Menopause is the time in a woman's life when her period stops. It usually occurs naturally, most often after age 45. Menopause happens because the woman's ovaries stop producing the hormones estrogen and progesterone. A woman has reached menopause when she has not had a period for one year.

1. MENOPAUSE
MUKESH SAH
PGI
GOODSAM MEDIAL CENTER

2. MENOPAUSE (1/2)
 Menopause is defined as permanent physiologic
cessation of menstruation at the end of reproductive
life due to loss of ovarian follicular activity.
 It is the point of time when last and final menstruation
occurs.

3. MENOPAUSE (2/2)
 Climacteric is the period of time during which a women passes from the
reproductive to the non-reproductive stage. This phase covers 5-10 years on
either of menopause.
 Perimenopause is the part of the climacteric when the menstruation is likely
 Post-menopause is the process of life that comes after the menopause.

4. AGE OF MENOPAUSE (1/2)
 Age at which menopause occurs is genetically predetermines.
The age of menopause is not related to age of menarche or age
at last pregnancy.
 It is also not related to number of pregnancy, lactation, use of
oral pill, socioeconomic condition, race, height or weight.

5. AGE OF MENOPAUSE (2/2)
 However, thinner women have early menopause.
 The age of menopause ranges between 45-55 years, average
being 50 years.

6. PHASES OF MENOPAUSE(1/2)
 The phases of menopause is usually broken down into four categories:
1. Pre-menopause: The broad definition of pre-menopause is the time prior to
menopause .The occurrence of menopause before the age of 40 years.
2. Peri-menopause: A period of women’s life characterized by the physiological
changes associated with the end of reproduction capacity and terminating with the
completion of menopause also called climacteric.

7. PHASES OF MENOPAUSE(2/2)
3. Menopausal phase : It is the end of menstruation . The age of
menopause ranges between 45 – 55 years , average being 50 years.
4. Post-menopausal : It is defined formally as the time after
which a women has experienced 12 consecutive month of
amenorrhea without period.

9. TYPES OF MENOPAUSE(1/5)
 There are several types of menopause and each depends on the cause and/or
timing of the end of menstruation.
 Natural menopause. This occurs when ovaries slowly stop functioning and stop
menstruating as a result. For most women, this happens between the ages of 45
and 55. As ovaries stop producing hormones like estrogen, progesterone, and
testosterone, women body responds and adapts. When women experience
troubling symptoms as women adapt.

10. TYPES OF MENOPAUSE(2/5)
 Induced menopause. Sometimes menopause does not come on its own but is
brought on by a deliberate action, like surgery or medication that affects
ovaries.
• A hysterectomy or other surgery that removes or damages the ovaries will
cause an abrupt menopause. Usually, women can anticipate this type of
menopause and plan ahead for treating the sudden symptoms that can result.

11. TYPES OF MENOPAUSE(3/5)
 A hysterectomy that removes only the uterus may not damage the ovaries
and, therefore, will not cause menopause. But if the ovaries are also
removed, this is "surgical menopause." Chemotherapy or radiation as
a cancer treatment will make ovaries shut down, and that, too, can cause at
least a temporary menopause.

12. TYPES OF MENOPAUSE(4/5)
 Premature or early menopause. This occurs when women stop
menstruating before the age of 40. Early menopause is one that occurs
before the age of 45. Besides surgery, there are many reasons a woman
might go through menopause early, including (if any of these apply to
women, women may go through menopause sooner than other
women):

13. TYPES OF MENOPAUSE(5/5)
 Smoking
 Heavy drinking
 Endocrine disorders
 Chemotherapy
 Autoimmune disease
 Thyroid disease

14. CAUSES OF MENOPAUSE
 Menopause occurs when the ovaries are totally depleted of
eggs and no amount of stimulation from the regulating
hormones can force them to work.

15. ENDOCRINOLOGY OF CLIMACTERIC AND
MENOPAUSE
 Few years prior to menopause, depletion of ovarian follicles occurs
and the existing follicles become resistant to gonadotropins.
 This results in impaired folliculogenesis and diminished estradiol
production.
 The serum estradiol level falls from 50-300pg/mL before menopause
to 10-20pg/mL after menopause.

16.  This decrease the negative feedback effect on hypothalamopituitary
axis resulting in increase in follicle stimulating hormone (FSH)
 The diminished folliculogenesis result in anovulation, oligo-
ovulation and corpus luteum insufficiency.

17.  The sustained level of estrogens may cause endometrial
hyperplasia and menstrual abnormalities.
 Shortening of the follicular phase leads to shorter menstrual cycles.
 There is fall in the levels of prolactin and inhibition.
 Ultimately, there are no more follicles responsive to gonadotropins.
 Estradiol production drops and endometrial growth stops resulting
in absence of menstruation.

18. ORGAN CHANGES (1/4)
1. Genitourinary system:
a. Ovaries shrink in size, become wrinkled and white. Thinning of cortex and
abundance of stroma cells occur.
b. Fallopian tubes show features of atrophy. The muscle coat becomes thinner,
the cilia disappear and the plicae become less prominent.

