Ageing & Sexual Dysfunction
PG Student- Dr. Sagar Gaikwad
PG Guide-Dr. Arun Humne
Department of Preventive and Social Medicine
Govt. Medical College Nagpur,Maharashtra
• Historical Theories of Developments
• Sexuality and Sexual Health
• Ageing theories
• Sexuality through life- cycle
• Sexual functioning
• Sexual disorders
• Sexual dysfunction in male
• Sexual dysfunction in female
• Andropause & Menopause
Is not mere physiological transaction but implies -
Love and love making
Forms nucleus of family and marriage
Pervades art and produces its spells and
Throughout the history of mankind Sex is supposed
to contribute events of major impact and even Rise and
Fall of Civilizations or Empires.
Thus Sex remains Sociological and Cultural force.
Perspective of Sex
Personal Perspective of sex comes from
A) Private- Personal experiences
Public social sources
B) Society - Religions
C) Historical perspective
These perspectives help to study sex from Biological,
Psychological, Behavioral, Clinical and Cultural dimensions.
Shape sexual behaviour by
establishing Values &Taboos
Historical Developments in Sexology
The first imminent personality who described central
importance of sexuality into Human Existence is Sigmund
Through his Psycho-analytical methods, described
Sexuality as a Primary force in motivation.
Also Freud was first who introduced principal of
Childhood Sexuality and aberrations into development
leading to various types of Neurosis.
Although his work is criticized much and other theories of
development, states more than one element apart from
sexuality only has pivotal roles in development, still
Psycho-analysis remains major form of diagnosis for
Freud’s Psychosexual Development Theory
Consequences of Psychological Fixation
Birth – 1
Aggressive: Chewing gums & ends of pencils etc.
Passive: Smoking, Eating, Oral sexual practices
Retentive: Obsessively organized or excessively neat
Expulsive: Reckless, Careless, Defiant, Disorganized,
Frigidity, Impotence, Unsatisfactory Relationships
Various Para-philias , aversions were proposed to occur due to level Psycho-sexual fixation
Historical Development Theories contd..
Malinowski - Postulates Sociological and Cultural
dimensions of Sexuality.
Henry Miller–Made Philosophical statements about Sexuality
in his works.
Gestalt Psychologists– Thought Mind as a Whole component
encompassing all aspects of development
through complete interactions between body,
mind and social determinants.
Thus there are many preponderant theories regarding
development of human and sexuality ….
What is Sexuality?
Gender Identities & Roles,
Sexuality is experienced and expressed in thoughts,
fantasies, desires, beliefs, attitudes, values, behaviours,
practices, roles and relationships”
• According to the current working definition, sexual
“…a state of physical, emotional, mental and
social well-being in relation to sexuality; it is not merely
the absence of disease, dysfunction or infirmity.
Sexual health requires a positive and respectful
approach to sexuality and sexual relationships, as well
as the possibility of having pleasurable and safe
sexual experiences, free of coercion, discrimination
For sexual health to be attained and maintained,
the sexual rights of all persons must be respected,
protected and fulfilled.”
Theories of Ageing
Senescence - state or process of ageing
Aging has been associated with Physiological and
Psychological changes that lead gradual dysfunction at
cellular level including those of Reproductive System.
Theories of Aging
Biological – Design
Wear and Tear
Non Biological- Activity
Reproductive – Cell Cycle Theory of Aging….
ʘ Chemical reactions that regulate cell growth,
development, and death, are believed to control ageing.
ʘ Cellular changes are directed by reproductive hormones
of the hypothalamic-pituitary-gonadal axis.
ʘ HPG axis hormones normally promote growth and
development of the organism early in life in order to
ʘ When the HPG axis becomes unbalanced, cellular
growth and development is disregulated, and cell death
and dysfunction can occur, both of which can initiate
Sexuality in Infancy
Sexual reflexes operate at the very start of infancy and
probably before birth
USG studies provided some evidence that reflex erections
occur in developing baby boys several months before
Many newborn baby boys have erections in the first few
minutes after birth, even before umbilical cord is cut.
