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Menopause (Signs and Symptoms)


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Menopause (Signs and Symptoms)

  1. 1. MENOPAUSE Clinical Features, Differential Diagnosis, & Investigations
  2. 2. MENOPAUSE, “ The Change” <ul><li>In menopause the estrogen levels don’t fall to zero, but it’s the decreased level of it and the relative increase of androgen which cause the symptoms. Strictly speaking, a woman has reached menopause when one year has passed since her last period. Before menopause, there is a transitional stage, known as the perimenopause, where women have declining fertility and fluctuating hormone levels. </li></ul><ul><li>A woman with vasomotor symptoms who has completely missed a menses is likely to experience her final menstrual period within the next 1 to 2 years. Menopause usually occurs several years after the onset of menstrual changes; however, about 10% of women experience abrupt onset of amenorrhea. </li></ul><ul><li>To determine whether the absence of menstrual periods is caused by menopause or another illness, mostly a physical examination and medical history of the patient is diagnostic. </li></ul>
  3. 3. CLINICAL FEATURES <ul><li>1) Psychological Changes </li></ul><ul><li>Decreased libido </li></ul><ul><li>Mood swings </li></ul><ul><li>Anxiety & nervousness </li></ul><ul><li>Irritability </li></ul><ul><li>Insomnia ( waking in middle of night) </li></ul><ul><li>Fatigue & dizziness ( ed sleep) </li></ul><ul><li>Loss of concentration & short term memory </li></ul><ul><li>Depression </li></ul><ul><li>Headaches </li></ul><ul><li>Tinnitus </li></ul><ul><li>Not obvious hormonal reasons but may be due to the stress of “The Change ” </li></ul>
  4. 4. CLINICAL FEATURES <ul><li>Hot Flushes ( Vasomotor Symptoms) </li></ul><ul><li>80% of white women experience VM symptoms </li></ul><ul><li>It’s a warm, hot feeling with perspiration & prickling sensation starting in the chest & shoulders moving up to face and neck </li></ul><ul><li>30 sec -5mins, spontaneous ,uncomfortable and unpredictable </li></ul><ul><li>Any time of day or night (night time hot flushes with night sweats) </li></ul><ul><li>Sometimes heavy sweating followed by chills </li></ul><ul><li>Red blotches may appear on neck, chest & arms </li></ul><ul><li>Some authorities say that the changing hormone levels cause BV in skin to expand rapidly and sending a rush of warm blood to skin raising temperature </li></ul><ul><li>More valid changes in estrogen levels influences hypothalamus temp.regul. mechanism in midbrain affected </li></ul>
  5. 5. CLINICAL FEATURES <ul><li>Flushes cease 4-5 years after 1 st onset , but 10% of women may experience for upto 10 years. </li></ul><ul><li>Non-hormonal SSRIs,vit E etc </li></ul><ul><li>& HRT. </li></ul><ul><li>Pre-menopausal women sudden drop of estrogen like in bilateral oophorectomy much freq and severe flashes </li></ul>
  6. 6. CLINICAL FEATURES <ul><li>What can be done about hot flushes? </li></ul><ul><li>Here are some tips which may be helpful: </li></ul><ul><li>Keep home and workplace cool. </li></ul><ul><li>Wear loose clothing in layers that are easily removed. </li></ul><ul><li>Drink plenty of water and juice. Avoid caffeine, alcohol and spicy foods if they bring on hot flushes. </li></ul><ul><li>Exercise regularly to help stabilise hormones and prevent insomnia. </li></ul><ul><li>Avoid confined spaces and hot, humid weather, if possible. </li></ul>
  7. 7. CLINICAL FEATURES <ul><li>3) Hair Changes </li></ul><ul><li>Hair loss of scalp </li></ul><ul><li>Become drier & thinner </li></ul><ul><li>Hair on chin,chest,abdomen & upper lip become coarser & darker </li></ul><ul><li>4) Skin Changes </li></ul><ul><li>Drier, less elastic, thinner, more wrinkled, fat under skin thins out, more vulnerable to injury </li></ul><ul><li>Because of the relative excess of androgens in the body </li></ul>
  8. 8. CLINICAL FEATURES <ul><li>5) Heart Changes </li></ul><ul><li>Peri-menopausal and early menopausal palpitations often during or just before hot flashes </li></ul><ul><li>Cholesterol ed due to def. estrogen CV diseases incidence ed </li></ul><ul><li>Healthy diet, regular exercise, stop smoking, keep BP down </li></ul><ul><li>Estradiol def. causes </li></ul><ul><li>Total cholesterol </li></ul><ul><li>HDL cholesterol </li></ul><ul><li>LDL cholesterol </li></ul><ul><li>Triglycerides </li></ul><ul><li>Estrogen def ed nitrogen synthase ed nitric oxide reversed vasodilation & loss of oxidant for subintimal lipoprotein </li></ul><ul><li>So, atherogenesis & vasoconstriction </li></ul>
