Done by: anmar magharbeh - PowerPoint Presentation

Slide1

Done by: anmar magharbeh

Menopause

Slide2

Menopause

is a retrospective diagnosis ,it is defined as 12 months of

amenorhhea

.

The average age at menopause is approximately 51 years. Happens gradually with irregular

anovulatory

cycle

Peri

menopause or climacteric

. It is the time period from when the ovaries start to fail until 12 months after the last menstrual period.

Premature

menopause

is defined as menopause that occurs

between

the age of

30 and

40 years

.

Premature ovarian failure

: menopause before age of 30

Slide3

symptoms

Hot

flushes

Night

sweats

Mood

swings

Urogenital

atrophy

Slide4

Diagnosis

The diagnosis of menopause is

mainly a clinical

diagnosis

. Symptoms include : menstrual

irregularities

,

amenorrhoea

, and

vasomotor

symptoms.

The use of serum endocrine tests such as hormone levels are of little value in the

perimenopausal

years

as they are unpredictable due to the hormonal variations that frequently occur in association

with episodic

and irregular

ovulatory

cycles.

An elevated serum FSH in association with

a low

serum

oestradiol

may be suggestive of menopause,

Slide5

Non-physiological menopause

Premature ovarian insufficiency

If menopause occurs before the age of 40 years it is defined as premature ovarian insufficiency (POI),

also sometimes called premature ovarian failure (POF), or premature

to

occur menopause

. It is thought

in

approximately 1% of women under 40 years

Causes :

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)

Slide6

Iatrogenic menopause

medical treatments and menopause after

cancer treatment

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

surgical

menopause

Bilateral

salpingo

-oophorectomy

(BSO) may also be performed prophylactically for women at high risk of inherited malignancies such

as breast

and ovarian cancer, with BRCA 1 and 2 gene mutation

screening

.

Slide7

Effects of the menopause by time of onset

Immediate (0–5 years)

Vasomotor symptoms, (e.g. hot flushes, night

sweats)

Psychological symptoms (e.g. labile mood, anxiety, tearfulness)

Loss of concentration, poor memory

Joint aches and pains

Dry and itchy skin

Hair changes

Decreased sexual desire

Intermediate (3–10 years

)

Vaginal dryness, soreness

Dyspareunia

Urgency

Recurrent urinary tract infections

Urogenital prolapse

Long term (>10 years)

Osteoporosis

Cardiovascular disease

Dementia

Slide8

Management

Diet

and

lifestyle

regular exercise, stopping smoking

and reducing

alcohol

consumption

Slide9

Non-hormonal approaches

considered

in the management

to

reduce

symptoms of hot flushes when hormones are

contraindicated or unwanted

Slide10

:

Alternative

and complementary treatments

These

groups of treatments are widely available

but most of them Lack sufficient scientific evidence .

Slide11

Complementary drug-free therapies (delivered by a

practitioner)

Acupuncture

Reflexology

Magnetism

Reiki

Hypnotism

Herbal/natural preparations (designed to be ingested)

Black cohosh (

Actaea

racemosa

)

Dong

quai

(Angelica

sinensis

)

Evening primrose oil (

Oenothera

biennis

)

Gingko (Gingko biloba)

Ginseng (

Panax

ginseng)

Kava

kava

(Piper

methysticum

)

St John’s wort (

Hypericum

perforatum

)

‘Natural’ hormones (designed to be ingested or applied

to the skin

)

Phytoestrogens such as

isoflavones

and

red clover

Natural progesterone gel

Dehydroepiandrosterone

(DHEA)

Slide12

Non-hormonal

treatments for vasomotor

symptoms

Alpha-adrenergic agonists

: Clonidine

Beta-blockers

:

Propanolol

:

Modulators

of central neurotransmission

Venlafaxine

Fluoxetine

Paroxetine

Citalopram

Gabapentin

Slide13

Hormonal replacement therapy

Oestrogen

only :

In

women with a uterus,

oestrogen

-only therapy is associated with a significantly increased risk of developing endometrial hyperplasia and cancer.

Used

in women who had hysterectomy.

Natural

conjugated:

Premarin

Synthetic

: Estradiol

Valerate

(

Estrofem

)

Slide14

: Combined hrt

Sequential

combined regimens

Continuous

combined regimens

Slide15

:

Sequential

combined regimens

The

addition

of Progestogen

to Estrogen therapy reduces the risk of endometrial disease, but regimens should usually include at least 10 days in each monthly cycle.

Slide16

Continuous combined regimens

:

For age

of 54, or her periods have stopped

more

than one year at any age

.

