Menopause by Dr numan alam

1. MENOPAUSE
Fit at 50, strong at 60

2. Permanent cessation of menstruation resulting from the
loss of ovarian follicles (WHO).
DEFINITION
• Effects every woman
• Cessation of menstruation for the
past twelve months
• Average Age - 51 years

3. Need...
Global population of age 60
yrs.
Currently -580 million
• 2020 - One billion
• 75% -Elderly
• 50% -Postmenopausal
women

4. Premature Menopause:
Causes
Primary
Autoimmune
disorders
Chromosome
anomalies
Enzyme
deficiencies
Secondary
Surgical
Infections
Chemotherapy
and
radiotherapy
if it occur before the age of 45?

5. Premenopause
The time period of
endocrine changes
before cessation of
menstruation.
Climacteric/
Perimenopause
The period of
endocrine changes
surround the
menopause is called
Climacteric
Postmenopause
The time period of
endocrine changes
After cessation of
menstruation
what is meant by Climacteric?

6. Actual change
around 35 years
sensitive germ
cells eleminated
germ cells
resistant to
normal
gonadotrophins
anovulation and
menstrual
irregularity
rise in
gonadotrophin
levels restores
ovulation and
normal
menstruation
compensated
ovarian failure
Pathophysiology

7. A time comes when raised
gonadotropins level fails to achieve
any significant follicular growth and
estrogen produced is not sufficient to
cause endometrial growth results in
cessation of menstruation and hence
menopause
Pathophysiology

8. Pathophysiology

9. Effect Of Menopause
Risk of
• Fracture
• Heart
Disease
Menopausal Symptoms
Estrogen &
Progesterone
level

10. •Short term effects
•Long term effects
Effects of menopause

11. Short term effects
•Menstrual irregularities
•Unintended pregnancy
•Hot flushes
•Palpitation
•Muscle And Joint Pain
•Low Backache
•Vaginal Dryness
•Urinary Leak
•Urinary Frequency
•Fatigue
•Mood Swings
•Depression
•Sleeping Problems
•Memory Lapse
•Decreased Libido
•Weight Gain
•Dryness Of Skin
•Hair Loss

12. • 75% women
• Intense heat (face,forehead,neck,chest,earlobe)
• Associated with night sweats,irritability,lethargy,insomnia and
tiredness
• More pronounced in premature and surgically induced menopause
Hot flushes

13. What can you do about Hot flushes
To reduce an attack
- Avoid spicy food, coffee,
tea, alcohol
- Wear loose cotton clothes
- Avoid hot water bath just
before sleeping
- Medical treatment options

14. (i) Urinary
• Dysuria
• Frequency
• Urgency
• voiding
difficulties
(ii) Genital
• Dyspareunia
• Apareunia
• genital tract
trauma
• loss of libido and
• uterovaginal
prolapse
Genitourinary Symptoms

15. • Anxiety
• Irritability
• Depression
• mood
• Fluctuation
• inability to concentrate
• poor memory
• lethargy
Psychological Symptoms

16. A young women is a gift of nature,
An old woman is a work of art.

17. • Osteoporosis
• Heart Disease
• Alzeihermen’s Disease
Of Menopause
Of Ageing
• Arthritis
• Diabetes
• Hypertension
• Problems of Hearing, vision
Long term effects

18. • Average rate of bone loss is 3% per annum
• 50% of women by age of 60 years
• Bones at high risk of fracture are
• Distal radius,neck of femur,vertebral body
• Results in structural deformity, Dowagers hump (fracture of vertebrae T8-L4)
Osteoporosis

19. Normal bone Osteoporotic
bone
Micro-fracture
Leads to fracture
Osteoporosis

20. Age
Incidence
of
fracture
> 60 yrs 25 %
> 65 yrs 40 %
> 70 yrs 50 %
Osteoporosis

21. GETTING SHORTER MAY BE JUST THE
BEGINNING
• Bone becomes weak which
leads to multiple breaks in the
spine
• With gradual accumulation of
these breaks people get shorter
• Could lead to a curved back
known as “Dowager’s Hump”

22. A FRACTURE CAN TURN YOUR LIFE
INTO ONE OF DISABILITY
Broken hips cause permanent
disability
One in four people who
suffer a hip fracture due to
osteoporosis will die within
one year

23. Predominant factor increasing risk of cardiovascular
diseases in post menopausal women is decreased
HDL:LDL ratio due to estrogen deficiency
Ischemic Heart Disease

24. • Incidence 3 times more in women aged 65 yrs or more
• Less common in obese women, because of endogenous estrogen
production by adipose tissues
• Prevention by estrogen replacement therapy.
Alzheimer’s disease

