b) Estrogen

related

• (i) Endometrial cancer• (ii) Ovarian cancer• (iii) Cervical,Vaginal,Vulval cancers• (iv) Breast cancer

(c) Hormone replacement therapy and

Cancers

Risks/side effects of HRT

THANK YOU

“Growing Old is Natural But

Feeling Old is Not.”

•PREPARED BY

• NUMAN ALAM• 08-146• FINAL YEAR MBBS