  9. 9. CLINICAL FEATURES <ul><li>6) Breast Changes </li></ul><ul><li>Breast tenderness </li></ul><ul><li>Loss of fullness, firmness & become pendulous </li></ul><ul><li>Some glandular tissue replaced by fibrous tissue </li></ul><ul><li>7) Body Shape </li></ul><ul><li>Changes slightly, body fat instead of hips and thighs, concentrates around waist and upper trunk this change assoc. with ed risk of diabetes & heart disease </li></ul><ul><li>Avoided by activity, healthy diet, bcz Wt. gain is easier after menopause </li></ul>
  10. 10. CLINICAL FEATURES <ul><li>8) Reproductive Changes </li></ul><ul><li>Ovaries & uterus become smaller, stoppage of ovulation & menstruation </li></ul><ul><li>Mostly, irregular periods (metrorrhagia), before complete cessation of menses </li></ul><ul><li>Periods may become heavier (menorrhagia) or lighter than usual during perimenopause </li></ul><ul><li>Pregnancy is still possible until no periods for a year, but less likely when ovulation begins to fluctuate </li></ul>
  11. 11. CLINICAL FEATURES <ul><li>9) Bladder & urethra (atrophic urethritis) </li></ul><ul><li>Urethra becomes shorter, lining becomes thinner </li></ul><ul><li>Bladder control is difficult, burningitching during urination (dysuria) </li></ul><ul><li>ed incidence of UTIs </li></ul><ul><li>Bladder support reduced weakened, less elastic pelvic floor muscles </li></ul><ul><li>Sphincter looses strength frequency, incontinence </li></ul><ul><li>Possible explanation estrogen receptors in trigone & prox. urethra </li></ul><ul><li>Avoidance by pelvic floor muscle exercises </li></ul>
  12. 12. CLINICAL FEATURES <ul><li>10) Vaginal Changes (Atrophic Vulvovaginitis) </li></ul><ul><li>10-40% of women </li></ul><ul><li>Vag. Shorter & narrower. </li></ul><ul><li>Less elastic, ed vag.secretions so dryness & dyspareunia </li></ul><ul><li>Vulvovaginal pruritis </li></ul><ul><li>ed vag.infection( ed estrogen pH) </li></ul><ul><li>Post coital spotting </li></ul><ul><li>Avoid dryness, vag. Lubricants, estrogen creams </li></ul><ul><li>Although libido ses but enjoy sex life afterwards who had active sex life before menopause </li></ul><ul><li>Maintain active sexual life maintains elasticity of vag. Wall decreased vaginal discomfort </li></ul><ul><li>ed estrogen </li></ul><ul><li>Thinning of vag. Cell lining </li></ul><ul><li>Fragile vag. Mucosa </li></ul><ul><li>ed elasticity, paleness, disappearance of rugae (small folds) in vag. Wall, decreased blood supply </li></ul>
  13. 13. CLINICAL FEATURES <ul><li>11) Bone Changes </li></ul><ul><li>Bone density decreases </li></ul><ul><li>Osteoporosis, & prone to fractures </li></ul><ul><li>Mostly spine, wrists, hip, and end of thighs affected </li></ul><ul><li>Take plenty of Calcium in diet, weight bearing exercises, Ca & vit.D supplements </li></ul><ul><li>12) Muscles </li></ul><ul><li>Muscular aches and pains </li></ul><ul><li>Muscle strength and coordination decreased </li></ul><ul><li>13) GIT </li></ul><ul><li>Indigestion, bloating, flatulence and constipation </li></ul>
  14. 14. HOT FLUSH
  15. 22. <ul><li>This animation shows what happens with estrogen deficiency. The resorption cavities are deeper and they occur more frequently. With these small changes, the individual BMU does not seem very different. But there are more BMU's and the trabeculae become perforated. They lose strength and have microfractures with microcallus formation. By 30 months the bone volume has decreased to 22%. </li></ul>
  17. 25. DIFFERENTIAL DIAGNOSIS <ul><li>Mental Changes DDx : </li></ul><ul><li>Younger females no VM symp abrupt menstrual changes PREMATURE OVARIAN FAILURE ? </li></ul><ul><li>Oligomenorrhea, secondary amenorrhea suspect </li></ul><ul><li>PREGNANCY, THYROID DYSF, PROLACTINOMA (BT Hemianop & galactorrhea ), MED OR SUPPL USAGE </li></ul><ul><li>Excessive intermenstrual bleeding THYROID DYSF, BLOOD DYSCRASIAS, LEIOMYOMA, ADENOMYOSIS, ENDOMETRIAL POLYPS, ENDOMETRIOSIS, CERVICALENDOMETRIAL NEOPLASIA (esp; >40 yrs IMB), MED SUPPL USE </li></ul>