25. • Like decrease in bone mass skin thickness also declines after
menopause
• Skin collagen declines by 30 % in first 10 yrs after menopause
• Collagen restored to premenopausal levels within 6 months of initial
hormone replacement therapy.
Skin

26. • Patients in premature menopause fails to have more children
• Reproduction with ovum donation remains only option.
Infertility

27. DIFFERENTIAL DAIGNOSIS
(1) Premenstrual syndrome
(2) Endogenous depression
(3) Hyperthyroidism
(4) Pheochromocytoma

28. • Gonadotrophin assessment
• FSH level > 15 iu/ml suggest perimenopause and
• FSH level > 40 iu/ml confirms menopause
Investigations

29. Hormonal Non Hormonal Add on
•Estrogen
•Tibolone
•SERMS
Raloxifine
• Bisphosphonate
Alendronate
Risedronate
•Others
• Calcium
• Vit D
Analog
•Alfacalcidol
Treatments Therapy

30. (i) Tibolone
• Non hormonal steroid with oestrogenic, progestogenic and
androgenic properties.
• Dose is 2.5 mg/day
• Reduces hot flushes, sleeplessness and improves mood and libido
• Increases bone density by 8 % after 2 years use
• Side effect is irregular bleeding
Non Hormonal therapy

31. (ii) Calcitonin
(iii) Bisphosphonates
Sodium etidronate and clonronate have beneficial effect on bone mass
(iv) Exercise
Decreases incidence of osteoporosis,ischemic heart disease and depression
(v) Calcium Supplements
Calcium alone no effect on osteoporosis
Calcium + estrogen = beneficial effects in lower doses
(vi) Hypnotics,Sedatives,Tranquilizers
Non Hormonal therapy

32. • Indications
(1) Women distressed with perimenopausal symptoms
(2) Women at increased risk of osteoporosis
(3) Women who wants to take it by choice
The risks of HRT must be explained and follow up ensured in such
patients.
Harmone Replacement therapy

33.  Before prescribing HRT,benefits and risks associated
with it should be discussed in detail
 Blood pressure,weight is recorded
 Breasts examined for any lump
 Pelvic examination for any mass
 Cervical smear is carried out
 In some cases pretreatment mammography is
indicated
Pre treatment evaluation

34.  Blood sugar estimation
 Renal and liver function tests
 Lipid profile
 Pelvic ultrasonography
 Endometrial sampling
 Bone densitometry
 Investigations not mandatory but indicated in
selective patients
Optional Investigations

35.  (A) Short period of time
 3 months to one year
 For perimenopausal symptoms
 (B) Long period of time
 5 to 10 yrs
 Prevention of cardiac diseases and osteoporosis
 Patients taking HRT should have checkups at
regular intervals for benefits and side effects of drug
Treatment duration and follow up

36.  (i) Oestrogen alone
 In patients where hysterectomy has been performed
 Natural oestrogens are prefered over synthetic,coz synthetic
oestrogen are metabollized 100-1000 times more than natural
oestrogen,hence chances of side effects (hypertension and
thromboembolism) is high
 Natural oestrogens include
 17 beta oestradiol oestriol
 Oestrone conjugated equine estrogen
 Estrogen and progestogen combination
To eliminate the risk of endometrial hyperplasia and carcinoma in
women with intact uterus progestogens along with estrogens are
given which causes regular endometrial shedding at menstruation
Types of Harmones

37. • Progestogens alone
 Indicated in patients cannot tolerate
estrogen/contraindicated
 Controls hot flushes and prevent bone loss
 Have no cardio protective role as it causes reduction
of HDL
Types of Harmones

38. (i) Absolute
• History of breast
cancer
(ii) Relative
• Hypertension
• Diabetes
• Endometriosis
• Fibroids
• History of
thromboembolism
Contraindications of HRT

39. • (i) return of menstruation in
postmenopausal women
• (ii) premenstrual syndrome like symptoms
(bloating,fluid
retention,mastalgia,headache,depressn)
• (iii) disturbance in lipid profile (reduced
HDL:LDL)
(a) Progestogen
related
• (i) risk of thromboembolism(b) Estrogen related
• (i) Endometrial cancer
• (ii) Ovarian cancer
• (iii) Cervical,Vaginal,Vulval cancers
• (iv) Breast cancer
(c) Hormone
replacement
therapy and Cancers
Risks/side effects of HRT

40. THANK YOU
“Growing Old is Natural
But
Feeling Old is Not.”

41. •PREPARED BY
• NUMAN ALAM
• 08-146
• FINAL YEAR MBBS