Menopause Dr MinalKadamJadhav - PowerPoint Presentation

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Menopause

Dr MinalKadamJadhav

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DEFINATION

MENOPASE :

Is a point in time when permanent cessation of menstruation occurs following the loss of ovarian activity ( loss of menses for >12 months)

Greek word: men –month & pausis- cessation

PERIMENOPAUSE:

The years prior to menopause that encompass the change from normal ovulatory cycles to cessation of menses.

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Defination

CLIMACTERIC : (Greek word for ladder)

Indicates the period of time when women passes from the reproductive stage of life through the perimenopausal transition and the menopause to the post-menopausal years.

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Women now live

a third of their

lives after

menopause.

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Demography

60 million women in India are above the age of 55 years.

Age of menopause ranges between 45-55 years.

Average age for menopause is 51 years.

Premature menopause is < 40 years

Late Menopause is > 55 years.

Perimenopausal transition, average age of onset-46y.

Early menarche- early menopause (Swedish study).

Late menopause has been associated with increase parity.

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Early menopause has been associated with

- Living at high altitudes.

- Lt handed women compared to Rt handed women.

- Growth retardation in late gestation.

- Smoking (1.5 years earlier).

- Nulli gravida

- Family history of early menopause

- Pinpoint area on chromosome X (region Xp21.3)

- Region on chromosome 9 and 8 (the gene encoding the GnRh releasing hormone is closer to ch.8)

Surgery induced menopause.

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Regulation of menstrual cycles.

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Stages of reproductive ageing.

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Menopausal loss of ovarian function

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Symptoms

Vasomotor symptoms

Psychological Symptoms

Sexual dysfunction

Dementia and cognitive decline

Osteoporosis

Cardiovascular diseases

Urogenital atrophy

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Vasomotor symptoms

Hot flash:

- Characterized by sudden feeling of heat followed by profuse sweating.

- More common during perimenopausal period (60%).

- May last for 1-10 minutes.

- Prerequisite is low estrogen level

- Coincides with GnRH pulse secretion with increase in

serum LH level.

- Altered levels of neurotransmitters (Nor epinephrine & Serotonin)

Night sweats.

Disturbed sleep.

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Psychological symptoms

Irritability

Anxiety

Headache

Insomnia

Mood swings

Poor memory

Depression

- Estrogen increases the opioid activity in the brain and is known to be important for memory.

- Estrogen improves cerebral perfusion and cognition.

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Sexual dysfunction

Vaginal dryness

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Consequences of menopause on the CVS system

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Pathogenesis of osteoporosis

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Urogenital symptoms

Genitourinary atrophy due to lack of estrogen leads to

Urethritis

Dysuria

Incontinence

Increase frequency

Recurrent UTI

Dry Vagina- prone for bleeding

Alkaline pH- more susceptible to infection.

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Diagnosis

Cessation of menses for consecutive 12 months.

Average age 51 years.

FHS increases by 10-20 fold.

LH increase by 3 fold.

Serum Estradiol <20 pg/ml.

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:Mx: Non hormonal treatment

Lifestyle modification

Nutritious Diet: More fruits and vegetables

Exercise: Yoga, Meditation,Taichi

Cessation of smoking and alcohol

Calcium and Vitamin D supplements.

Calcium- 1.5-1 gm/day

Vitamin D- 700-800IU/day

Bisphosphonates –prevents bone resorption, improves bone density.

Calcitonin- inhibits bone resorption.

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Management

Selective estrogen receptor modulators (SERMs)

Raloxifene

inhibits the estrogen receptors at the breast and endometrial tissue, makes it tissue specific in action.

Increases bone mineral density.

Reduces LDL increases HDL2 levels

Reduces risk of Breast and Endometrial CA.

No effect on hot flashes and urogenital atrophy.

Increase risk of VTE.

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Mx :Hot Flashes

Clonidine: œ2 adrenergic agonist.

Paroxetine: Selective serotonin receptor reuptake inhibitor.

Gabapentine: Analog of Gamma-aminobutyric acid.

Phytoestrogens: Isoflavones.

Soy Protein: acts as SERMs

Vitamin E.

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Hormone replacement therapy

Indications:

Relief of menopausal symptoms.

Relief of Vasomotor symptoms

Prevention of osteoporosis

To maintain quality of life in menopausal years specially in

Premature ovarian failure

Gonadal dysgenesis

Surgical or radiation menopause.

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HRT

Contraindications

K/C/O or suspected breast CA.

Undiagnosed Vaginal bleeding

Estrogen dependent neoplasm (Endometrial CA)

H/

o

VTE or active DVT

Active liver disease

Gallbladder disease

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HRT Types

Estrogen & Progesterone: Most common used. Best to use in women with intact uterus.

Estrogen only : Preferred in women who have undergone hysterectomy.

conjugated estrogen- 0.625-1.25 mg/day.

micronized estradiol- 1-2mg/day

Progestin's only: Preferred in patients with h/o breast or endometrial cancer.

Medroxyprogesterone – 2.5-5 mg/day

micronized progesterone – 100-300 mg/day

Dydrogesterone – 5-10mg/day

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HRT

Oral estrogen regime:

Conjugated equine estrogen 0.3mg or 0.625mg/ day

Estrogen & cyclic progestin:

Continuous estrogen for 25 days add progestin for last 12-14 days.

Continuous estrogen and progestin therapy:

chances of irregular bleeding and prevents endometrial hyperplasia.

Transdermal patches

: this route avoids the “first pass hepatic metabolism”.

Sub dermal implants:

17ß estradiol implants 25mg,50mg & 100mg. Subcutaneously inserted. Duration 6 months. Preferred in post-hysterectomy patients.

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HRT

Percutaneous estrogen gel

: applied on to the skin. Delivers 1mg estradiol daily, keeping blood estradiol levels 90-120pg/ml.

Transdermal patch

: 3.2 mg of

ß

-estradiol. Releases 50µg/day. To be applied below the waistline.

Vaginal cream:

Conjugated equine estrogen vaginal cream 1.25mg/daily. Effective in atrophic vaginitis.

Progestins

:

MPA 2.5-5 mg/day.

Tibolone

:

19-nortestosterone derivative. Weak

estrogeinc

,

progestogenic

& androgenic action.

Increase libido.

Prevents osteoporosis.

Prevents atrophic vaginitis.

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HRT

Testosterone:

Short term use is suggested. Preferred in hypoactive sexual desire disorder (HSDD). Improves mood, bone, muscle mass and

QoL

.

Parythyroid

hormone (PTH

): route – SC injection. Dose-20 µ

g

/day. Prevents osteoporosis and fracture.

LNG-IUS

– Releases 10µg/day. Lower systemic side effects of progestin.

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HRT: Duration

Hormone therapy should be used with lowest effective dose and for shorter period of time.

Counseling of the women should be done.

Annual or semiannual reviews should be done.

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HRT: Risk Factors

Endometrial cancer

Breast cancer

VTE

Coronary heart disease: relative hazard

Lipid metabolism: Increases cholesterol in bile.

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HRT :Monitoring

Blood pressure

Physical examination and pelvic examination.

Breast examination.

Cervical cytology

TVS – endometrial thickness (normal<5mm)

Endometrial biopsy or hysteroscopy –if irregular bleeding.

Serum estradiol levels- 100pg/ml during HRT

DEXA scan.

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Questions????