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Menopause

Menopause marks the permanent cessation of menstruation, signifying the end of a woman's reproductive years. It is diagnosed after 12 consecutive months without a menstrual period, typically occurring between the ages of 45 and 55.

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Menopause

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  1. MENOPAUSE Dr. Sagar D Dherange MS- OBGYN-A

  2. Defination • It is the permanent cessation of menstruation at the end of reproductive life due to loss of ovarian follicular activity • It is diagnosed as amenorrhea of 12 consecutive months without any other pathology

  3. Defination • Climectric The period during which a woman passes from reproductive to non reproductive stage (5-10 years on either side of menopause) • Perimenopause Part of climacteric when menstrual cycles is likely to be irregular • Post menopause Phase of life after menopause

  4. Age of Menopause • Around 45-55 years mean age 47-shaw 50- Dutta 45-Sheshadri

  5. Factors affecting age of Menopause • Genetic factor • Smoking • Ethinicity • Prior surgery – Hysterectomy, ovarian surgery • Prior chemotherapy • Prior radiotherapy • Socio economic status • parity

  6. Risk factor for Menopause related diseases • Early menopause • Surgical menopause/radiation • Chemotherapy especially alkalytic agent • Smoking, alcohol,caffeine • Family history of menopausal diseases • Drugs for prolong period(>6month) Gnrh,heparin,corticosteroid,clomiphene • Diabetes

  7. Physiology of Menopause

  8. Hormonal Changes

  9. Effects of menopause

  10. Hot flushes • In 75% women, severe in 10-15% • Reduce by 2-3 years but can continue up to 10 yrs • It is acute sensation of heat & skin changes including sweating • Mediated by noradrenaline & serotonin by hypothalamus • It can cause sleep deprivation & irritability • They respond to estrogen

  11. Vasomotor symptoms- • Sweating • Palpitation

  12. Urinary symptoms • As lining epithelium of lower urinary tract is dependent on estrogen • In post menopausal woman changes of urothelioum occurs • Which predispose to frequent UTI • It can cause urethral curuncle • Increased frequency, urgency, dysuria

  13. Mood disturbances • Fluctuating estrogen level lead to reduction in central neurotransmitters like serotonin • Depression • Anxiety • Irritability

  14. Sexual dysfunction • Vaginal dryness- dysparenuia • Decreased androgen- loss of libido • Rarely senile vaginits

  15. Insomnia • Due to hot flushes & depression

  16. Cognitive dysfunction • Due to hypoestrogen • Memory loss • Poor concentration • Tiredness • Lack of motivation

  17. Other • Pseudocyesis • Due to fear of pregnancy & amenorrhoea • Increased abdominal girth • Cancer phobia

  18. Anatomical changes during menopause • Genital Organ • Atrophy & retrogresssion • Ovaries • Shrinked,white • 2cm*1.5cm*1cm • Volume 8cc • (after 15 years it shouldn’t be>2cc) • Surface grooved & furrowed

  19. Anatomical changes during Menopause • Fallopian tube • Atrophic • Muscle boat thinner • Cilia absent • Tubal plicae less prominent

  20. Anatomical changes during Menopause • Uterus • Smaller • Ratio of body: cervix 1:1 • Endometrium- thin,atrophic only basal layer present • Endometrial gland dilate just before menopause leading cystic glandular hyperplasia which results in metropathicahaemorrhagica

  21. Anatomical changes during Menopause • Cervix • Smaller • Chances of cervical stenosis,pyometra • Vagina • Narrow,thin,pale,dry • Rugae flattens • No glycogen-no doderlin bacilli-more prone foe infection • Ph become alkaline

  22. Anatomical changes during Menopause • Vulva • Atrophies • Skin at labia flattens , pale • Pubic hair reduced & greyish • Bladder & urethra • Epithelium thin • Prone for infection • Dysuria, urgency,frequencymicturation

  23. Anatomical changes during Menopause • Breast • Breast fat reabsorption forming • pendolus breasts • Glandular tissue reduces from 30% to 5% • So breast become flat & pendolus

  24. Anatomical changes during Menopause • Skin • Wrinkled,easy bruising • Vulnerable to trauma & infection • Urodynamic • Incontinence • Stress urge frequency incontinence • Pelvic organ prolapse • It can lead or worsen prolapse already present

  25. Bone Metabolism • Estrogen receptor present in • osteoblast (for new bone formation) • Osteoclast (for bone resorption) • Estrogen increases osteoblastic activity • Decreases osteoclastic activity • In post menopausal women, chances of osteoporosis & osteopenia are common

  26. Risk factor for osteoporisis • Family history of osteoporosis • Low calcium intake diet • Smoking • Excess of caffeine,alcohol • Early menopause • Low weight , BMI • Surgical menopause after hysterectomy (with or without oopherectomy) • Radiation menopause • Women on GnRh,heparin,corticosteroid,danazol,clomiphene • Sedentary lifestyle • Diabetes • Peak bone mass at puberty • Poor vit D status, exposure to sunlight • Multiparity • Other endocrine disorders- Cushing syndrome, hyperparathyroidism, hyperthyroidism, multiple myeloma

