Menopause Done by : Bayan Abu-Alia - PowerPoint Presentation

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Menopause

Done by :

Bayan Abu-Alia

Saef B Al-

Abbadi

Slide2

LEARNING OBJECTIVES

Definition of menopause ,,causes ,,types

Impact on life

Management

Slide3

Definition

The

menopause is defined as the woman’s final menstrual

period.

1

year of amenorrhea.is cessation of regular ovarian function.

Slide4

The stages of the menopause

Perimenopause

:

The 3-5 year period before menopause

when your estrogen and hormone levels begin to drop is called

climacteric phase. You typically enter into perimenopause in your late 40's and could begin to experience

irregular menstrual cycles

and

symptoms. There

is still a chance that you could get pregnant during this time and if

you want

to avoid this, a form of birth control is recommended until one year after your last

period

The menopause

: The

final menstrual period (no more

eggs)

Postmenopause

: Starts

when you have had no

periods for

12 months

Slide5

When does

the

menopause happen?

The menopause can start at any time

from late 30s to late 50s. For most women it happens between age 45 and

55

.

A natural

menopause between the ages of 40 and 45 is called

an

early

menopause

.

A natural menopause before the age of 40

is considered

a

premature

menopause

which is mostly

idiopathic , but can also occur after radiation therapy or surgical oophorectomy

.

Slide6

Endocrine changes

control of reproductive functions done by interactions between

(

GnRH

), the pituitary hormones

(LH) and (FSH), the ovarian peptide hormone inhibin B

and

the steroid

hormones

oestrogen

,

progesterone

and

testosterone

. These hormones not only change during

the menstrual

cycle but

also throughout

a woman’s reproductive life,

with their production changing

at differing

times and rates according to the age of the

woman.

Inhibin

B is produced by follicles within the ovary, so as the

number of follicles decline

the

production

of

inhibin

decreases

. In the

perimenopausal

years

small

declines in

inhibin

drive an

overall increase

in the

pulsatility

of

GnRH

secretion and overall serum FSH and LH levels

, which results in

an increased

drive to the remaining follicles in an attempt to maintain follicle production and

oestrogen

levels.

Androgenic hormone production comes from ovaries, peripheral adipose tissue and the

adrenal glands

, with the ovaries producing approximately 30–50% of total circulating levels.

A decline in

ovarian testosterone

and other androgens accompanies the process of ageing in

women

.

Slide7

Laboratory markers of menopause include the following:

An

increase

in

serum follicle-stimulating hormone (FSH

) and decreases in estradiol and inhibin are the major endocrine changes that occur during the transition to menopause (no negative feedback on FSH,, SO there will be a high level of it)

FSH levels are higher than luteinizing hormone (LH) levels, and both rise to even

higher

values than those seen in the surge during the menstrual cycle

The

FSH rise precedes the LH rise

; FSH is the diagnostic marker for ovarian failure, while LH is not necessary to make the diagnosis

Slide8

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Diagnosis

The diagnosis of menopause is a largely

clinical

diagnosis that is made according to

symptoms experienced, mostly due to lack of estrogen.

• Irregular periods • increased vaginal pH and increased vaginal infections• Hot

flushes

• Night

sweats

•

Heart

palpitations

•

Decreased

libido

and Vaginal dryness

• increase risk of

cvs

diseases

• osteoporosis• Psychological : Mood swings, Irritability, Increasing anxiety, Insomnia ,

An

elevated serum

FSH

in association with

a low

serum

oestradiol

may be suggestive

of menopause

Hystrectomy

cases : no vaginal bleeding already ,,we can diagnose here with signs and symptoms like hot-

flushes,,night

sweat ….

-

Hysterectomy

(uterus removed)—symptoms appear

gradually

-

Oophorectomy

(ovaries removed)—symptoms appear

immediately

.

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Non-physiological menopause

Premature ovarian

insufficiency

Iatrogenic menopause – medical treatments and menopause

after cancer treatment

Iatrogenic menopause – surgical menopause

Slide11

Premature ovarian insufficiency

If menopause occurs

before the age of 40 years it is defined as premature ovarian insufficiency (POI

),

OR

premature ovarian failure (POF).It is thought to occur in approximately 1% of women under 40 years and 0.1% under 30 years. It is a distressing diagnosis for

a woman

to receive, especially if it occurs prior to the completion of her family

.

