Transcript Menopause

Menopause
Gyne I
1.
Menopause is the period in which a permanent
cessation of menses occurs because of loss of
ovarian activity.
2. Menses usually stop between 50 and 52 years of
age; the median age of menopause is 51.3 years,
with a range of 41 to 55 years.
3. Premature menopause is defined as the permanent
cessation of menses occurring before 40 years of
age.
Peri-menopause
1. The perimenopause refers to the period just before and after the
menopause, usually ranging from 40 to 55 years of age.
2. The transition is a term used to describe the years leading up to
and preceding the menopause.
a.
This period is marked by menstrual cycle irregularity
b.
The median age of onset of menstrual irregularity is 47.5
years; the transition lasts an average of 4 years.
c.
Ten percent of women abruptly stop menstruating without
preceding cycle irregularity.
Climacteric
1. Climacteric is a broad term encompassing
the transitional years, the menopause, and
the postmenopausal years.
2. This period reflects the decline and loss of
ovarian function and the long-term
consequences of reduced estrogen levels.
PHYSIOLOGY OF THE
PERIMENOPAUSE
Ovarian function..
1. The number of remaining follicles is reduced and those
remaining are less sensitive to gonadotropin stimulation
2.
Follicular function varies from cycle to cycle within the same
individual.
3.
As follicular maturation declines, ovulation becomes less
frequent as the menopause approaches.
Although fertility rates are markedly reduced, conception can occur
during this time of fluctuating ovarian activity.
Endocrinology
1. Inhibin production by the ovary is reduced. Inhibin exerts a negative
feedback on the secretion of follicle-stimulating hormone (FSH) by the
pituitary.
2. An increase in FSH levels
3. Luteinizing hormone (LH) secretion escapes the negative feedback of
inhibin, LH levels rise much later in the transition than FSH levels
4. Estradiol levels fluctuate but remain within normal until follicular
development stops completely.
5. Progesterone levels fluctuate depending on the presence and adequacy
of ovulation and are frequently low during the transition.
6. Androgen levels steadily decline during the transition period.
Menstrual cycles
Changes in the menstrual cycle reflect changes in ovarian function
1. Changes in menstrual cycle regularity occur as a woman
progresses through her forties. Cycle length is determined by
the length of the follicular phase. It is variable and may be
normal, shortened, or prolonged.
2. Shortening of cycle length occurs early in the transition and is
associated with ovulatory cycles,
3. Anovulatory cycles and prolonged cycles become more frequent
as the menopause approaches, resulting in dysfunctional
uterine bleeding (DUB) and oligomenorrhea.
Manifestations of hormonal
fluctuation
1. Menstrual cycle changes.
a. Menorrhagia Increased flow may result from
a relative reduction in progesterone levels.
b. Metrorrhagia or polymenorrhea
c. Midcycle spotting. With a drop in estradiol
levels just before ovulation, midcycle
estrogen withdrawal bleeding may occur.
d. Oligomenorrhea. As the menopause
approaches,
2. Other symptoms
a. Hot flushes or flashes.
b. Headaches. Premenstrual migraines may
appear or worsen during this time.
c. Premenstrual psychological symptoms.
d. Sleep disturbances.
CLINICAL MANIFESTATIONS
OF MENOPAUSE
Urogenital atrophy.
The vaginal epithelium becomes pale, thin, and dry
vaginal walls lose elasticity and compliance; the vagina becomes
smaller, and the size of the upper vagina diminishes
The labia minora have a pale, dry appearance, and there is a
reduction of the fat content of the labia majora.
The pelvic tissues and ligaments that support the uterus and the
vagina lose their tone, predisposing to disorders of pelvic
relaxation
The epithelium of the urethra and bladder mucosa becomes
atrophic; there is a loss of urethral and bladder wall elasticity
and compliance
2. Uterine changes
a. The endometrial tissue becomes sparse, with
an atrophic appearance.
b. The myometrium atrophies, and the uterine
corpus decreases in size.
c. The squamocolumnar junction relocates high
in the endocervical canal; the cervical os
frequently becomes stenotic.
d. Fibroids, if present, reduce in size but do not
disappear.
