menopause by dr numan alam
TRANSCRIPT
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
Effect Of Menopause
Risk of • Fracture• Heart
Disease
Menopausal Symptoms
Estrogen & Progesterone level
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
•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
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