Novak 29 Menopause -1-

1. Novak 29 Menopause -1- 백병원 산부인과 2003-11-04 R2 길 민 경

2. ≥ 30% of female population of U.S.A. : postmenopausal, increasing • each woman’s response to menopause : may be different → management must be individualized to each woman’s needs

3. Menopause : permanent cessation of menses for 1 years, physiologically correlated with decline in estrogen secretion resulting from loss of follicular function • Perimenopausal period • encompasses the time before, during, and after menopause • usually begins in the mid- to late 40s • often insidious & uneventful but may be abrupt and symptomatic – Sx that begin with the menopausal transition usually continue into the postmenopausal period

4. Perimenopausal Phases • period surrounding the menopause – before, during, and after • length : varies, usually considered to last approximately 7 years

5. Menopausal Transition • varying degree of somatic changes that reflect alterations in the normal functioning of the ovary • early recognition of the Sx and use of appropriate screening tests : minimize the impact of this potentially disruptive period • In some women, menstrual irregularity : most significant Sx of the menopausal transition • Ut bleeding associated with this transition period : 2’ to normal physiologic estrogen fluctuations rather than underlying pathology and may be treated medically

6. Menopause • Cessation of menses resulting from the loss of ovarian function : natural event, a part of the normal process of aging. Resulting from loss of ovarian follicular function, should be characterized as an event rather than a period of time • Time of menopause is determined genetically and occurs at a median age of 51 years, related neither to race nor nutritional satatus • Menopause occurs earlier in nulliparous women, in those who smoke tobacco • Modern laboratory testing, menopause may now be more precisely defined as amenorrhea, with signs of hypoestrogenemia, and an elevated serum FSH level of greater than 40 IU/L

7. Postmenopausal Period • This period comprise more than one-third of the average woman’s life • Hormone replacement therapy : one of primary concerns of many postmenopausal women’s health care

8. Premature Ovarian Failure(1) • Loss of ovarian function is usually a gradual process that occurs over a number of years • Ovarian function is lost earlier and more suddenly than expected in some women as a result of natural causes, chemoTx, or surgery • Defined as menopause occurring spontaneously before 40 years of age • Both psychological and hormonal support may be necessary, possibility of associated endocrine abnormalities should also be considered

9. Premature Ovarian Failure(2) • More than 40% of women who have hysterectomies, both ovaries are removed : relatively young age of these women and the abrupt onset of associated Sx create special problems • Most obvious problem with surgical menopause is the acute onset of hot flashes → after several months, followed by signs of vaginal atrophy, long-term surgical menopause has been associated with significantly higher risk for both osteoporosis and cardiovascular disease than has natural menopause • Relative risks and benefits of oophorectomy in conjunction with estrogen replacement therapy : should be thoroughly discussed with any woman considering bilat oophorectomy at the time of hysterectomy

10. Hormonal Changes

11. Menopausal Transition • Ovarian follicle become increasingly resistant to FSH stimulation even though levels of estradiol remain relatively constant • Progesterone : produced almost exclusively by granulose cells and is highest in the med luteal phase, During menopausal transition, ovulation becomes less frequent, with a decrease in overall progesterone production

12. Menopause(1) • Hormones most affected are those produced by the ovaries and include estrogen, progesterone, and androgens

13. Menopause(2) • Estrogen • Even though the amount of estrogen secreted by the postmenopausal ovary is negligible, postmenopausal women continue to have measurable amounts of both estrone and estradiol • Androstenedione is produced by the adrenal and ovary and is aromatized to estrogen primarily by muscle and adipose tissue • Obese women : increased level of circulating estrogens, unopposed estrogen places them at an increased risk for endometrial cancer, not appear to protect them form acute menopausal Sx : however, higher levels do provide some skeletal protection • Thin women : decreased level of circulating estrogens, increased risk for developing osteoporosis

14. Menopause(3) • Progesterone • After menopause, progesterone production ceases • Associated with the absence of premenstrual Sx • Decreased progesterone levels affect organs that are responsive to gonadal hormones, such as endometrium and breast → higher risk of endometrial hyperplasia and cancer, development of breast cancer

15. Menopause(4) • Androgens • Third class of steroids produced by the ovaries, most notably testosterone and androstenedione • Prior to menopause, ovaries produce approximately 50% of the circulating androstenedione and 25% of the testosterone produced by a woman’s body • After menopauses, total androgen production decreases, mainly because ovarian production decreases but also because adrenal production decreases • ovaries are responsible for 20% of the androstenedione and 40% of the testosterone as a result of continued gonadotropin stimulation of ovarian stromal cell • oophorectomy also results in a marked reduction in androgen production, significance of these decreases will remain uncertain until the physiologic role of these hormones becomes more fully elucidated

16. Patient Concerns about Menopause(1) • the loss of fertility and menstrual function may have an impact on a woman’s sense of well-being → physician should be sensitive to the potentially significant emotional distress faced by women entering menopause and be prepared to offer psychological support

17. Patient Concerns about Menopause(2) • Loss of Childbearing Capacity • loss of fertility may cause great distress • Loss of Youth • the degree to which this may affect a woman may be related to the value she places on personal appearance • aging may not be important to many women, but the possibility that this may cause anxiety or depression should be considered • Skin Changes • estrogen therapy may help to maintain skin thickness • estrogen therapy cannot completely prevent the effects of aging in skin, nor can it counteract the effects of environmental stresses on skin, such as sun exposure and cigarette smoking