Slide17

Testosterone :

given

to women with disorders of sexual desire and energy

levels who

have failed to respond to normal HRT.

Slide18

Raloxifene

( SERM ) :

Reduces the incidence of vertebral fractures in women with osteoporosis.

There

is no current evidence of protection against fractures at the hip or at other sites.

Use

of

raloxifene

is associated with reduced risk of breast cancer but

: Increased

incidence of vasomotor symptoms

Slide19

Tibolone

(

livial

) :

has

oestrogenic

,

progestogenic

and androgenic properties.

It

appears to be effective in the treatment of vasomotor symptoms.

Recent

data suggest that

tibolone

may also be associated with an increased risk of breast cancer, but less than that associated with combined

oestrogen

and progestogen preparations.

Slide20

Routes of hormone therapy administration

The two main routes of HRT delivery are oral and

Transdermal

But

Progestogen

in the form of

levonorgestrel

may be administered as an intrauterine releasing system

(IUS),

Mirena

®

Slide21

Benefits of HRT

Vasomotor symptoms

: hot flushes. Improvement is usually noted within four weeks. In most cases, 2–3 years’ therapy is sufficient

Mood

or sleep disturbances

: HRT often improve sleep by alleviating night sweats. .

Urogenital

symptoms

: vaginal dryness, soreness,

Paiful

sex, and urinary frequency and urgency respond well to estrogens, which may be given either topically or systemically.

Slide22

Bone :

-

HRT

reduces the risk of spine and hip osteoporotic fractures.

- HRT

is currently not recommended as a first line

for osteoporosis

prevention

.

- While

alternatives to HRT are available for the prevention and treatment of osteoporosis in elderly women, estrogen may still remain the best option, particularly in younger and/or symptomatic women. It is cheaper than other alternatives such as bisphosphonates.

The colon :

While the WHI study demonstrated a clear benefit of HRT on the incidence and mortality of colon cancer,

the

use

of HRT to prevent this malignancy is not indicated.

Slide23

Contraindications

Absolute

contraindications

:

• suspected pregnancy;

• breast cancer;

• endometrial cancer;

• active liver disease;

• uncontrolled hypertension;

• known current venous thromboembolism (VTE);

• 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.

.

Slide24

Side-effects

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

Slide25

Risks of hormone therapy

:

Cancer

Breast cancer is without doubt the cancer that attracts most

concern from patient

Endometrial cancer and ovarian cancer are not considered significant risks with HRT use.

Endometrial malignancy risk is largely eliminated if women are given progestogens. Incidence of

ovarian cancer does

not

significantly

increase with HRT use.

Slide26

Cardiovascular disease and

stroke

most of the effects of HRT on the cardiovascular system when given to younger women

are

beneficial.

when given to older women the effects may become

deleterious and the risk is higher

in women taking combined HRT

Stroke

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

The effect is small and is only on the incidence of

ischaemic

stroke, thought to be an increase of

an additional

2 women per 10,000 women per year when on HRT

Slide27

Venous

thromboembolism:

The

influence of HRT on the clotting system is similar to that of the oral contraceptive. The

background incidence

of all VTE in women over 50 is low (approximately 15–20 per 10,000) and HRT doubles

this risk

. There is evidence to suggest that transdermal HRT, through its avoidance of effects on the liver, may

not have such a great effect on VTE incidence.

Slide28

Post MenopausalBleeding

Slide29

Definition

I

s any unscheduled

vaginal bleeding

that occurs

after 12 months

of

amenorrhoea

in a woman

of postmenopausal

age

.

It

is a serious symptom which may indicate the

presence of

malignant disease in the genital

tract,

So Every woman with PMB should be assumed to have

carcinom

a until proven otherwise

.

Slide30

Causes of Postmenopausal U

terine Bleeding

Atrophic vaginitis

60-80%

Estrogen

treatments

15-25%

Polyps - endometrial or

cervical

2-12%

Endometrial

Hyperplasia

5-10%

Endometrial

Cancer 10

%

idiopathic10

%

Slide31

Vaginal Atrophy

It is the most common cause

of postmenopausal

uterine

bleeding.

Is

thinning, drying and inflammation of the vaginal walls

due to low estrogen levels.

This is

a benign

condition

Clinical

features:

In

addition to postmenopausal bleeding: Vaginal dryness ,

burning sensation

, discharge, itching with increased frequency, urgency ,

incontinence

and urinary tract

infections

Treatment:

1.Vaginal moisturizers

2

.

Estrogen

either in form of creams, ring or tablet.

