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What is it? -and why do we care?And WHY there is so much controversy?
Menopause – Cessation of Menstruation. Its derived from a Greek words “Menos and Pause” Meaning Cessation of Menstruation. Definition: Permanent stoppage of Menstruation as a result of declining ovarian function leading to deficient ovarian hormonal secretions.
FSH & LH Estrogen and Progesterone
Fertile Years: Fairly Predictable Teen years: Perimenopause: +/- Rough Variable Menopause: Menses “Pause”Age 0 10 20 30 40 50 60 70 80 90 100 Menarche: The Beginning SPC SURAT 9825356080/31-07-11
“Ideal” monthly cycles:smooth hormonal balance d d d d d d d d d d d d
Menopause strictly means the end (pause) of menses. Menopause is a hypo-estrogenic state. Estrogen surges have caused growth of the endometrium. Now no growth = no shedding = no period ~ FSH over 40 Average age 51-52.
By definition means the time around menopause. (Could mean anytime from birth to death. ) Usually refers to the transitional years leading from regular menses to the end of menses and the symptomatic years. Ages 35 to 60. Low, unreliable Progesterone & Fluctuating Estrogen.
Age related depletion of ovarian follicles Degeneration of Granulosa & Theca cells Degenerating Theca cells fail to respond to Gn Leads to fall in estrogen levels Decrease in negative feedback on HPA axis Consequent rise in Gn attempting to stimulate ovaries Sharman et al 1976
These process begins 5 year before actual menopause At this time FHS and Estradiol LH and Progesterone levels remain unchanged, indicating that cycle probably continue to be ovulatory. Estradiol – Hot flushes
In contrast to follicular cells, the stromal cells continue to produce androgens in response to LH after Menopause, The adrenals continue to produce androgens The physiologic in Estrogen / Androgen ratio accounts for increase in facial hair growth after menopause. In obese women androgens are converted by peripheral body fat to a weak estrogen – estrone Hence they are less prone to menopausal symptoms and osteoporosis but increase chance of endometrial hyperplasia and malignancy.
30 to 50 years of your life. Uncomfortable Symptoms. Possibly disruptive Possible increase PMS (mood changes, sadness, lack of concentration). More abnormal bleeding – iron deficiency. Decline in general health. Huge impact on reproductive system.
● 200 years ago, fewer than 30% of women lived long enough to experience menopause.● 100 years ago the average women‟s life expectancy just reached 50 years of age.● NOW-Average life expectancy is 80 and most of you will far surpass that.● Ready or not, you can already expect a better QUANTITY of life.● So the question really becomes - “How can I maintain the best QUALITY of life?”
They welcome Menopause – freedom from bleeding and risk of pregnancy Feel free to participate in religious and social activities. Psychological symptoms are fewer – joint family strong support Lifestyle of rural India – more physical activities fiber rich diet, low fat, good intake of milk and exposure to sun shine Hot flushes are common in the white Caucasian women then Indian. Urogenital symptoms common in Indians. Decreased libido – shy to discuss
Survey of knowledge attitude and symptomatology menopause and HRT in qualified nurses – revealed substantial degree of paucity of knowledge amongst them. 66.6% - only were familiar in premenopausal group 48.5% - in menopausal group KEM hospital – Mumbai (Kansaria et al 2000)
Survey (on the basis of questionnaire) of knowledge attitude and symptomatology of menopause, HRT and Cancer in qualified 352 educated working class women. 40% of them had read about menopause in newspapers. 48% considered it as media hype, and the despite of the fact that 26% of them being postmenopausal, only 2.9% were on HRT. This survey emphasizes the need for enhancing public awareness of menopause and its implications. Monali Desai 2003, Vadodara
Menopausal impacts can be divided into two categories - short term and long termEstrogen Withdrawal Symptoms-short term (Resolve with time)hot flashesnight sweats sleeplessness fatigue mental lapses moodiness irritability palpitations headaches many others MOST DISAPPEAR WITH TIME.
Estrogen Deficiency -- ( Worsen with time)● Vaginal effects (dryness, atrophy) ● Genitalia (atrophy)● Brain (cognitive decline) ● Loss of libido● Bone (loss of mineral density) ● Joints (tightness)● Blood vessels (atherosclerosis) ● Metabolic ( insulin● Skin (wrinkling) resistance)● Mucus membranes (dryness) ● Macular degeneration ● OthersTHESE IMPACTS DO NOT FADE - THEY GET WORSE.
● Questions to resolve: ● A. Could anything be done? --- YES ● B. What would be the options? ● C. How safe are they?
