Saef B Al Abbadi LEARNING OBJECTIVES Definition of menopause causes types Impact on life Management Definition The menopause is defined as the womans final menstrual period 1 ID: 919784
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Slide1
Menopause
Done by :
Bayan Abu-Alia
Saef B Al-
Abbadi
Slide2LEARNING OBJECTIVES
Definition of menopause ,,causes ,,types
Impact on life
Management
Slide3Definition
The
menopause is defined as the woman’s final menstrual
period.
1
year of amenorrhea.is cessation of regular ovarian function.
Slide4The 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
Slide5When 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
.
Slide6Endocrine 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
.
Slide7Laboratory 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
Slide8Slide9Diagnosis
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
.
Slide10Non-physiological menopause
Premature ovarian
insufficiency
Iatrogenic menopause – medical treatments and menopause
after cancer treatment
Iatrogenic menopause – surgical menopause
Slide11Premature 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
)
Slide12Iatrogenic 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.
Slide13Iatrogenic 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.
Slide14Symptoms 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
Slide16Central 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 .
Slide172) 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 .
Slide18The 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
Slide19Bone 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.
Slide20Cardiovascular 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
Slide21Assessment and Management
Slide22Diagnosed
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
Slide23Management
1-lifestyle modification
2-diet and exercise
3-non hormonal therapy
4-hormonal replacement therapy
Slide24Lifestyle 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
Slide25Diet and excersice
Ca+2 and vitamin D intake
Weight bearing
excersise
Biphosphonatees Estrogen replacement therapy
Slide26One 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
Slide27Non-hormonal treatments for vasomotor symptoms
---
Alpha-adrenergic agonists
ex .
Clonidine
---Beta-blockers ex.Propanolol
----anti-depression
---
Venlafaxine
---
Fluoxetine
---
Paroxetine
---
Citalopram
Hormonal Replacement Therapy
70-85%
of women remain healthy need only good nutrition and healthy life style.
So not all women requires HRT
Slide29ESTROGEN
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
.
Slide30Why 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
Slide31Progesterone
--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
Slide32Oestrogen 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)
Slide33Testosterone
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
Slide34Routes 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
Slide35IMPLANT
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
Slide36Beneficial 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
Slide37Side 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.
Slide38contraindications
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
Slide39Risks 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
Slide40Thank you