While

no cause

is found in most cases of primary POI, a suspected case should be investigated

where possible

for causes

that

are associated with issues that require separate

treatment.

Primary

Chromosome anomalies

(e.g. Turner’s, fragile X)Autoimmune disease (e.g. hypothyroidism, Addison’s, myasthenia gravis)

Enzyme

deficiencies

(

e.g. galactosaemia, 17a-hydroxylase deficiency)

Secondary

Chemotherapy

or

radiotherapy

Infections

(e.g. tuberculosis, mumps, malaria, varicella

)

Slide12

Iatrogenic menopause – medical

treatments

If

GnRH

is given in a constant high dose, it desensitizes the

GnRH receptor and reduces LH and FSH release. Drugs that are GnRH agonists (e.g. buserelin and goserelin

) can be used as treatments

for endometriosis

and other

gynaecological

problems.

when administered

continuously they will down-regulate the pituitary and

decrease

LH and

FSH secretion

. This will induce a

temporary menopause

with a relatively

rapid onset, which can be managed with the introduction of hormone therapies and other drugs to relieve some of the unwanted menopausal symptoms – known as add-back therapy.

Slide13

Iatrogenic menopause – surgical menopause

Surgeries that interrupted ovarian functions

surgical management aiming to permanently treat benign

gynaecological

conditions such as menstrual disorders, fibroids and endometriosis

. Bilateral salpingo-oophorectomy (BSO) may also be performed prophylactically for women at high risk of inherited malignancies such as breast and ovarian cancer

,

.

Good clinical practice in

these women

should ensure that before making the irreversible decision to have a BSO for these diseases

they consider

the correct time in their life for the procedure and that they are given plans for how they

can manage

the sudden hormone deficits that they will have to endure.

Slide14

Symptoms and how affect life??

Slide15

** While most effects of the menopause have

long-term implications

, the effects of

menopause are commonly categorized as having an

early onset

or an onset in the medium to long term

Slide16

Central nervous system

1) Vasomotor symptoms :

The colloquial term applied to vasomotor symptoms is ‘

hot flush

’, and when a hot flush occurs at night it is termed ‘night sweat .The exact aetiology of a vasomotor symptom is

unknown

but is thought to be

loss of the modulating effect of oestrogen on

serotinergic

receptors within the thermoregulatory centre in the brain

, resulting in

exaggerated peripheral

vasodilatory

responses to minor atmospheric changes in temperature

.

Hot flushes occur in up

to 80% of women

.

the most distressing effect of vasomotor symptoms is through the occurrence of night sweats. The woman may be asleep at the time of the sweat, but during the episode she can be fully woken or

her level of sleep can be converted from deep rapid eye movement (REM) sleep to a shallower sleep

that is less refreshing .

additional

triggers

include

alcohol, caffeine and smoking. Women with a high body mass index (BMI) tend to get worse

vasomotor symptoms .

Slide17

2) Psychological symptoms :

menopause is associated with

low mood

,

irritability

, lack of energy, tiredness and impaired quality of life from the early perimenopausal period .3)

Cognitive function :

At present there is

no clear evidence

that menopause is associated with an

acceleration of the onset or incidence of dementia .

Slide18

The genital tract

The initial irregular or scanty vaginal bleeding is due to the

reduction in

oestrogenic

endometrial

stimulation with failing ovarian function, ultimately resulting in periods completely stopping when the endometrium is no longer stimulated.

fluctuations in oestrogen levels leads to unpredictable

progestogenic

levels

, which usually has the effect of

inadequate regular endometrial shedding

. This can then lead to some women experiencing

irregular heavy bleeding

vaginal dryness

,

irritation

,

burning

, soreness and dyspareunia.Other conditions that frequently worsen during the menopause, including incontinence and prolapse

The inherent resistance of the

urogenital

system to

infection

is also impaired, considered to be due to an

increase in pH of the normally mildly acidic environment within the vagina

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Bone health

There will be loss of the oestrogenic support of skeletal metabolism.

Disturbances between

resorption

and

formation of bone.Bone density naturally increases during childhood, reaching a peak

between 20 and 30 years of age

.