Similarly newborn baby girls have vaginal lubrications and
clitoral erections in their first twenty four hours.
By 3 to 4 months genital stimulation accompanied by
smiling and cooing.
Sensuous closeness of parents through holding, clinging
and cuddling forms important phase of infantile sexuality.
A child who is deprived of warm, close bonding during
infancy may experience later difficulties forming intimate
relationships or being comfortable in his/her sexuality.
Sexuality in Childhood
2 to 3 Years
Solitary ,In-pair or Group sexual play.
If parent give negative messages that it dirty Children
take literal meaning of “Dirtiness” paving to later life
Has vague and magical notations about child birth.
Ask many questions .
Fascinated with learning words about sex parts and;
jokes about sex and genital functions, although do not
6 to 7 Years
Have clear anatomical differences between sexes.
Become modest to show body to others.
Sex plays in two thirds occurs, also involving siblings. 14
Sexuality in Childhood contd..
8 to 9 Years
Has knowledge of erotic element in sex plays.
Sexual fantasies, falling in love occurs.
Learn to relate others leading to development of adult
Up to 12 Years –
Indulge infrequently (and less important in meaning)
many types of sexual activities like masturbation, Hetero
or Homosexual activities.
Few also has sexual activities including Animal or Object,
Sometimes Oral or Anal sex
Why we do not remember ??
Ernest Borneman – Puberty characterized by a special amnesia
“Blocked Memories” about prior sexual experiences.
Sexuality in Puberty
Sexual fantasies and dreams are common, often
accompanied by masturbation.
Fantasy add pleasure of sexual activity- a substitute to
real but unavailable experience, that induce arousal or
orgasm and provide form of mental rehearsal for later life
real sexual experience and provide a safe, controlled un-
embarrassing means of sexual experimentations.
It also paves path for later sexual existence & confidence.
Patterns of Sexual behaviour
Homosexuality ( Generally isolated or transient
Early Adulthood (20 to 40 Years) Sexuality
More driven by internal need to become more sexually
knowledgeable and has more sexual opportunities.
Conflicts may arise due to attitude of sexual guilt carried over
from earlier age.
Coming out for Homosexuals – associated with marked
Pregnancy : sexual desire may vary between individuals.
Ist Trimester : Nausea, Vomiting and fatigue –Aversion
IInd Trimester: Increase in Desire & Physical response in 80%
IIIrd Trimester: Drop in in frequency of intercourse
In married couple
Integration between burden of needs and responsibility may
fail leading to sexual dysfunction.
Extramarital affairs may sprout and divorces may arise due
to sexual dysfunction.
Middle Adulthood(40 to 60 Years)Sexuality
Midlife Crisis:-for most-life must be reappraised in terms of Goals,
accomplishments and experiences-as a result midlife crisis
begins to take shape.
Male – more vulnerable and are at “over the hill” position. Once
start questioning about sexual capabilities, the odds are that he
will experience difficulty getting or keeping an erection.
Female – Those who remain mothers mostly, children attain
independence leading to “empty nest syndrome”. These
changes causing depression and listlessness that may coincide
with menopause .
However leaving children gives couples a chance to their own
interactions and opportunities for freer more relaxed sex.
Sexual Burnout – Stems from tedium and satiation with same
sexual routines, marked by sense of depletion, emotional
emptiness and negative self-concept. Although most recover
over time, 10% remain sexually inactive.