3. Breast changes
a. Progressive fatty replacement with atrophy of
active glandular units
b. Regression of fibrocystic changes
Others
4. Skin changes. Skin collagen content and skin thickness
decrease proportionately with time after the menopause.
5. Bone changes. Bone loss is accelerated for the first 5 to 7
years after the menopause associated with decreased
estrogen levels.
a. The greatest effect is seen in trabecular bone, particularly in
the spine.
b. Excessive loss predisposes to the development of
osteoporosis and increased fracture risk.
6. Hair changes. As estrogen decreases, circulating androgens
increase and the chance of developing increased facial hair
and androgenic alopecia increases.
7. Brain changes. Estrogen receptors are located
throughout the brain. Reduced estrogen levels may
affect cognitive function and moods after the
menopause, although the precise contribution has
not been fully defined.
8. Cardiovascular changes. The incidence of
cardiovascular disease increases after the age of 50
years in women coincident with the age of
menopause. Cardiovascular disease is the cause of
the largest number of deaths of menopausal women.
Symptoms related to estrogen
reduction
1. Vasomotor instability
Hot flushes or flashes are the most common symptom related to
the menopause and occur in 75 to 85% of perimenopausal
women.
(1) more frequent and severe at night or during times of stress.
(2) They also can be precipitated by foods and beverages that are
hot or spicy or contain methylxanthines; they can be precipitated
by alcohol as well.
(3) The vasomotor instability lasts for I to 2 years in most women
but may last for as long as 5 years or more in up to one third of
symptomatic women.
Hot flushes are the result of inappropriate stimulation of the body's heatreleasing mechanisms by the thermoregulatory centers in the
hypothalamus.
Although the core body temperature is normal, the body is stimulated to lose
heat.
The onset of the flushes initially depends on a reduction of previously
established estrogen levels.
Flushes are characterized by progressive vasodilation of the skin over the
head, neck, and chest, accompanied by reddening of the skin, a feeling of
intense body heat, and perspiration.
Palpitations or tachycardia may accompany the flush. The flush may last a few
seconds to several minutes and recur with variable frequency.
Treatment
(1) Hormone replacement or estrogen replacement
reduces or eliminates hot flushes.
(2) Progestins, clonidine, methyldopa, vitamin E, and
herbal remedies are used to treat hot flushes in
women in whom estrogen is contraindicated. Relief is
not as complete as that seen with estrogen therapy.
(3) Venlafaxine, an inhibitor of serotonin and
norepinephrine reuptake, given in low doses has
been effective in reducing or eliminating vasomotor
instability in 60% of symptomatic women.
2. Altered menstrual function.
Oligomenorrhea is followed by amenorrhea.
If vaginal bleeding occurs after 6 months of
amenorrhea, endometrial disease (e.g.,
polyps, hyperplasia, or neoplasia) must be
ruled out.
3. Vaginal atrophy
a. Dyspareunia (painful intercourse).
(1) Changes in the vaginal epithelium and vaginal vasculature lead to decreased
lubrication during sexual activity. Decreased compliance and elasticity of the
vaginal wall contribute to vaginal stenosis.
(2) Continued sexual activity into the menopause is associated with increased
vaginal blood flow and fewer problems with sexual function compared with
women who are less frequently sexually active.
b. Atrophic vaginitis
(1) The postmenopausal vagina becomes more susceptible to pathogenic and
nonpathogenic organisms.
(2) Atrophy of the vaginal mucosa and changes in pH predispose to vaginitis, which
presents with symptoms of discharge, pruritus, odor, and irritation.
c. Treatment. Symptoms related to vaginal atrophy respond to estrogen therapy.
4. Urinary tract symptoms
Changes in the mucosal lining of the urethra and
bladder may lead to symptoms of dysuria, nocturia,
urinary frequency, urgency, and urge incontinence.