Males generally achieve a greater peak bone density in comparison to females

.

After

peak bone mass

attainment in women there is a

steady decline until the menopause

, then an

accelerated phase of bone loss until 60 years

,

followed by

further steady decline until death

.Osteoporosis more frequent in women than men with an approximate ratio of 4:1.

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Cardiovascular system

Approximately

30%

of all deaths occur as a result of

ischaemic

heart disease and stroke . there are several changes in the female physiology that can influence

individual risk of CVD :

1)

lifestyle issues

such as nutrition and exercise,

2)

changes in the distribution in fat

from a more

gynoid

(fat

on breasts and hips) to

android

(abdominal fat deposition) estrogen favour gynoid fat

3) and

changes in serum lipid levels

that include

increases

in

triglycerides, total cholesterol and low-density lipoprotein (LDL) cholesterol 4) reduction in high-density lipoprotein (HDL) cholesterol.Oestrogen also has a supportive effect on the vessel wall that favours

vasodilatation

and

prevents

atherogenesis

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Assessment and Management

Slide22

Diagnosed

mainly clinically

•

--Vasomotor,,

Uro

-genital tract,,, including sexual concerns.,,psycho,,,Joint pains ,,,Vaginal bleeding (if relevant).There is rarely a need for investigations to confirm menopause. While a serum FSH level more than 30 IU/l is highly suspicious of menopause, the diagnosis can be confidently made in most women based on history alone

Also post menopausal women should screen for breast cancer and cervical cancer

((

((

Cuz

if they want to take

H

omrmonal

R

eplacment

T

herapy

Slide23

Management

1-lifestyle modification

2-diet and exercise

3-non hormonal therapy

4-hormonal replacement therapy

Slide24

Lifestyle modification

1-stop smoking (

smoking by it self has anti-estrogen effect

)

---Prevention of lung cancer ---Reduction of CVD---Beneficial effects on bone loss2-reduce alcohol consumption ---Reduction of calorie intake ---Fewer, less severe vasomotor symptoms

---Beneficial effects on bone loss ---less CVD

---Prevention of alcohol-related liver damage

3-aim for normal BMI

---Reduction of calorie intake ---Fewer, less severe vasomotor symptoms

---Beneficial effects on bone loss ---Reduction in incidence of breast cancer

---Reduction in incidence of endometrial cancer

---Reduction of CVD

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Diet and excersice

Ca+2 and vitamin D intake

Weight bearing

excersise

Biphosphonatees Estrogen replacement therapy

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One of the more challenging messages to communicate to women after the menopause is that on

average body weight increases

by approximately 1 kg per year

and this, along with a

more android fat

distribution( EFFECT OF NO ESTROGEN), contributes to a greater sensation of being overweight. Often women who start HRT early inthe

menopause erroneously blame this weight gain on HRT

. They should be informed that there is no

evidence from extensive research to support the belief that hormone therapy causes weight gain

Slide27

Non-hormonal treatments for vasomotor symptoms

---

Alpha-adrenergic agonists

ex .

Clonidine

---Beta-blockers ex.Propanolol

----anti-depression

---

Venlafaxine

---

Fluoxetine

---

Paroxetine

---

Citalopram

Slide28

Hormonal Replacement Therapy

70-85%

of women remain healthy need only good nutrition and healthy life style.

So not all women requires HRT

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ESTROGEN

Systemic

oestrogen

-only

HRT is suitable for women who

no longer have a uterus following a hysterectomy.Because if oestrogen is given without progestogenic

opposition, there is a

risk that in time endometrial hyperplasia and cancer may develop

Oestrogens

:

•

oestradiol

(the main physiological

oestrogen

);

•

oestrone

sulphate

;• oestriol;• congugated equine

oestrogen

.

Slide30

Why Estrogen?