Late Adulthood ( 60 + Years) Sexuality
Biological Considerations in Male
Sexual organ atrophy
Diminished testosterone level
Delay in attaining erection
Erection of poor quality
Longer delay in achieving and maintaining erection
Decline in intensity of orgasm
Late Adulthood( 60 + Years) Sexuality
Biological Considerations in Female
Loss of elasticity in breast tissue and loss of breast
Cervix and uterus shrink in size
Walls of the vaginal canal atrophy
Vaginal length and width decrease
Decrease in vaginal lubrication
Sex steroid starvation may indirectly affect sex drive
Causes of Sexual Dysfunction in Late Adulthood
Numerous factors contribute to a varied and complex
Biological Changes Of Ageing,
Negative Cultural Expectations,
Medical Or Surgical Problems
Effects Of Drugs
Mental Illnesses -Depression, Psychosis, Dementia
Availability of Partner
Physiology of Coitus
Excitement Plateau Orgasm Resolution
All show Age related Changes
Sexual dysfunction covers the various ways in
which an individual is unable to participate in a sexual
relationship as he or she would wish.
Sexual response is a psychosomatic process and
both psychological and somatic processes are usually
involved in the causation of sexual dysfunction.
Male Sexual Dysfunction
Erectile Dysfunction or Impotence
Female Sexual Dysfunction
Erectile dysfunction or impotence-
Is the inability to have or maintain an erection that is
firm enough for coitus.
Primary ED- Never been able to have intercourse
Secondary ED – Has succeeded to have intercourse
before dysfunction began
ED can occur at any age.
Total absent of erection is infrequent
Partial erection - that weak for vaginal insertions
Firm erections - that quickly disappear if intercourse is
ED with normal erections –
Changed sexual pattern(Intercourse/ Masturbation)
Erectile Dysfunction contd..
Isolated episodes of having no erections or loosing an
erection at an inappropriate time are so common that they
are universal occurrence among men.
So Masters and Johnson classified a man as secondarily
impotent only if his erection problems occurred in at least
25 percent of his sexual intercourse.
Isolated episodes may be due to -
Inebriation ( drunken )
Lack of privacy
Erectile Dysfunction contd..
• Fears of sexual performance-
– Will I loose my erection?
– Will I satisfy my partner?
Are likely to dampen sexual arousal and cause
of loss of erection. The stronger and more insistent such
fears become the man will experience an actual inability
to get and keep an erection.
On long term basis, it will lead to-
Avoidance of sex,
Loss of self-esteem,
Anxiety to overcome ED– sex becomes performance
Erectile Dysfunction Cycle
Etiology of ED
Coronary or pulmonary
Alcohol, Beta blockers
Monoamine oxidase inhibitors
Age related decline in T
Sickle cell anemia
Acute and chronic Leukemia's
Spinal cord transection or tumors
Impaired blood flow
CRF, Cirrhosis, Obesity
Maternal or paternal dominance
Conflicted parent-child relationship
Severe negative family attitude
Traumatic coital experience
Gender identity conflict
Acceptance of cultural myths
Anxiety- performance and size
Poor self esteem
Fear of VD
Hostility toward partner
Lack of physical attraction to
History & Physical Examination
Eliminate Causes (drugs, alcohol, diabetes, thyroid disease) & Reassess Improved
Not ImprovedLikely to be Organic Likely to be Psychogenic
Refer for Psychotherapy
Not Improved Improved
Organic impotence etiology?
Measure Testosterone level Further
Measure LH &
Prolactine Level Low Normal
LH & Prolactine
PBI vascular testing ;Neurologic testing
Vascular or Neurologic ED
Consider surgery : prosthesis or revascularization
Treatment of ED
• Noninflatable, semi rigid devices
• Inflatable devices
• Oral phentolamine
• Apomorphine sublingual tablets
• Intracaversonal injection of vasoactive drugs
• Intraurethral insertion of prostaglandin
• Use of vasoactive cream
• Sildenafil Citrate, Tadalafil, Vardenafil
Treatment of psychogenic ED
Sex therapy is indicated if counseling attempts have not reversed the
Sex therapy ideally includes both the impotent man and partner, since
therapeutic cooperation of the wife appears determinant of the outcome
of therapy. Patterns of communication within the relationship as well as
related behavior occurring between therapy sessions.