  19. 27. DIFFERENTIAL DIAGNOSIS <ul><li>Vasomotor Symptoms DDx: </li></ul><ul><li>Premenstrual syndrome (serum FSH normal) </li></ul><ul><li>Hyperthyroidism </li></ul><ul><li>Pheochromocytoma (episodic HT) </li></ul><ul><li>Carcinoid </li></ul><ul><li>Occult infection </li></ul><ul><li>Hodgkins disease </li></ul><ul><li>Pre-existing obesity and weight gain (for increased perspiration and warmth) </li></ul><ul><li>Anxiety, guilt, strong emotions </li></ul><ul><li>Rosacea </li></ul><ul><li>Exercise, sex and stressful conditions </li></ul><ul><li>Alcohol use and intolerance </li></ul><ul><li>Routine spicy food, MSG </li></ul>
  20. 28. DIFFERENTIAL DIAGNOSIS <ul><li>Sunburns, heat stroke </li></ul><ul><li>Dehydration, & circulatory disorders </li></ul><ul><li>Ch. Broncitis and emphysema </li></ul><ul><li>Diabetes </li></ul><ul><li>Chronic O2 deprivation </li></ul><ul><li>Polycythemia vera </li></ul><ul><li>Cushing syndrome </li></ul><ul><li>SLE </li></ul><ul><li>Certain Medications LIKE some anti-diabetics, anticholesterol, some anti HT, Niacin (all over flushing) </li></ul>
  21. 29. DIFFERENTIAL DIAGNOSIS <ul><li>Changes in Libido,Sleep,Mood,Cognition: </li></ul><ul><li>Mood anxiety disorders, thyroid dysfunction, stress </li></ul><ul><li>Medication </li></ul><ul><li>Unrecognised sleep disorders LIKE Obstructive Sleep Apnea, Restless Leg Syndrome, Inflammatory neoplastic processes, multiple sclerosis </li></ul><ul><li>New cognitive dysfunction can be 1 st manifestation of Dementia </li></ul>
  22. 30. DIFFERENTIAL DIAGNOSIS <ul><li>In addition to surgery , there are several other potential triggers of premature menopause. This is defined as any menopause that occurs before age 40, whether natural or induced. POF may occur because of several factors, including: </li></ul><ul><ul><li>Genetics. The age at which a woman enters menopause often corresponds closely with that of her mother. </li></ul></ul><ul><ul><li>Cancer treatments. Chemotherapy or radiation to the pelvic area can damage the ovaries, triggering POF. The younger a woman is when she has these treatments, the less likely she is to experience premature menopause. </li></ul></ul><ul><ul><li>Smoking. Tobacco use may cause menopause to occur up to two years earlier than normal. </li></ul></ul><ul><ul><li>Chromosome defects . For example, women born without a second X chromosome, or born without part of the chromosome have a condition known as Turner Syndrome. In this disorder, the ovaries do not form normally, which leads to early menopause. </li></ul></ul><ul><ul><li>Autoimmune diseases . The body’s immune system sometimes mistakenly attacks part of the reproductive system, damaging ovaries and preventing them from making female hormones. Examples of diseases that can cause these symptoms include thyroid disease and rheumatoid arthritis. </li></ul></ul>
  23. 31. INVESTIGATIONS <ul><li>The Dx of menopausal transition is mostly clinical, i.e., on basis of menstrual irregularities, VM symptoms etc. in a woman >40. </li></ul><ul><li>The clinical diagnosis of natural menopause is made if a woman of an appropriate age has had 12 months of amennorrhea accompanied by symptoms suggestive of ovarian failure, at which point , the FSH serum concentration is certainly so elevated that testing is usually not useful. </li></ul><ul><li>TESTS </li></ul><ul><li>Urine serum B-hCG bcz potential for pregnancy even in menopausal transition </li></ul><ul><li>High sensitivity TSH </li></ul><ul><li>Platelet count, PT, APTT </li></ul><ul><li>FSH, LH, estradiol not useful during transition bcz wide variation unless if any other cause suspected </li></ul><ul><li>sing serum FSH levels decling ovarian func. But cannot predict last menstrual period </li></ul>
  24. 32. INVESTIGATIONS <ul><li>12 MONTHS WITHOUT MENSES FSH > 25 IU/L on two separate occasions Estradiol < 50 pg/ml OR 100 pmol/L </li></ul><ul><li>Oral contraceptive use ed FSH levels so FSH levels done 7 th day of placebo pills or 7 th day of pill free week </li></ul>
  26. 34. INVESTIGATIONS <ul><li>Tests of other Body Fluids: </li></ul><ul><li>Vaginal pH raised after menopause </li></ul><ul><li>Vaginal cytology ed maturation index ( se in parabasal cells) </li></ul><ul><li>Microscopy of vaginal fluid candidiasis, trichom., bact.vaginosis </li></ul><ul><li>Imaging </li></ul><ul><li>To rule out other abdominopelvic lesions </li></ul><ul><li>Biopsy </li></ul><ul><li>Rule out endometrial neoplasia in obese, diabetic woman </li></ul>
  27. 35. INVESTIGATIONS <ul><li>US FDA has approved a home urine testing kit that measures FSH in woman’s urine , and can indicate menopause or perimenopause </li></ul>