Short term estrogen therapy

To relieve symptoms like; hot flush, night sweats, palpitations, disturbed sleep

for dyspareunia, urethral syndrome and senile vaginitis

Long term therapy:– For delaying osteoporosis

– Reduce

the risk of CV disease

– Beyond 8-10yr

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Progesterone

--necessary to protect the

endometrium

in women who have not had a hysterectomy

(estrogen alone with

endometrium >> risk for endometrium ca--Prevents breast cancer--Improves bone mineral density

Progestogens

:

• norethisterone;

• levonorgestrel;

• dydrogesterone;

• medroxyprogesterone acetate;

• drospirenone;

• micronized progesterone

Slide32

Oestrogen with

progestogen

during the

perimenopause

or early postmenopausal years

: normally given cyclically in preparations over a 28-day cycle, of which 16–18 days will provide oestrogen alone and 10–12 days provide estrogen and progestrone

combined

postmenopausal or over the age of 54 years

:

Oestrogen

and progesterone may be given continuously (continuous combined HRT)

Slide33

Testosterone

Also testosterone decline in menopause

peroid

leading to decrease libido

given to women with disorders of sexual desire and energy levels who have failed to respond to normal HRT

testosterone needs to be instigated under the care of a doctor with specialist menopause knowledge

Slide34

Routes of hormone therapy administration

Oral way

daily tablet that contains the appropriate mix of

oestrogen

and

progestogenAdvantages

:

Easy to take & cheap.

Disadvantages :

influence lipid metabolism and the coagulation system through its

effects on the liver during first-pass metabolism

transdermal route

either given as

patches

applied to the skin on the trunk or as

gel

Advantage :

delivery of

oestradiol

directly into the circulation, avoiding the adverse effects on the liver and the coagulation system

No

thromboembolic

risk or hypertension

Disadvantages

:

– More expensive

– Not well tolerated in warm climates

– Variable absorption

Slide35

IMPLANT

Inserted under the skin into loose tissue through an incision

•

Sub

cutaneous

implant (estradiol): -– 25 / 50 / 100 mg. 6 monthly.

• Advantages

.

– Pure

estradiol

, 6 monthly insertion,

high level of

estradiol

in

blood

.

– Avoids first pass effects

(

did not influence lipid metabolism and the coagulation system)

– Better response in severe osteoporosis.• Disadvantages.

– Needs surgical procedure

– Unable to control absorption

– Difficult to remove pellet

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Beneficial effects of hormone therapy

Vasomotor symptoms :

--90% of women note a significant improvement within 6 weeks

--reductions in frequency and severity of hot flushes and night sweats

--consequent improvements in sleep and daytime energy levels

The skeleton :--Prevention of osteoporosis --increased bone mineral density; & reduce risk of fracture

The lower genital tract :

--improves vulvovaginal dryness, irritation, dyspareunia and symptoms of cystitis like

dysuria

Cardiovascular system :

reduction in ischemic heart disease and overall mortality

Colon

:

Decreased incidence and mortality of colon cancer

Slide37

Side effect of HRT

Side-effects associated with

oestrogen

:

• breast tenderness or swelling;

• nausea;• leg cramps;• headaches.

Side-effects associated with

progestogen

:

• fluid retention;

• breast tenderness;

• headaches;

• mood swings;

• depression;

• acne.

Slide38

contraindications

Absolute contraindications

:

• suspected pregnancy;

• breast cancer;•

endometrial cancer

;

•

active liver disease

;

• uncontrolled hypertension;

• known current venous

thromboembolism

(VTE

);( estrogen increase transcription of clotting factors)

• known

thrombophilia

(e.g. Factor V

leiden

);

•

otosclerosis

.

Relative contraindications:• uninvestigated abnormal bleeding;• large uterine fibroids;

• past

history of benign breast disease

;

•

unconfirmed

personal history or a

strong family history of VTE

;

• chronic

stable liver disease

;

• migraine with aura

Slide39

Risks of hormone therapy

That’s mean why there is an Absolute contraindications?? What is the Risk??

1 - Cancer

:

risk of breast cancer

Endometrial cancer and ovarian cancer are not considered significant risks with HRT useEndometrial malignancy risk is largely eliminated if women are given progestogens.

2 – Cardiovascular and stroke :

when given to younger women are beneficial but older women the effects may become deleterious

.

Stroke incidence has a similar age effect, with the increased incidence greater in the older woman

.

3 - Venous

thromboembolism

:

HRT doubles risk in older women

transdermal HRT, through its avoidance of effects on the liver, may not have such a great effect on VTE incidence

Slide40

Thank you