1) NATURAL - Live a Healthy Lifestyle Enhance and accept what nature has given you.2) ALTERNATIVE – use supplements, vitamins, naturopathic and homeopathic remedies.3) MEDICAL TREATMENTS – treat specific symptoms or problems with medications as they arise.4) HORMONAL – replace the original substance that is missing - prevention. (Similar to treatment of low thyroid)
1. Detail personal and family history, physical examination including height, weight and BP2. Breast examination, pelvic examination & PAP‟s test3. Evaluation of symptoms and need for medication4. Evaluation of individual risk Vs benefits from treatment5. Routine screening test: CBC, Urine analysis, blood sugars, RFT, LFT6. Lipid profile and CVS risk assessment
7. TVS and Assessment of Endometrial thickness8. Routine mammography9. Assessment of BMD – DEXA (Dual Energy X-ray Absorptiometry) test is preferable10. Endometrial biopsy – in postmenopausal bleeding or F/H/O cancer or P/H/O late menopause, infertility and PCOD.11. Stool test for occult blood [for colorectal disease]12. TSH, and free T3, T413. FHS, LH in women on OC pills with secondary amenorrhea or in hysterectomised patients.
● Medical treatments begin after a problem develops.● Traditionally, this is what most of us choose.● We seem to assume that disease is inevitable. “Eventually we all will get something.”● This refers to specific drug therapies to treat conditions or disease states as they arise, or even before that.
Improves vasomotor stability, reducing hot flashes. Helps maintain elasticity of skin and tissues. Improves sleep patterns, decreases fatigue. Increased „sense of well being‟. Better recall, memory, problem solving.
Cardiovascular Risk Insomnia Osteoporosis Ovarian cancer Colon cancer Diabetes Endometrial cancer Breast cancer Dementia Clotting – Deep Vein Thrombosis & Stroke Macular degeneration Arthritis
Timing of treatment - It‟s important to start early to get the full benefit. Many of the benefits persist if you continue therapy for longer periods of time. Mode of delivery –Various routes NON-ORAL Have advantages over oral.
● Let‟s assume for the moment that there are safe choices.● Therapy depends on your particular situation.● “Where you are” in this transition process.● Depends on your goals, health conditions, budget, etc.
● NO symptoms. ● It‟s great not to have symptoms , still you face the decline in health associated with the loss of estrogen. ● This is a group of Patients that‟s harder to convince! Pt. doesn‟t have symptoms so she doesn‟t feel “bad”. They won‟t “feel” the slow loss of calcium in bones until it‟s too late. ● Consider HRT to prevent some of the long term effects of chronic estrogen deficiency.
Lifestyle changes and Personal habits Exercises: Brisk walking for 40 – 60 min., at least 5 times / week Physical workout: Wt. bearing exercises for limbs and back strengthening. Yoga and Meditation: Breathing exercises stress Simple Diet: Plenty of vegetables, fruits fat, Sugar Fluid Intake: Plenty of fluids to maintain hydration. Control or Abstain: smoking, alcohol intake, more tea and coffee.
Women‟s bodies are genetically programmed to gothrough a fertile phase that ends with the onset ofmenopause. Natural phenomenon - “why not accept it gracefully,and work to improve life quality by diet, exercise, andnatural supplements.” Much to be said for this lifestyle.Symptoms - not everyone has them, or they may bemild, and even if uncomfortable, will usually resolve <5 years. Learn to “Live with it”.
Most of these issues will be accepted by women asnatural aging, not realizing they could have beenprevented.Estrogen deficiency will NOT resolve, and over time thedamage will become apparent.At some point the damage is irreversible.Most women at this point will be switched to”Option 3 - Medical Treatments.” because now theyhave genuine medical issues.
Many options available. No Rx needed. OTC (Over-the Counter).May consist of herbal supplements, nutrients,Homeopathic treatment, Chinese herbs andacupuncture treatments, massage, mental imaging,crystal treatments.
Alternative tx‟s give people power to make theirown choices. Especially when so many of ushave become so skeptical of our health caresystem and the motives of people makingdecisions and recommendations.Draw criticism as unproven. Most are“unproven” in truly scientifically controlledstudies, but thats not the point.Most likely they are safe. Most have extremelylimited data on safety so remember it‟s-“Buyerbeware”.No data regarding disease prevention.
Plants make chemicals that are necessary for their ownsurvival.It turns out that those chemicals can have effects onhumans.Certain plants make chemicals that will weakly stimulateestrogen and progesterone receptors.Supplementing with these,can frequently alleviate mildsymptoms.
They are extremely weak compared toour own ovarian hormones.They cannot be measured in availablehormonal assays.Little risk of harm is known,but limiteddata.
Premarin - derived from purified urineof pregnant mares. Longest track record of any estrogen. Hundreds of studies have documented its effectiveness. Study drug from the Women‟s Health Initiative (that received such bad press in 2002). Most of those negative findings have been totally disproved. The negative image still lingers, but the medication is totally valid.
If you are pre-menopause (perimenopause) , buthaving symptoms &/or abnormal bleeding: Rule out underlying medical disease. The goal of therapy would be to evaluate/correct the bleeding issue. Suppress the symptoms, necessary changes in nutrition/life. LOW DOSES of hormonal supplements if needed. Frequent monitoring and adjustments due to volatility.
Hormonal changes constitute a natural progression in women‟s lives - from birth to death. Menses and any accompanying symptoms are driven by these changing hormone levels. There are monthly cyclic changes that create fertile reproductive cycles. There are plateaus that lead to months or years of milder or stronger symptoms or suboptimal fertility. And then the eventual low plateau of menopause. Unpleasantly, there can be daily fluctuations.