1. lt is not useful to blame one's partner or oneself for the occurrence of
2.There is no such thing as an uninvolved partner when sexual
3.Sexual dysfunctions are common problems and do not usually
4.lt is not always possible to be certain of the precise origin of a sexual
dysfunction, but treatment can frequently proceed successfully even
when knowledge is lacking.
5.ln general, cultural stereotypes about how men and women should
behave or function sexually are misleading and counterproductive. 33
Treatment of psychogenic ED contd..
6. Sex is not something a man does to a woman or for a woman;
something a man and a woman do together.
7. Sex does not only mean intercourse, apart from procreative purposes;
is nothing inherent in coitus that makes it always more exciting, or
more valuable than other forms of physical contact.
8. Sex can be a form.of interpersonal communication at a high intimate ;
when sexual communications are not satisfactory, it often indicates
aspects of the relationship might benefit from enhanced
communication as well.
9. Using past feelings or behaviors to predict the present is not likely
helpful, since such predictions tend to become self-fulfilling freedom
l0. Developing awareness of one's feelings and the ability to
feelings and needs to ones partner sets the stage for effective sexual
11.Assuming responsibility for oneself rather than delegating this
responsibility to one's partner is often an effective means of improving
the sexual relationship.
Although premature ejaculation is a common sexual
dysfunction, there is no precise definition of this problem
that is clinically satisfactory at present; partly because of
the relative nature of the timing of ejaculation in the
context of the female partner's sexual response cycle.
Masters and Johnson not consider it a problem, unless it
occurs 50% or more of the times coitus is attempted.
If the man's rapid ejaculation limits his partner's ability to
reach high level of sexual arousal or orgasm, then a
problematic situation do exist.
Male who persistently ejaculates unintentionally during
non coital sexual play or while trying to enter his partner
has a greater problem(10%)
Premature Ejaculation contd…
Ejaculation is a reflex phenomenon regulated by
neurologic and possibly endocrine pathways.
Common historical cause - First coital experiences under
circumstances of fear or being encouragement for rapid
ejaculation from a prostitute
In effect, the man became conditioned to fast ejaculation
and in subsequent sexual encounters he was often unable to
alter the pattern that has been established.
Thus primarily it is psycho physiologic disorder.
Some authors have suggested that; relationship problems,
unconscious hostility toward or fear of women, or hidden
female sexual arousal problems are all processes underlying
premature ejaculation. But these dynamics appear
infrequently in couples seen by Masters and Johnson.
Premature Ejaculation contd…
Although the precise neurophysiologic events that
trigger ejaculation in the male are not known, a program of
reconditioning the ejaculatory reflex response can be easily
1) Discuss physiology of ejaculation.
2) Squeeze Technique- When genital touching is begun the
women puts her thumb on the frenulum of the penis and
places her first and second fingers just above and below the
coronal ridge on the opposite side of the penis. A firm
grasping pressure is applied for four seconds and then
Pressure is given from back to front never from side to
side. Use pads of fingers and thumbs and avoid pinching
the penis or scratching with nails.
Premature Ejaculation contd…
For unknown reasons the squeeze technique reduces the
urgency to ejaculate (and it also may cause temporary partial
loss of erection).
It should not be used at the moment of Ejaculatory
Can be used whether penis is erect or flaccid.
When couple begins having intercourse the women is asked
to use the squeeze three to six times before attempting
insertion. Once the penis is fully inside her she should hold
still for fifteen to thirty second period with neither partner
thrusting and then move off the penis apply squeeze again
and reinsert. This time slow thrusting pattern can begin.
Premature Ejaculation contd…
Once the man improves his ejaculatory control both partners
are taught the “Basilar squeeze”, so that the intercourse need
not be interrupted by repeated dismounting to apply squeeze.
Kegel exercises is to improve muscle tone by strengthening
the Pubococcygeus muscle of the pelvic and aid in
reducing premature ejaculation in men.
Drugs that increase serotonin signaling in the brain slow
ejaculation and have been used successfully to treat PE.
These include selective serotonin reuptake
• Infrequent, generally below age of 35.
