Menopause

Resident Lecturer:

Abigail Polintan, MD

Consultant Facilitator:

Divina Rojas, MD, FPOGS

Menopause

• Defined by the WHO as the permanent cessation of menstruation resulting from loss of ovarian follicular activity

• Determined retrospectively from the date of the last menstrual period, after 12 months of amenorrhea, with no other attributable cause

Perimenopause

• Menopausal transition• Includes the years prior to menopause that

encompasses the change from normal ovulatory cycles to cessation of menses

• Hallmark: Skipped periods, or longer duration between periods (40-60 days)

Climacteric

• Refer to the period of time when a woman passes from a reproductive stage of her life to a non-reproductive stage

• Includes menopausal transition, menopause, and the post-menopausal years

Premature Ovarian Failure

• Refers the cessation of menstruation due to depletion of ovarian follicles before the age of 40

• Also known as premature menopause.

Estrogen Replacement Therapy (ERT)

• Refers to the administration of physiologic doses of estrogen by oral or topical routes to postmenopausal women without addition of progesterone

Menopause

• Genetically programmed• Between 51-52 years of age• Average menopause age for Filipinas is 47

Hormonal Changes in Menopause

• Reduction in E2 and E1(Estrone)• FSH and LH- Normal Growth Hormone (GH)- Normal Thyroid Stimulating Hormone

(TSH)- Normal ACTH- Continued production of androstenedione,

DHEA,DHEA-S by the adrenals- Testosterone

Systemic Effects of Menopause

• Central Nervous System• Vasomotor Symptoms (hot flush)

• Due to the fall in estrogen level precipitates• Results from a hypothalamic response probably

mediated by cathecolamines.

• Depression• Irritability

Systemic Effects of Menopause

• Integument• Decrease in collagen

• Reproductive System• Genital atrophy

• Skeletal System• Bone Loss

• Cardiovascular System• Accelerated rise in total cholesterol

Management of Perimenopausal and Postmenopausal Women

• Vasomotor symptoms• lifestyle changes: cool body temperature• regular exercises• paced respiration• avoidance of hot flush trigers• Maintain a healthy weight

• low-dose HRT/ERT• Transdermal estradiol

• Tibolone

Management of Perimenopausal and Postmenopausal Women

• Urogenital atrophy• HRT/ERT and vaginal moisturizers• Low-dose vaginal products are the treatment

of choice• Regular sexual activity• Tibolone

Management of Perimenopausal and Postmenopausal Women

• HRT/ERT have beneficial effects in maintaining skin thickness, prevention of dementia, and improving mood disorders

Osteoporosis

• HRT/ET; Tibolone• Calcium(1200-1500mg/day)

• Calcium carbonate has 40% elemental Ca• Calcium lactate has 10% elemental Ca

• Vitamin D (400-600 IU)• Engage in regular weight-bearing

exercises like walking

Perimenopausal Bleeding

• Should always be investigated to rule out organic causes

• Medical management may be recommended if the endometrium is normal

• NSAIDS may be used to minimize abnormal bleeding in the absence of menopausal symptoms

Postmenopausal Phase

• Osteoporosis• Calcium and vitamin D• HRT/ERT• Alendronate, Risedronate,

raloxifene,parathyroid hormone

Cardiovascular Disease

• There is significant increase in cardiovascular events after HRT use, its use should only be reserved for those experiencing severe menopausal symptoms and the recommendation should include only the low-dose HRT/ERT.

Congraindications to HRT/ERT

• Current, past or suspected breast cancer• Known or suspected estrogen-dependent

malignant tumors(e.g. endometrial cancer)• Undiagnosed genital bleeding• Previous idiopathic or current venous

thromboembolism(deep venous thrombosis, pulmonary embolism)

Congraindications to HRT/ERT

• Active or recent arterial thrombolic disease(e.g. angina, myocardial infarction)

• Untreated hypertension• Known hypersensitivity to the active

substances or to any of the excipients• Porphyria cutanea tarda(absolute

contraindication)

Hormonal Therapy

1. Estrogens

Oral= oral CEE – 0.625 mg

Transdermal patch

Vaginal cream

2. Progestins

Oral= medroxyprogesterone acetate -10mg

3. Combinations

CEE+ MPA

Hormonal Therapy

4. Androgens

Oral- Esterified estrogen and methyl testosterone

Transdermal

5. Biphosphanates

Alendronates,Risedronate, Ibandronate, Eridronate

Hormonal Therapy

6. SERM(Selective Estrogen Receptor Modulators)

Raloxifene,Tibolone,Human parathyroid Hormone

Alternative Therapy

• Phytoestrogens• plant-derived estrogen-like compounds that

can produce estrogen-like effects

THANK YOU!