Slide32

Hormone Replacement T

herapy

Any

vaginal bleeding in a

menopausal

woman other than

the expected

cyclical bleeding

that occurs

in women taking

sequential HRT

should be

managed

A

. .Estrogen- cyclical

progsetrone

:

Estrogene

will be given

everyday.

Progestrone

will be given for the last (12_14) days

. Bleeding

is considered normal if bleeding starts after the

nineth

day

of progesterone use or soon after the

progestogen

phase

.

B. Combined estrogen-

progestrone

therapy:

Breakthrough bleeding is common in the first 3-6 months

, Evaluation

of the endometrium is recommended during the

first year

, if bleeding is heavy, prolonged or if any bleeding

occurs after

one year of use.

Slide33

Endometrial Hyperplasia

Is an abnormal proliferation of the endometrium (glands

). It

accounts for 5_10 % of

PMB. It

occurs due to excessive estrogen stimulation

.

More than 4mm is significant

.

classification:

1

. Hyperplasia without

atypia

Rx is

Progestogens

: oral preparation or LNG-IUS (

Mirena

)

2

. Hyperplasia with

atypia

(premalignant)

Rx is Total abdominal hysterectomy with or

without BSO.

as

significant risk

of progression

to malignancy

Slide34

Slide35

Endometrial Carcinoma

2nd most common gynecological cancer.

Is mainly adenocarcinoma arising from the lining of

the uterus

and is an estrogen-dependent tumor.

Accounts for 10% of postmenopausal bleeding.

90% of patients with endometrial cancer will present

with bleeding

.

Has 4 stages:

I. Confined to uterine body

II. Involves cervix

III. Outside uterus but inside the pelvis

IV. Extended to

blader

or rectum

Slide36

Slide37

Risk Factors of Endometrial Carcinoma

:

Early

menarche

Late

menopause

Nulliparity

Chronic anovulation

(

P.C.O.S)

Obesity

(conversion of steroids to

oestrone

in their peripheral fat)

Diabetes

mellitus

Unoppsed

estrogen therapy

Tamoxifen

therapy

(ESTROGENIC ACTIVITY ON ENDOMETRIUM)

Personal

or family history

of: endometrial

, ovarian, breast or colon cancer

Slide38

Treatment of Endometrial Carcinoma

Stage 1 and 2

: total

abdominal hysterectomy +

bilateral

salpingoopherectomy

. If

resectable

surgery followed by

chemotherapy

Stage

3 and 4

: radiotherapy

If

its not

resectable

neoadjuvant

radiotherapy followed

by surgery.

High

dose of progestin if unfit for surgery.(

paliative

)

Slide39

Management

I

. History

II.

Examination

III.investigations

Slide40

History:

Details of the bleeding

(onset, duration, amount,

color, presence

of clot

, whether

it was related to trauma or not

).

Associated symptoms

such as pain, fever or changes

in bladder

or bowel function might suggest an infective

process such

as

pyometra

or the bleeding may be arising from

the bowel

or bladder

.

exclude risk factors of endometrial carcinoma.

Slide41

Examination

General examination:

general condition,

obesity. exclude

signs of malignancy ( weight loss,

pale

Abdominal examination

: for any palpable mass

.

pelvic examination

:

Inspection

of the vulva and vagina, particularly looking

for atrophy

( The vaginal skin looks thin, red and inflamed with

areas of

pinpoint bleeding

).

A

speculum examination

(cervical polyp and

cancer)

A

bimanual examination

to evaluate uterine size,

mobility and

the

adnexae

.

4.

Per rectal examination:

to exclude colorectal problems

.

Slide42

Investigations

1

.

Complete blood count

2.

Coagulation studies

3.

LFT, RFT

specific

investigations:

I.

Ultrasound

II.

CA125

III.

Pippelle

smear

IV.

Dilitation

and

curetage

with biopsy

V.

Hysterescopy

with endometrial biopsy

Slide43

A- Pipelle endometrial suction curette. Endometrial Brush

B-

Vabra

aspirator

Slide44

A tissue

sample is taken from the lining of the

uterus (endometrium),

and is checked under a microscope for any

abnormal cells

or signs of cancer.

Slide45

Hysteroscopy

The

Gold Standard

Allows Direct Visualization Of Uterine Cavity

Slide46

Management of post menopausal bleeding

General

measures :

Correct general condition(Anti-shock measure):

Hospitalization

•Assessment

of blood loss

:

In some cases the blood volume loss may

be excessive

, rapid and possibly life threatening

.

So rapid restoration of blood volume ,vital

parameters is

followed by local examination to find out the

site and

source of

bleeding

Definitive Treatment :

The condition after diagnosis treated according to

the underlying

cause .

Slide47

Thank you