• Primary-Never been able to ejaculate in vagina.
• Secondary-men who have lost the ability to ejaculate intra
vaginaly or who do so infrequently after prior history of
normal coital ejaculation.
• In 85 % ejaculation is possible by masturbation or by non
coital partner stimulation. (50%)
• In 15% ejaculation occurred only in nocturnal emissions.
• It may be partner relative.
• Ej. Incompetence may be source of pleasure as it permits
prolonged periods of coitus.
• Women may feel their partner do not find her attractive or
withholding of orgasm is sign of selfishness.
• In Procreational sex – it can be frustrating.
• Only in 5% drug use and neurological disorders can be
Ejaculatory incompetence Theropy
• In depth attention to underlying psychological components
combined with sensate focus experiences that seek to lead the
man through a sequence of
1) Ejaculating by masturbation while alone
2) Ejaculating by masturbation in presence of his partner
3) Ejaculating by manual stimulation received from his partner
4) Having the partner stimulate the penis vigorously to the
point of ejaculatory inevitability ad then quickly inserting in
• With ejaculating once or twice intra vaginally, fears or
inhibitions about this act disappear completely.
• Where sequence has not worked it may helpful to have the
man ejaculate externally onto women's genitals. After he
becomes used to seeing his semen in genital contact with his
partner, intravaginal ejaculation may occur more easily.
• Seen in all groups, 2 to 3 times common than
• It may be source of sexual enjoyment but prolonged
periods of coital thrusting required to bring about
ejaculation are uncomfortable both physically and
• Women may become resentful
• However both Ejaculatory Incompetence and retarded
ejaculation may be isolated. And causes may be fatigue,
tension, illness, too much sex in short time, effects of
alcohol or other drugs, or when man do not like partner
but he feels its expected from him.
Sexual dysfunction in Rape
Masters and Johnson has reported a fascinating study of 101
Of these Erectile dysfunction occurred in 27 men.
Premature ejaculation occurred in 5 men.
Ejaculatory incompetence was seen in 26 cases.
• Thus rape is not primarily an act of sexual desire.
• 58 % of the rapist in this study were sexually dysfunctional.
Ejaculatory incompetence high rates signifies there
preoccupation with expressing power in rapist or anger
inhibits their sexual responsiveness.
Second point- Absence of semen in rape victim is not
So those acquitted on this ground can be prosecuted
and also others, those who prematurely ejaculated. 43
Vaginismus is a condition in which the muscles around the
outer third of the vagina have involuntary spasms in response to
attempts at vaginal penetration.
Less that 10% of female dysfunction cases.
Occurs at any ages and severity varies.
Less severe but considerable distressing is- pelvic pain
In milder form women may have intercourse but only with
Most women do have little or no difficulty with arousal.
Vaginal lubrication occurs normally, non coital play may be
pleasurable and satisfying, orgasms may be unaffected.
Effects- Male partner thinks he is hurting her
Becomes more passive, ED may develop
Procreative sex not possible.
Causes-Mainly psychosocial problem
However any of the organic cause of dyspareunia
can condition a women into vaginismus, as a natural
Even when underlying organic problem is treated
vaginismus may remain ,particularly when it has been
present for a long period of time.
Treatment- Explain the nature of involuntary reflex muscle
spasm to couple and demonstrating the reflex in carefully
conducted pelvic examination with male partner and
women urged to watch by use of mirror.
Techniques for relaxing muscles around vagina-
First deliberate tightening and simply let go.
Various sized plastic dilators are used. First physician
insert smallest dilator. Women is shown how to insert the
dilator herself using plenty of sterile lubricating jelly and
advised to practice this at home several times a day,
keeping the dilators in place for ten to fifteen minutes at a
Most women can use largest dilator by end of 5-6 days,
that is of erect penis thickness.
• Primary anorgasmia –women who were never had an
• Secondary anorgasmic women who were regularly
orgasmic at one time but no longer are.
