Climacteric

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Climacteric

  1. 1. *menarche (puberty) *menstrual cycle *menopause and HRT *climacterium praecox, climacterium tardum, iatrogenic menopause. *senium
  2. 2. Hormones: 1) Estrogens - estradiol (12-80x more potent) - estrone - estriol 2) Progestin - progesterone -17-hydroxyprogesterone 3) Androgens - testosterone
  3. 3. menarche (puberty) • sequence of biochemical and physiologic events (adrenarche and gonadarche) result in the growth spurt of adolescence, development of secondary sex characteristics, and reproductive capacity
  4. 4. • Adrenarche:  ↑ secretion of androgens by the adrenal gland, (age 5 – 20) • Gonadarche:  the initiation of production of significant amount of sex steroids
  5. 5. Age at menarche, (n = 397) • 
  6. 6. Natural menopause *end of reproductive life *the permanent cessation of menstruation *loss of ovarian follicular activity *no pathological cause
  7. 7. Dx menopause : 1) No menses > 12 mths 2) 17β-estradiol levels < 74 pmol/L 3) FSH levels > 30 IU/L (Nik Nasri Ismail, ‘Menopause and HRT in Malaysia’ in First Consensus Meeting on Menopause in the East Asian Region)
  8. 8. Age and menopausal status :
  9. 9. Perimenopause • immediately prior to the menopause and the first year after menopause.
  10. 10. Climacteric -incorporates the perimenopause (a longer variable period before and after the perimenopause). -“climacteric syndrome.”
  11. 11. senium • Phase of life started from 65 – 70 years upwards • FSH and LH levels drop again (age-related involution of the pituitary gland).
  12. 12. Statistics • Mean age for menopause is 50.7 years (Seng CK, 1986). • Women’s life expectancy : 68 yrs in 1985 to 74 yrs in 1993 (Arshat H et al., 1989). ☞ 1/3 life, in a hypoestrogenic state.
  13. 13. Endocrinology of menopause Less negative feedback, ↑FSH, ↑LH Hypothalamo-pituitary tact ↓ovarian follicular estrogen ↓ circulating estrogen (estrone) to target tissues
  14. 14. Endocrinology of menopause • adrenal androgen (by ovarian stromal) • in response to elevated LH levels • Androgen : estrogen ratio (facial hair, male pattern baldness)
  15. 15. Pituitary gonadotropins FSH - follicle stimulating hormone LH - luteinizing hormone PRL - prolactin
  16. 16. FSH - follicle stimulating hormone In Females, • responsible for the early growth of ovarian follicles In Males, • helps mantain the spermatogenic epithelium by stimulating Sertoli cells
  17. 17. LH - luteinizing hormone In Females, • final maturation of the ovarian follicles and their estrogen secretion, for ovulation, the initial formation of the corpus luteum and secretion of progesterone In Males, • stimulation of testosterone production from Leydig cells of testis
  18. 18. Action of Estrogen :
  19. 19. Common Clinical Symptoms • Vasomotor flushes (hot flushes) - 95% ☞ within three months, (85% : symptom > one year) - sudden sensation of intense warmth accompanied by a visible ascending flush of the thorax, neck, and face, followed by profuse sweating.
  20. 20. • Osteoporosis -Estrogens, ☺inhibit osteoclast function ☺increase intestinal Ca2+absorption -Peak bone mass age 30, with 0.2% loss/year after age 40, becomes 4%/year at menopause -bone fragility and fracture
  21. 21. • Urogenital atrophy - atrophic urethritis and cystitis - Vulva and vagina : ↓ mucuos production, thin epithelium
  22. 22. • Cardiovascular disease - ↑↑ CHD in postmenopausal ≈ men at the age 70 (B.Ettinger et al.,1996 and S.A Samaan et al.,1995) by influencing: 1) lipoprotein level 2) direct action on arterial wall - Abnormal coagulation system
  23. 23. Circulation index (hot flushes, sweats, palpitations, dizziness) and Nervosity index (irritability, headache, depression, insomnia) :
  24. 24. Increased Risk factors for Menopause: • Environmental influences may alter the ovarian aging process. • Smoking and high coffee intake advances the age of menopause by about 2 years (Kaufmann DW et al,1980). • Familial and genetic factors • Ovarian surgery, adhesions, and pelvic endometriosis
  25. 25. Selection of patients for HRT: • 1. Pap smear for those with uterus • 2. Fasting lipid profile • 3. Mammography • 4. Fasting blood sugar • 5. Others if indicated — endometrial biopsy, FSH, LH, ultrasound
  26. 26. HRT or NO HRT???
  27. 27. Controversial : • Important studies : 1) The Heart and Estrogen/Progestin Replacement Study (HERS) 2) Women’s Health initiative study (WHI)(JAMA, 2002)

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