18. Patient Concerns about Menopause(3) • Changes in Mood and Behavior • Depression • common problem for women and older patients • belief that depression is increased during the perimenopausal period, studies have failed to show a relationship between clinical depression and hormonal status • many psychiatric Sx occurring during this period may be more related to psychosocial events • Anxiety and Irritability • many women report an increased level of anxiety and irritability during the perimenopausal period • multiple studies, however, have found no evidence to suggest that psychological Sx experienced during the menopausal transition are related to estrogen changes • increased anxiety and irritability associated with the perimenopausal period are more clearly associated with psychosocial factors than with estrogen status

19. Patient Concerns about Menopause(4) • Decreased Libido • major concern for some women is a decrease in libido or sexual satisfaction that may occur with natural or surgical menopause • Sexual activity, however, remains relatively stable in menopausal women • Vaginal changes associated with menopause may also contribute to decreased sexual satisfaction, also lead to dyspareunia → treated easily with oral or vaginal estrogen therapy • The role androgens play in libido before and after menopause is uncertain

20. Menopausal Transition(1) • Beginning at the age of 40 years, routine health maintenance should include screening for problems related to hormonal changes

21. Menopausal Transition(2) • Abnormal bleeding • Menstrual irregularity occurs in more than one-half of all women during the menopausal transition • Ut bleeding can be irregular, heavy, or prolonged • in most cases, this bleeding is related to anovulatory cycles • disruption of normal menstrual flow has been attributed to a gradual decrease in the number of normally functioning follicles and is reflected by a gradual increase in early follicular-phase FSH levels • although anovulation is one of the more common causes of abnormal Ut bleeding, pregnancy must always be considered • Malignant precursors such as complex endometrial hyperplasia become more common during the menopausal transition • perimenopausal women with abnormal Ut bleeding should undergo an endometrial Bx to exclude a malignant condition

22. Menopausal Transition(3) • Evaluation • Goal of evaluation of abnormal Ut bleeding is to achieve the greatest accuracy with the least risk and expense for the Pt • With development of less invasive office procedures and more accurate outpatient surgical approaches, Ut curettage without hysteroscopy is seldom done • Fig 29.1

23. Menopausal Transition(4)

24. Menopausal Transition(5) • Vaginal Ultrasonography • Vaginal USG : established first step in the evaluation of perimenopausla bleeding • With saline injection, sonohysterography can accurately visualize polyps and other focal intrauterine lesions • Endometrial stripe < 5mm thick : associated with an extremely low risk of endometrial hyperplasia or cancer • Endometrial Sampling • The importance of the endometrial Bx cannot be overemphasized for the pre or postmenopausal woman with abnormal Ut bleeding • well accepted that endometrial Bx performed in the office is just as accurate as D&C and certainly more economical • D&C should be reserved for Pt with abnormal endometrial bx or for conditions that preclude performing an office bx , such as Cx stenosis

25. Menopausal Transition(6) • Hysteroscopy with Uterine Curettage • Addition of hysteroscopy to Ut curettage : greatly improved diagnostic accuracy in the evaluation of focal intrauterine lesions

26. Treatment(1) • Hormonal or surgical, depending on the pt’s Sx and Dx • Anovulation is one of the most common cuases of abnormal Ut bleeding during menopause, hormonal therapy is the first approach after the presence of intrauterine pathology has been excluded

27. Treatment(2) • Hormonal Therapy

28. Treatment(3) • Oral Contraceptives • Modern low-dose(0.35mg ethinyl estadiol) oral contraceptives offer many advantages with minimal risk : use of OCs until menopause has been found to be safe in women with no risk factors for CVD • Before starting the administration of OCs in the age group, pt should be free of the following risk factors • hypertension • hypercholesterolemia • ciagarette smoking • previous thromboembolic disorder • cerebral vascular disease or coronary artery disease • because the estrogen dose in these pills is approximately 4 times the dose used after the menopause, women taking this therapy should be switched to traditional estrogen therapy by 50 years of age or sooner if Sx occur

29. Treatment(4) • Cyclic Progestins • medroxyprogesterone 10mg daily for 10 days each month • induce withdrawal bleeding and to decrease the risk of endometrial hyper

30. Treatment(5) • Surgical Therapy

31. Treatment(6) • Dilatation and Curettage • endometrial polyps are determined to be the cause of abnormal Ut bleeding, curettage can be both therapeutic and diagnostic • with exception of endometrial polyps, curettage has not been shown to have any long-term benefit in the Tx of abnormal Ut bleeding

32. Treatment(6) • Hysterecotmy • Although removal of uterus is most common and effective surgical Tx for abnomal Ut bleeding, hysterectomy is associated with a certain degree of morbidity and cost • Prior to recommending hysterectomy, an adequate preoperative evaluation must include endometrial sampling and adequate trial of hormonal therapy to control bleeding • Standard practice for postmenopausal women undergoing hysterectomy to have their ovaries removed to avoid the subsequent risk of ovarian cancer • Oophorectomy has been recommended in women older than 40 to 45 years for the same reson

33. Treatment(7) • Endometrial Ablation • A relatively new and potentially advantageous approach to DUB during the menopausal transition : endometrial ablation • Minot surgical procedure involves destrying the functioning endometrium with electrical energy using a hysteroresectoscope • Most Pt report either decreased bleeding or amenorrhea, and both intraoperative and postoperative complications are uncommon • Risk of Ut malignancy after any type of endometrial ablation procedure remains uncertain • subsequent endometrial cancer after endometrial ablation has been reported only in women who had preexisting endometrial hyperplasia ⇒ thorough fractional curettage should be performed prior to the procedure • until long-term data become available, women considering this therapy should be informed about the potential risk of endometrial ablation