• Situational anorgasmia- women who have had orgasms
on one more occasions but only under certain
circumstances-may orgasmic during masturbation but
not when stimulated by partner.
• Coital anorgasmia- Women who have orgasm in other
that coital act
• Random anorgasmia- Women who have experienced
orgasms in different types of sexual activity but only on
an infrequent basis
• Some anorgasmic women get little pleasure out of sex
and see it as an obligation of marriage or a means of
maintaining a relationship.
• Other anorgasmic women find that sex is stimulating and
• Not having orgasm can create fears of performance that
propel women into spectator role, dampening her overall
• Anorgasmia also leads to less self esteem, depression
and sense of futility.
• The male partner may feel threatened as they may
assume that it is their responsibility to make their partner
• Treatment of anorgasmia depend greatly upon nature of
• A women with poor body image may be helped to find
various ways of regarding her body more positively.
• A women who is distracted from high levels of arousal by
disturbing fantasies might be taught though blocking.
• Women who can not go beyond plateau be encouraged
to experiment with fantasies.
• Dealing with performance issue with partner to curtail
spectator role Reducing inhibitions. that limit the
women's arousal or orgasm.
• Masturbation or stimulation by partner.
• Bridging technique – stimulation of clitoris.
Other approaches to sex therapy
• Stop-start Method- by James seman
• Manual penile stimulation-stopped as man reaches to
ejaculation rapidly so the sense of ejaculatory urgency
disappears. Stimulation then begins again.
• Behavioural Theorpy
Greek ; “Andras” =human male
“Pause” = cessation
Androgen Decline in the Ageing Male (ADAM)
Partial Androgen Deficiency in Ageing Male (PADAM)
Ageing Male Syndrome (AMS)
Late Onset Hypo-gonadism
• A syndrome in which the changes accompanying ageing are
associated with the signs and symptoms of androgen deficiency
in the older male (traditionally age >50).
• Signs and symptoms are accompanied by a low serum
Testosterone levels with Age
Hypogonadism in aging men.
Total testosterone less than 11.3 nmol/L (325 ng/dL) (shaded bars).
Total testosterone/SHBG (free T index) less than 0.153 nmol/Ls (striped bars).
Numbers above each pair of bars indicate the number of men who were studied.
Signs and Symptoms of the Andropause
• Decreased vigor
• Easily fatigued
• Poor exercise
• Decrease in
• Limited Quality
• Mood changes
• Loss of
Diagnosis of Late Onset Hypogonadism
Screening beginning age 50 or 55
Exclude -Sexual dysfunction is due to psychological or local
If total testosterone (T) <200ng/dL - hypogonadism is present
regardless of age
If total T 200ng/dL to 400ng/dL, obtain free T
Once T deficiency is established, obtain LH and prolactin
Medications and low T
Decrease Leydig Cell T Production
Bind to the Androgen Receptor
Decrease Gonadotropin Secretion
Rx That Raise Prolactin (Opiates, metoclopramide, s)
Decreases Conversion of T to DHT
Available T Preparations
a) Oral preparation that is available in capsule form. It needs to be
given one to three capsules daily.
b) Transdermal Testosterone given as testosterone gel preparations. It
need to be applied any part of skin once a day.
c). Transdermal Testosterone scrotal patch are also available which are
very effective even if used in small doses.
d) Sublingual Testosterone cyclodextrin is now available which is very
fast acting & very effective.
e) Local application of D.H.T. gel available as Andractim gel is a new
preparation for male hormone replacement.
f) Injection Testosterone esters these includes Testosterone enanthate
& testosterone cypionate given intramuscular injections every 10 to
g) Long acting testosterone as testosterone bucilate given once in 4
h) Testosterones implants are now available which once injected
remain effective for up to six months.
• Menopause - permanent cessation of menstruation
resulting from loss of ovarian follicular activity.
• Perimenopause (climacteric) – The period immediately
prior to the menopause (when the endocrinological,
biological and clinical features of approaching
menopause commence) and at least the first year after
• Postmenopause - dates from the menopause, although it
cannot be determined until after period of 12 months of
spontaneous amenorrhea has been observed.