Urinary stress incontinence may progressively worsen
after the menopause because of urethral changes
and a loss of pelvic support.
There is an increased incidence of bacteriuria
b. Treatment. Vaginal, urethral, and bladder symptoms
improve with estrogen therapy.
5. Osteoporosis
.
This systemic skeletal disease is characterized by low
bone mass and microarchitectural deterioration of
bone structure
Both result in fragile bones that are at an increased risk
for fracture.
Osteoporosis may be a primary disease state or may be
secondary to other diseases that affect calcium and
bone metabolism.
Epidemiology and etiology
(1) Peak bone mass is reached in the late
twenties for trabecular bone and the early
thirties for cortical bone.
(2) Thereafter, there is a gradual loss of bone with
aging.
(3) Bone loss is accelerated for the first 5 to 7
years after the menopause as a direct result of
declining estrogen levels.
Problem size
In the United States;
An estimated 1.3 million fractures occur annually.
Approximately 25% of white American women older
than 60 years of age who are not treated with
estrogen replacement have spinal compression
fractures.
Approximately 32% of white American women older
than 75 years of age suffer hip fractures;
Risk factors
Inadequate calcium intake
Sedentary lifestyle
Smoking
Alcohol use
Thinness
premature menopause
genetic predisposition
white and Asian race
Steroid and thyroxine use.
Diagnosis
Imaging modalities can be used to detect bone loss and
bones at risk for fracture earlier in the disease.
(1) Dual-energy x-ray absorptiometry is the most
popular technique used today to measure bone
density.
Independent measurements can be made at the hip,
spine, and other bone sites.
(2) Quantitative computed tomography gives the most
precise measurement of bone density at specific
sites. However, its use has been limited by expense
and higher radiation doses.
Prevention of osteoporosis
Exercise
adequate calcium intake (early)
estrogen replacement after the menopause
The higher a woman's bone mineral density at the onset
of menopause, the less risk of fracture.
Treatment
 Calcitonin √
 Fluoride X
 Androgens X
 bisphosphonates (alendronate, etidronate
disodium, risedronate)√
 SERMs (selective estrogen receptor
modulators such as raloxifene). √
 HRT: not therapeutic
Regimens of HRT
1. Unopposed estrogen.
This is the treatment of choice in women who have
undergone hysterectomy.
If not, Endometrial biopsy on an annual basis is
recommended.
2. Sequential combined therapy. Estrogen is
administered every day, and progestogen is
administered for 12 to 14 days every month.
Scheduled bleeding should occur on completion of
the progestogen.
3. Continuous combined therapy
a. Estrogen and progestogen are administered daily.
(1) There is no scheduled withdrawal bleeding.
(2) Symptoms that worsen with hormonal fluctuations,
including mood disturbances, migraines, and cyclic
mastalgia, are improved.
(3) The regimen is easy for patients to remember.
But irregular spotting and bleeding in up to 40% of
women during the first year.
4. Periodic or quarterly progestogen X
a. Progestogen is administered for 14 days
once every 3 months
b. Withdrawal bleeding may be heavy
5. Local applications
a. Topical estrogen is used intravaginally to treat
symptoms of urogenital atrophy and dyspareunia.
Estrogen-containing creams, tablets, and synthetic
rings are available for this use.
b. Peak systemic absorption is in the first few days of
initial use. Once the vaginal mucosa becomes
cornifled, there is minimal systemic absorption of
estrogen.
c. Progestin intrauterine devices are being used as a
way to provide endometrial protection and avoid the
side effects of systemic progestin.
Route
1. Estrogens. Estrogens, for the purpose of
replacement, are administered orally or
transdermally or locally
2. Progestogens medroxyprogesterone acetate.
Starting doses depend on the regimen used.
(1) 5 mg for 12 days monthly for sequential
therapy
(2) 2.5 or 5 mg for continuous regimens