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Overview of menopause, the issues related to this subject and clinical implications for the student
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An Overview of Menopause
Associate Prof Dr Hanifullah Khan
objectives
! to understand this condition & terminology
! physiology of menopause
! problems linked with menopause
! clinical scenarios
what is menopause?
! A physiological loss of ovarian hormonal activity ! Closely allied to loss of reproductive potential ! Permanent cessation of the primary ovarian
functions
Physiology
The Ovaries
! 2 functions - produce ova & secrete hormones
! Start secreting estrogen & progesterone from puberty to menopause
! Most of the beneficial effects derive from estrogen
actions of estrogen ! formation of the 20 sex characteristics ! Develop ovaries, tubes, uterus & vagina ! HPO axis interaction ! endometrial proliferation ! Increases fat deposition ! maintain the skin & vessels ! bone - incrrease formation & reduce
resorption
actions of progesterone
! its actions are amplified in the presence of estrogen
! Interacts with hypothalmus and pituitary to regulate menstrual cycle
! converts endometrium to secretory stage ! makes cervical mucous & vaginal
epithelium impenetable to sperm ! inhibits lactation during pregnancy ! makes the uterus less contractile
When does menopause occur?
! Tends to occur over a period of years
! A consequence of biological ageing
! Genetic & environmental factors
! Malaysian women - 48 - 52 years*
*Jahanfar SH 2006, Ismael NN 1994
Types of menopause
- Premature Menopause - menopause in a woman aged <40 years
- Early Menopause - menopause in a woman aged 50 - 59 years - Late Menopause - menopause in a woman aged >60 years - Surgical menopause - a result of surgical removal of both ovaries - Medical menopause - - permanent damage to both ovaries - chemotherapy or
radiotherapy - temporary - GnRHa tx in endometriosis
Perimenopause - the time just before and soon after the occurence of menopause
- symptoms of menopause have started
- not yet certain if menopause is established yet
Diagnosis of menopause ! The diagnosis of menopause is mainly clinical
• a. Clinical Criteria
1. age around menopause ( around 50 years )
2. no periods for 12 months
3. menopausal symptoms
• ( NB. All 3 clinical criteria need not be present for a diagnosis )
• Laboratory diagnosis is generally not necessary for the diagnosis of menopause. However, where in doubt, laboratory testing of FSH may support the diagnosis, viz
• b. Laboratory Criterion
• 1. FSH level > 35miu/ml
The consequences of menopause
primary symptoms
- Menstrual changes - Abnormal - Oligoamenorrhea – amenorrhea - Vasomotor - hot flashes, night sweats - Urogenital - Vaginal dryness, micrurition altered
secondary symptoms
- Physical symptoms - Muscle & joint pains - Skin dryness, decreased stamina, backache - Sexual - Decreased libido - Avoiding intimacy - Psychophysiologic changes - Decrease concentration - Depressive symptoms
Monitoring symptoms
Long term effects
! Cardiovascular
! Bone
! Cancers
! Cerebrovascular
Clinical implications of menopause
Minor conditions
- Urinary tract infections - Vaginal dryness
- Vaginal infections - Joint & muscle pains
Symptoms mimicking disease ! Abnormal vaginal bleeding
! Perimenopausal
! Postmenopausal
! General pains e.g. Breast
Perimenopausal abnormal bleeding - At this age, there are many conditions that peak
- e.g. Adenomyosis, polyps, fibroids, hormonal
- Cancers are always a concern, esp Ca Cx
- Infections are the most common occurrence
- All these must be ruled out before a diagnosis of perimenopausal bleeding is made
Postmenopausal bleeding
- Consider it as always abnormal
- Always think of cancer
- Usually due to atrophy or infection
Cardiovascular disease
! CV risk increases as estrogen levels decline
! 1 in 2 women will die from cardiovascular disease
! Estrogen exerts beneficial effects on CV system through
! Direct effect on the vasculature
! Indirect effect of lipid metabolism
Kramarow E et al. Health and Aging Chartbook. Health, United States, 1999. National Center for Health Statistics; 1999.
Cholesterol metabolism
! “Only total cholesterol, low-density lipoprotein cholesterol, and apolipoprotein B demonstrated substantial increases within the 1-year interval before and after the FMP, consistent with menopause-induced changes. This pattern was similar across ethnic groups.”
Matthews K. J Am Coll Cardiol. 2009;54(25):2366-2373
Fracture risk ! decreased
bone density
! osteoporosis
! common fractures involve hip, forearm & spine
you wanna be like this?
Psychomotor & Mental
! loss of libido
! suicidal tendencies
! marital discord
Urogenital problems
Menopausal Hormone Therapy
potential risks & concerns
- Breast cancer - Cardio vascular disease - Venous thrombosis - Endometrial cancer - Compliance/therapy - The Women’s health initiative study aimed to confirm all these
Conclusion • “Estrogen plus progestin was associated with greater
breast • cancer incidence, and the cancers are more commonly
node
• positive. Breast cancer mortality also appears to be
• increased with combined use of estrogen plus progestin.”
• Writing Group for the Women’s Health Initiative Investigators
JAMA. 2010;304(15):1684-1692
Current recommendations
- hormone therapy should be initiated for the treatment of menopause-related symptoms
- the lowest dose should be used for the lowest duration - 5 years recommended for estrogen+prog therapy
- hormone therapy risks - all forms of tx increse risk of VTE (deep vein thrombosis & pukmonary emboli)
- increased risk of breast Ca with est+prog combination
Stuenkel CA et al. Menopause. 2012;19(8):846-847
Summary
! menopause is a natural occurence
! it is associated with long- & short-term issues
! some of the menopausal symptoms may mimic medical disorders
! postmenopausal conditions such as bleeding & masses must be seriously looked into
! hormone therapy should be used but it has its problems
The important points
Q. A 40 year old woman presented with no periods for 1 year. How would you diagnose menopause?