• Usual age 45 to 50 yrs average being 47yrs.
• Premature menopause - before 40 yrs
• Late menopause – menstruation beyond 52 yrs
• Delayed menopause
– Due to good health and better nutrition.
– Also seen in women with uterine fibroids .
– Also in women with high risk of endometrial
• Menopausal age is directly associated with
smoking and genetic disposition.
• Smoking induces premature menopause
• During climacteric, ovarian activity declines.
• Initially, ovulation fails, no corpus luteum forms and no
progesterone is secreted by the ovary.
• Later, graffian follicle fails to develop, estrogenic
activity decreases and endometrial atrophy leading to
• Increased secretion of FSH and LH by anterior pituitary.
• Other Causes
• Surgical menopause or radiation.
• Chemotherapy esp. alkylating agents.
• smoking., caffeine, alcohol.
• Drugs related such as GnRH, heparin, corticosteroids
and clomiphene(anti- estrogen) when given over
prolonged period can cause estrogen deficiency.
• Anatomical changes
Genital organs Atrophy and regression
Ovary Shrink, surfaces: grooved ,
Plain muscle in fallopian
Endometrium As basal layer: deeply stained
stroma and a few glands
Vaginal fornices Disappears
Epithelium Pale, thin, and dry: senile vaginitis
Vulva Atrophy (+narrow vagina:
Skin of labia minora and vestibule Pale, thin, dry
Labia majora Reduction in fat
Pubic hair Reduced and grey
Breast More pendulous(fat dep)
Glandular tissue <5%
Pelvic cellular tissue Becomes lax
Ligaments supporting the uterus and
Lose their tone: prolapse of genital
organs, stress incontinence of urine,
and fecal incontinence
• 60-70% women go
• Rest needs guidance
Hormone replacement therapy
Not all women require HRT. 70-85% of women remain healthy need only good nutrition
and healthy life style.
Indications of HRT
1) Women having climacteric symptoms
2) All asymptomatic high-risk women having
Family history of osteoporosis
Poor diet, excess alcohol
CVD, Alzheimer's disease, colonic cancer
Corticosteroid & other medications
Low plasma estradiol
Short term estrogen therapy
1) To relieve symptoms like; hot flush, night sweats,
palpitations, disturbed sleep
In smallest effective dose for 3-6 months
Combined hormone therapy(femet). 2mg
17-β- estrodiol & 1mg of norethisterone acetate.
2) for dyspareunia, urethral syndrome and senile vaginitis
Local estrogen cream(oestriol: 1/2g-everyday-10-12
days each month for- 3-6 months)
Estring(vaginal ringreleases 5-10microgram 3
• Long term therapy:
– For delaying osteoporosis
– Reduce the risk of CV disease
– Beyond 8-10 yr
THE RISKS OF HRT
• Vaginal bleeding
• Endometrial cancer if E2 is taken alone
• Brest cancer due to progestogen if HRT is taken over
• CHD in a women with CVD.
• Role in HRT
• Prevents endometrial hyperplasia.
• Implant may replace oestrogen, where
estrogen is c/I or sensitive
• Prevents breast cancer
• Improves bone mineral density
– Primolut-N 2.5mg ,
– Medroxyprogestrone & duphaston
– Mirena IUCD- levonorgestrel
• Def: ovarian failure occurring 2 SD in year before the
mean menopausal age in the population.
• Clinically: sec. amenorrhea for at least 3 months with
raised FSH/LH & low E2 level in a women under 40 year
• Inc. 1% -be. 30yr-1:1000
• -at 35yr-1:250
• Def: cond. in which menstruation cond. beyond 52 year.
• Late menopause occurs in women with fibroids and is
seen in women who develop endometrial cancer. Often
it is constitutional. Beyond 52 yr , endometrial biopsy is
required to rule out endometrial pathology.
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