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28.Peri Menopausa

The document summarizes the peri-menopausal period and peri-menopausal syndrome. It describes peri-menopause as the transitional phase before and after menopause, encompassing the 2-8 years leading up to the final period and the first years after. Common symptoms during this time include hot flashes, night sweats, mood changes, sleep disturbances, and vaginal dryness due to declining estrogen levels. Treatment options discussed include hormone replacement therapy using estrogen and progestogen to relieve symptoms, as well as traditional Chinese medicine therapies.

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Peri-menopausal period syndrome Zhanghuiying Department Of Obstetrics & Gynecology Tianjin Medical University General Hospital
Staging of women climacteric period adolescence 40yrs Final period 1yrs after the Final period 60-65 yrs Life stop Pre menopause Post menopause Peri menopause Transitional phase ( 参考 WHO 的定义 ) climacteric period
Definition Menopause the cessation of menses for a year or more. It is caused by ovarian failure. It marks the end of a women’s reproductive life It occurs normally between the ages of 45– 55 years and at a mean age of 51 years. It is a physiological process Peri-menopause is a period before and after the menopause. Encompasses the years leading up to menopause-anywhere from 2-8 yrs-plus the first years after final period
Peri-menopausal Period Syndrome peri-menopause accompanied by the symptoms of climacteric, including hot flashes, excessive perspiration, night sweats, depression, agitation, vaginal dryness, insomnia Premature ovarian failure ----- the cessation of menses before the age of 40 years. Artificial menopause ------ the cessation of menses is secondary to some causes, such as oophorectomy, radiation therapy.
The basic causes of the Peri-menopausal syndrome are a progressive decline in ovarian production on estrogens and other sex hormones
Negative Feedback Secretion of estrogens decreased (ovary) ↓ FSH increased (40-45 years old) ↓ FSH,LH increased(45-50 years old) ↓ FSH increased 13 times LH increased 3 times (the first year menopause ) ↓ FSH, LH gradually decline (3 years after menopause)
Symptoms and signs 1. Early Symptoms and signs   1) menstruation disorder Oligomenorrhea--- intervals greater than 35 days. Polymenorrhea---- intervals less than 21 days hypermenorrhea amenorrhea menopause
2) vasomotor symptoms ( hot flashes, sweats) estrogen depletion result in instability in the vessels of the skin. The hot flashes begins on the chest and spreads quickly over the neck, face and upper limbs which lasts only seconds but may recur many times one day. Sweat often follows hot flashes.
3) mood changes and sleep disturbances insomnia, headache, backache, depression, hate having difficulty falling asleep and waking up soon after going to sleep 4)urinary tract problem atrophic change in the urinary epithelium decreased elastic of reproductive and urinary tract supporting structures
5) vaginal dryness and genital tract atrophy atropic vaginitis, dyspareunia the vaginal skin become thin and loses its rugose appearance small red spots appear on the vagina
2. Late symptoms and problems 6)osteoporosis Accelerated bone loss in women is clearly related to the loss of ovarian function. Studies show that a rapid decrease in bone mass occurs within 2 months of ovariotomy
There is now general agreement that postmenopausal osteoporosis is related to estrogen deficiency Estrogen reduce bone resorption more than they reduce bone formation Other factors lack of exercise Malabsorption of calcium
7) cardiovascular lipid changes perimenopaual women have a lower incidence of coronary heart disease than men of same age. After the menopause a woman’s risk increase progressively until age 70 when it become equal to that of men HDL （ high density lipoprotein ）  ,LDL  , total cholesterol  This observation led to the supposition that estrogen might be a key factor. Estrogen has protection against heart disease
Diagnosis 1) History menstrual abnormality 2) Symptoms: vasomotor symptoms, vaginal dryness, urinary frequency, insomnia, irritability, anxiety, skin change, breast changes, urinary tract problem, pelvic floor change( cystocele. Rectocele. Prolapse), skeletal change(backache, ) and so on.
3)Physical examination: The clinical findings vary greatly depending on the time elapsed since menopause and the severity of the estrogen deficiency Skin: thin ,dry Breast loss turgor The labia are small The uterus becomes much smaller The muscles of the pelvic floor are looser and thiner Prolapse may be present
4) Laboratory diagnosis Cytologic smear from the vaginal wall E2, FSH, LH determination
Treatment 1)   education, understanding, reassurance Every woman with climacteric symptoms deserves an adequate explanation of physiologic event she is experiencing ,in order to dispel her fears and minimize symptoms such anxiety , depression and sleep disturbance. Reassurance should be emphasized
2)   hormone replacement therapy(HRT ) Estrogen therapy The use of estrogens can relieve the menopausal symptoms. The hot flashes , sweats and other complaints disappear or improve within a few days of starting estrogens therapy . 3) traditional medicine therapy
The administration of estrogen without progestogen increases the risk of endometrial cancer and breast cancer. So, correct cyclical therapy, with 10-14 days progestogen per month , can reduces the incidence of cancer.
Contraindication vascular thrombosis hypertension diabetes chronic liver disease myoma, endometriosis, breast disease gallbladder disease
The common hormone of HRT Estrogen Progestogen Tibolone
Estrogen natural synthetic estradiol estrone estriol Conjugated estrogen ethinylestradiol mestranol
Progestogen Medroxyprogesterone acetate(MPA) progesterone
Tibolone Tibolone is a synthetic steroid having weak estrogenic, progestogenic,and androgenic properties. it reduces endometrail hypoplasia , improves symptoms of dryness and painful intercourse,improves libido. Can be used in those with a personal history of breast cancer
Routes of administration of HRT Oral Transdermal Subcutaneous vaginal
The types of HRT Combined sequential therapy Continuous combined therapy Estrogen only –hysterectomised women Tibolone
Combined sequential therapy Estrogen are given continuously(30 days) MPA 10-14 days Withdrawal bleeding Stop Next month
Continuous combined therapy Estrogen continuously MPA continuously No Withdrawal bleeding
Side-effects of HRT Irregular uterine bleeding Breasts tenderness Progestogen-related symptoms (abdominal bloating,edema)
Risk of HRT Breast cancer Endometrial cancer Venous thromboembolism Do evaluation every year may find any abnormals ， reduce the incidence of the above risk
Information Next Monday afternoon clinic learning 2 ： 30 pm Tianjin Medical University General Hospital outpatient department building 10 th floor reproductive medicine center Group II -1 Teather : wang yanxia
Thank you!