Menopause overview

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Overview of menopause, the issues related to this subject and clinical implications for the student

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Menopause overview

  1. 1. An Overview of MenopauseAssociate Prof Dr Hanifullah Khan
  2. 2. objectives!   to understand this condition & terminology!   physiology of menopause!   problems linked with menopause!   clinical scenarios
  3. 3. what is menopause? !   A physiological loss of ovarian hormonal activity !   Closely allied to loss of reproductive potential !   Permanent cessation of the primary ovarian functions
  4. 4. Physiology
  5. 5. The Ovaries!   2 functions - produce ova & secrete hormones!   Start secreting estrogen & progesterone from puberty to menopause!   Most of the beneficial effects derive from estrogen
  6. 6. actions of estrogen!  formation of the 20 sex characteristics!  Develop ovaries, tubes, uterus & vagina!  HPO axis interaction!  endometrial proliferation!  Increases fat deposition!  maintain the skin & vessels!  bone - incrrease formation & reduce resorption
  7. 7. actions of progesterone!   its actions are amplified in the presence of estrogen!   Interacts with hypothalmus and pituitary to regulate menstrual cycle!   converts endometrium to secretory stage!   makes cervical mucous & vaginal epithelium impenetable to sperm!   inhibits lactation during pregnancy!   makes the uterus less contractile
  8. 8. When does menopause occur?!   Tends to occur over a period of years!   A consequence of biological ageing!   Genetic & environmental factors!   Malaysian women - 48 - 52 years* *Jahanfar SH 2006, Ismael NN 1994
  9. 9. Types of menopause- Premature Menopause - menopause in a woman aged <40years- Early Menopause - menopause in a woman aged 50 - 59years- Late Menopause - menopause in a woman aged >60 years - Surgical menopause - a result of surgical removal of bothovaries- Medical menopause - -  permanent damage to both ovaries - chemotherapy or radiotherapy-  temporary - GnRHa tx in endometriosis
  10. 10. Perimenopause- the time just before and soon after theoccurence of menopause- symptoms of menopause have started- not yet certain if menopause is establishedyet
  11. 11. Diagnosis of menopause!   The diagnosis of menopause is mainly clinical•  a. Clinical Criteria1.  age around menopause ( around 50 years )2.  no periods for 12 months3.  menopausal symptoms•  ( NB. All 3 clinical criteria need not be present for a diagnosis )•  Laboratory diagnosis is generally not necessary for the diagnosis of menopause. However, where in doubt, laboratory testing of FSH may support the diagnosis, viz•  b. Laboratory Criterion•  1. FSH level > 35miu/ml
  12. 12. The consequences of menopause
  13. 13. primary symptoms - Menstrual changes -  Abnormal - Oligoamenorrhea – amenorrhea - Vasomotor -  hot flashes, night sweats - Urogenital -  Vaginal dryness, micrurition altered
  14. 14. secondary symptoms- Physical symptoms-  Muscle & joint pains-  Skin dryness, decreased stamina, backache- Sexual-  Decreased libido-  Avoiding intimacy- Psychophysiologic changes-  Decrease concentration-  Depressive symptoms
  15. 15. Monitoring symptoms
  16. 16. Long term effects!   Cardiovascular!   Bone!   Cancers!   Cerebrovascular
  17. 17. Clinical implications of menopause
  18. 18. Minor conditions- Urinary tract infections- Vaginal dryness- Vaginal infections- Joint & muscle pains
  19. 19. Symptomsmimicking disease!   Abnormal vaginal bleeding !   Perimenopausal !   Postmenopausal!   General pains e.g. Breast
  20. 20. Perimenopausalabnormal bleeding- At this age, there are many conditions that peak-  e.g. Adenomyosis, polyps, fibroids, hormonal- Cancers are always a concern, esp Ca Cx- Infections are the most common occurrence- All these must be ruled out before a diagnosis ofperimenopausal bleeding is made
  21. 21. Postmenopausal bleeding- Consider it as always abnormal- Always think of cancer- Usually due to atrophy or infection
  22. 22. Cardiovascular disease!   CV risk increases as estrogen levels decline!   1 in 2 women will die from cardiovascular disease!   Estrogen exerts beneficial effects on CV system through !   Direct effect on the vasculature !   Indirect effect of lipid metabolism Kramarow E et al. Health and Aging Chartbook. Health, United States, 1999. National Center for Health Statistics; 1999.
  23. 23. Cholesterol metabolism !   Only total cholesterol, low-density lipoprotein cholesterol, and apolipoprotein B demonstrated substantial increases within the 1-year interval before and after the FMP, consistent with menopause-induced changes. This pattern was similar across ethnic groups.Matthews K. J Am Coll Cardiol. 2009;54(25):2366-2373
  24. 24. Fracture risk!   decreased bone density!   osteoporosis!   common fractures involve hip, forearm & spine
  25. 25. you wanna be like this?
  26. 26. Psychomotor & Mental!   loss of libido!   suicidal tendencies!   marital discord
  27. 27. Urogenital problems
  28. 28. MenopausalHormone Therapy
  29. 29. potential risks & concerns- Breast cancer- Cardio vascular disease- Venous thrombosis- Endometrial cancer- Compliance/therapy- The Women s health initiative study aimedto confirm all these
  30. 30. Conclusion•  Estrogen plus progestin was associated with greater breast•  cancer incidence, and the cancers are more commonly node•  positive. Breast cancer mortality also appears to be•  increased with combined use of estrogen plus progestin. •  Writing Group for the Women s Health Initiative Investigators JAMA. 2010;304(15):1684-1692
  31. 31. Current recommendations- hormone therapy should be initiated for thetreatment of menopause-related symptoms- the lowest dose should be used for the lowestduration -  5 years recommended for estrogen+prog therapy- hormone therapy risks-  all forms of tx increse risk of VTE (deep vein thrombosis & pukmonary emboli)-  increased risk of breast Ca with est+prog combination Stuenkel CA et al. Menopause. 2012;19(8):846-847
  32. 32. Summary
  33. 33. The important points!   menopause is a natural occurence!   it is associated with long- & short-term issues!   some of the menopausal symptoms may mimic medical disorders!   postmenopausal conditions such as bleeding & masses must be seriously looked into!   hormone therapy should be used but it has its problems
  34. 34. Q. A 40 year old woman presented with no periods for 1 year. How would you diagnose menopause?

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