19. ORGAN CHANGES (2/4)
c. The uterus becomes narrower due to gradual loss of elasticity. The
rugae progressively flatten. There is no glycogen and Doderleins
bacillus. The vaginal pH becomes alkaline.
d. The vulva shows features of atrophy. The labium becomes flattened
and the pubic hair becomes scantier resulting in a narrow introitus.

20. ORGAN CHANGES (3/4)
e. Breast fat gets reabsorbed and the glands atrophy. The glands atrophy.
The nipples decrease in size, the breasts become flat and pendulous.
f. In bladder and urethra, the epithelium becomes thin and is more prone
to damage and infection.
g. Loss of muscle tone leads to pelvic relaxation, uterine descend and
anatomic changes in the urethra and neck of bladder.

21. ORGAN CHANGES (4/4)
2. Skeletal system:
following menopause there is loss of bone mass by about 3%-5% per year
due to deficiency of estrogen leading to osteoporosis.
3. Cardiovascular system:
Deficiency if estrogen increases the risk of cardiovascular disease the risk of
cardiovascular disease because of its function of decreasing high density
lipoprotein (HDL) cholesterol and antioxidant property.

22. MENSTRUATION PRIOR TO MENOPAUSE
Any of the following patterns may be observed prior to menopause:
• Abrupt cessation of menstruation.
• Gradual decrease in both amount and duration.
• Irregular with or without excessive bleeding.

23. MENOPAUSAL SYMPTOMS (1/4)
Majority of women do not experience any symptoms apart from
cessation of menstruation. Some women experience symptoms and
health concerns:
1. Vasomotor symptoms: The characteristic symptoms of menopause is
‘hot flush’. It is characterized by sudden feeling of heat followed by
profuse sweating with cutaneous vasodilation.

24. MENOPAUSAL SYMPTOMS (2/4)
1. Genital and urinary symptoms: Atrophy of the epithelium of vagina, urinary
bladder and urethra causes dyspareunia, vaginal infections, dryness, pruritus and
Leukorrhea, urinary symptoms include urgency, dysuria, stress incontinence and
frequent urinary tract infections.
2. Psychological symptoms: estrogen deficiency is associated with decreased sexual
desire. There may be psychological changes such as increased anxiety, headache,
insomnia, irritability, dysphasia and depression. Dementia, mood swings and
inability to concentrate are also seen.

25. MENOPAUSAL SYMPTOMS (3/4)
4. Osteoporosis:
- Osteoporosis occurs in postmenopausal women due to estrogen loss,
deficiency of calcium and vitamin D or hereditary.
- Osteoporosis may lead to back pain, loss of height and kyphosis and
fracture of bones.
- Fracture may involve vertebral body, femoral neck or distal forearm.

26. MENOPAUSAL SYMPTOMS (4/4)
5. Cardiovascular and cerebrovascular effects:
- Risks of ischemia, heart disease, coronary artery disease and
stroke are increased due to atherosclerotic changes,
vasoconstriction and thrombus formation

27. DIAGNOSIS OF MENOPAUSE
 Cessation of menstruation for 12 consecutive months during
climacteric.
 Occurrence of hot flushes and night sweats.
 Features of low estrogen on vaginal cytology.
 Serum estradiol is less than 20pg/ml.
 Serum FSH, LH is greater than 40mIU/mL at 1 week interval for
three times.

28. MANAGEMENT (1/3)
1. Counselling: Adequate explanation to every women with
symptoms may help understand and accept the changes. Those
who have artificial and early menopause due to bilateral
oophorectomy or radiation may require more reassurance.

29. MANAGEMENT (2/3)
2. Non-hormonal treatment:
a. Nutritious diet balanced with protein and calcium.
b. Supplementary calcium: total daily requirement of calcium is
1.5g.
c. Exercise: walking, jogging and weight bearing exercises.

30. MANAGEMENT (3/3)
3. To follow healthy lifestyle, health promotion and regular health screening:
a. Supplementation with vitamin D 400-800 IU/day.
b. Cessation of smoking and alcohol.
c. Hormone replacement therapy (HRT): replacement of estrogen and progestin are
prescribed for women with premature ovarian failure, gonadal dysgenesis and
surgical or radiation menopause.

31. ABNORMAL MENOPAUSE
Premature menopause occurs at or below the age of 40. Treatment by
substitution therapy is usually forward.
1. Delayed menopause: menopause does not occur beyond 55 years
of age. Detailed investigations for any pelvic pathology and
appropriate treatment are indicated.

32. 2. Artificial menopause: permanent cessation of ovarian function as a
result of surgical removal of ovaries or by radiation.
3. Surgical menopause: menstruating women who have bilateral
oophorectomy, experience menopausal symptoms. It is sometimes more
troublesome than natural menopause.

33.  Radiation menopause: the ovarian function may be suppressed by external
gamma radiation in women below the age of 40. The menstruation may
resume after 2 years and even conception is possible.

34. REFERNCES
 https://www.verywellhealth.com/what-is-menopause-2322697
 https://www.slideshare.net/swatipatanwal/menopause-ppt-
34603737?next_slideshow=1
• DC Dutta’s. Textbook of gynecology including contraception. 7th.
New Delhi: Jaypee brothers; Nov2013. p. 57-64.
• Annamma Jacob. A comprehensive textbook of midwifery and
gynecological nursing. 4th edition. New Delhi: Jaypee brothers;
2015. p. 903-905.