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Overview of menopause, the issues related to this subject and clinical implications for the student

Overview of menopause, the issues related to this subject and clinical implications for the student

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    Menopause overview Menopause overview Presentation Transcript

    • An Overview of MenopauseAssociate Prof Dr Hanifullah Khan
    • objectives!   to understand this condition & terminology!   physiology of menopause!   problems linked with menopause!   clinical scenarios
    • what is menopause? !   A physiological loss of ovarian hormonal activity !   Closely allied to loss of reproductive potential !   Permanent cessation of the primary ovarian functions
    • Physiology
    • The Ovaries!   2 functions - produce ova & secrete hormones!   Start secreting estrogen & progesterone from puberty to menopause!   Most of the beneficial effects derive from estrogen
    • actions of estrogen!  formation of the 20 sex characteristics!  Develop ovaries, tubes, uterus & vagina!  HPO axis interaction!  endometrial proliferation!  Increases fat deposition!  maintain the skin & vessels!  bone - incrrease formation & reduce resorption
    • actions of progesterone!   its actions are amplified in the presence of estrogen!   Interacts with hypothalmus and pituitary to regulate menstrual cycle!   converts endometrium to secretory stage!   makes cervical mucous & vaginal epithelium impenetable to sperm!   inhibits lactation during pregnancy!   makes the uterus less contractile
    • When does menopause occur?!   Tends to occur over a period of years!   A consequence of biological ageing!   Genetic & environmental factors!   Malaysian women - 48 - 52 years* *Jahanfar SH 2006, Ismael NN 1994
    • Types of menopause- Premature Menopause - menopause in a woman aged <40years- Early Menopause - menopause in a woman aged 50 - 59years- Late Menopause - menopause in a woman aged >60 years - Surgical menopause - a result of surgical removal of bothovaries- Medical menopause - -  permanent damage to both ovaries - chemotherapy or radiotherapy-  temporary - GnRHa tx in endometriosis
    • Perimenopause- the time just before and soon after theoccurence of menopause- symptoms of menopause have started- not yet certain if menopause is establishedyet
    • Diagnosis of menopause!   The diagnosis of menopause is mainly clinical•  a. Clinical Criteria1.  age around menopause ( around 50 years )2.  no periods for 12 months3.  menopausal symptoms•  ( NB. All 3 clinical criteria need not be present for a diagnosis )•  Laboratory diagnosis is generally not necessary for the diagnosis of menopause. However, where in doubt, laboratory testing of FSH may support the diagnosis, viz•  b. Laboratory Criterion•  1. FSH level > 35miu/ml
    • The consequences of menopause
    • primary symptoms - Menstrual changes -  Abnormal - Oligoamenorrhea – amenorrhea - Vasomotor -  hot flashes, night sweats - Urogenital -  Vaginal dryness, micrurition altered
    • secondary symptoms- Physical symptoms-  Muscle & joint pains-  Skin dryness, decreased stamina, backache- Sexual-  Decreased libido-  Avoiding intimacy- Psychophysiologic changes-  Decrease concentration-  Depressive symptoms
    • Monitoring symptoms
    • Long term effects!   Cardiovascular!   Bone!   Cancers!   Cerebrovascular
    • Clinical implications of menopause
    • Minor conditions- Urinary tract infections- Vaginal dryness- Vaginal infections- Joint & muscle pains
    • Symptomsmimicking disease!   Abnormal vaginal bleeding !   Perimenopausal !   Postmenopausal!   General pains e.g. Breast
    • Perimenopausalabnormal bleeding- At this age, there are many conditions that peak-  e.g. Adenomyosis, polyps, fibroids, hormonal- Cancers are always a concern, esp Ca Cx- Infections are the most common occurrence- All these must be ruled out before a diagnosis ofperimenopausal bleeding is made
    • Postmenopausal bleeding- Consider it as always abnormal- Always think of cancer- Usually due to atrophy or infection
    • Cardiovascular disease!   CV risk increases as estrogen levels decline!   1 in 2 women will die from cardiovascular disease!   Estrogen exerts beneficial effects on CV system through !   Direct effect on the vasculature !   Indirect effect of lipid metabolism Kramarow E et al. Health and Aging Chartbook. Health, United States, 1999. National Center for Health Statistics; 1999.
    • Cholesterol metabolism !   Only total cholesterol, low-density lipoprotein cholesterol, and apolipoprotein B demonstrated substantial increases within the 1-year interval before and after the FMP, consistent with menopause-induced changes. This pattern was similar across ethnic groups.Matthews K. J Am Coll Cardiol. 2009;54(25):2366-2373
    • Fracture risk!   decreased bone density!   osteoporosis!   common fractures involve hip, forearm & spine
    • you wanna be like this?
    • Psychomotor & Mental!   loss of libido!   suicidal tendencies!   marital discord
    • Urogenital problems
    • MenopausalHormone Therapy
    • potential risks & concerns- Breast cancer- Cardio vascular disease- Venous thrombosis- Endometrial cancer- Compliance/therapy- The Women s health initiative study aimedto confirm all these
    • Conclusion•  Estrogen plus progestin was associated with greater breast•  cancer incidence, and the cancers are more commonly node•  positive. Breast cancer mortality also appears to be•  increased with combined use of estrogen plus progestin. •  Writing Group for the Women s Health Initiative Investigators JAMA. 2010;304(15):1684-1692
    • Current recommendations- hormone therapy should be initiated for thetreatment of menopause-related symptoms- the lowest dose should be used for the lowestduration -  5 years recommended for estrogen+prog therapy- hormone therapy risks-  all forms of tx increse risk of VTE (deep vein thrombosis & pukmonary emboli)-  increased risk of breast Ca with est+prog combination Stuenkel CA et al. Menopause. 2012;19(8):846-847
    • Summary
    • The important points!   menopause is a natural occurence!   it is associated with long- & short-term issues!   some of the menopausal symptoms may mimic medical disorders!   postmenopausal conditions such as bleeding & masses must be seriously looked into!   hormone therapy should be used but it has its problems
    • Q. A 40 year old woman presented with no periods for 1 year. How would you diagnose menopause?