  27. Osteoporosis A condition in which there is fall in bone mass excedding 2.5 SD below the mean for young adult Types Primary type 1 Due to estrogen loss,age,deficient estrogen Secondary type 2 Due to endocrine disease or medication Age related bone loss occurs in everyone at the rate of 0.4% annually Women are additionally exposed to accelerated rate of bone loss during perimenopausal period Osteopenia-Low bone mass

  28. Osteoporosis Clinical features • Backache • Loss of height • Kyphosis • Fracture of vertebrae,femoral neck or distal forearm(colle’s fracture)

  29. Effects on CVS Estrogen is cardioprotective byit Increases HDL Decreases LDL & Triglyceride So post menopausal women prone for • Atherosclerosis • IHD • Myocardial infarction • Thromboembolism • Coronary artery disease • stroke

  30. Psychological changes • Estrogen deficiency can cause reduction in neurotransmitters production & affect vasculature of CNS leading to • Cognitive decline • Dementia • Alzheimer’s disease

  31. Adrenal • DHEA Carcinoma tic changes

  32. Other Changes • Tooth decay • Keratoconjuctivitis • Cataract • Glaucoma • Macular degeneartion • Anocolonic cancer • Mild virilization & hirsutism

  33. Diagnosis • Cessation of menses for 12 consecutive months • Appearance of menopausal symptoms • Vaginal cytology • Maturation index 10/85/5 • Sr. estradiol <20 pg/ml • Sr FSH & Sr. LH <40 mIU/ml • (3 values at weeks interval )

  34. Investigations • Serum Calcium • Serum Vit D • Serum ALK • (increased levels suggests osteomalacia) • DEXA • Mammography

  35. Management • Counseling • Hormone Replacement Therapy • Non Hormonal Management

  36. Hormone Replacement Therapy Highly recommended in • Premature ovarian failure • Gonadaldysgenesis • Surgical /radiation menopause

  37. Benefits of Hormone Replacement Therapy • Improvement in vasomotor symptoms • Improvement in uro genital atrophy • Improvement in bone mass density • Decrease risk of fracture • Decrease risk of colorectal cancer • cardioprotection

  38. Contraindications for HRT • Undiagnosed genital tract bleeding • Estrogen dependent neoplasm • History of Venous Thromboembolisnm • Active liver disease • Active Gallbladder disease

  39. Risk of HRT • Estrogen Alone (In Intact Uterus) Endometrial Proliferation Hyperplasia Carcinoma • Estrogen + Progestin Increases risk of Ca Breast • Oral estrogen + Progestin Venous Thromboembolism (Not in trans dermalroute) • CHD • Lipid disorder - Increases the disease • Dementia - Increases the disease • Alzhimer’s disease - Increases the disease

  40. Estrogen Therapy for 3-6 month • Conjugated estrogen 0.625mg to 1.25mg daily Tb Premarin • Estriol 1-2 mg Tb EVALON • Ethinylestradiol 0.01 mg • Micronised 1-2 mg

  41. Progestogen Therapy for 10-12 days each months Medroxy progesterone Tb Deviry10 mg 2] NorethisteroneTbPrimalut N 2.5 mg 3) Dydrogesterone Tb Duphaston 10 mg Tb Femet (2 mg estradiol + lmgnorethisterone) preferred which leads to endometrial Atrophy Progesterone is not required in hysterectomized Woman

  42. Other Route Subdermal Implant Subcut For 6 month 17B estradiol implant of 25mg,50mg, 100mg

  43. Other Route Percutaneous gel 1gm gel deliver 1 mg estradiol

  44. Transdermal patch • Contain 3.2 mg estradiol • Releasing 50 mg estrdiol in 24hr • Should be changed twice in week • Applied on arms, legs, thighs away from breast • Side effect- Skin Reaction, Irritation, Itching

  45. Vaginal Cream Evalon Ointment Releases 1.25 Mg Daily In Atrophic Vaginitis,Urinary Symptom

  46. Vaginal Ring • Estring • releases 5-10 mcg estrogen • 90% effective over 3 month use • Releases 0.0075 mg daily

  47. Intranasal Route • 300 mg of estrogen • raises estrogen level in 30 min • Side effects- Break through bleeding Sneezing Itching

  48. Intra Uterine System • LNG-IUS • MIRENA • Releases 10-20 uglevonogesterol daily

  49. Tibolone • Synthetic derivative of 19 norethisterone • Weak estrogenic, progestogenic, androgenic • 2.5 mg tablet orally • It doesn't cause hyperplasia & causes regular bleeding- • Relieves – Mood Disorder, Vasomotor Symptom, Sex Drive, Reduces Bone Resorption, Caradioprotective • Side Effect- Wt Gain, Edema, Tenderness Of Breast, Gi Symptoms, Vaginal Bleeding, greasy Skin, Increased Hair Growth • Should be used after 1 year of menopouse. • May increase risk of ca breast

  50. Non Hormonal Treatment Lifestyle modification – • Exercise • Diet- Rich in Calcium & Protein • Cessation of Smoking & Alcohol • Supplements- Calcium, Vit D3]

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