Menopause

Menopause

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  MENOPAUSE NIKITA SHARMA
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  INTRODUCTION  Menopause isderived from the Greek word: Mens ------ monthly Pausis-------cessation  Menopause is a part of a women’s natural ageing process when her ovaries produce lower level of the estrogen & progesterone and when she is no longer able to become pregnant.
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   Menopause isthe physiologic cessation of menses associated with declining ovarian function.  It is usually considered complete after 1 year of amenorrhea (absence of menstruation). INTRODUCTION
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   Menopause isthe permanent cessation of menstruation at the end of reproductive life due to loss of ovarian follicular activity.  Natural menopause is secondary amenorrhea for more than 6 months (12 months) in a woman aged 45 years or over without any pathological cause.  Average age of menopause = 51 years.  Menopause before the age of 40 years is called premature ovarian failure (POF) DEFINITION
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  PREMENOPAUSE PERIMENOPAUSE MENOPAUSE POST- MENOPAUSAL PHASES OF MENOPAUSE
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   This phaseis the part of the climacteric when menstrual cycle is to be irregular.  It is the time prior to menopause  It occur before 40 years. PREMENOPAUSE
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   This isthe period around menopause (40-55 yrs.)  This phase is also known as Climacteric .  In this phase, physiological changes associated with end of reproductive capacity and terminating with completion of menopause. PERIMENOPAUSE
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   In thisphase, end of menstruation occur.  It occurs between the age of 45-55 years.  Average age = 50 yrs. MENOPAUSE
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   This phaseis the time after which women has experienced 12 consecutive months of amenorrhea without period. POST-MENOPAUSAL
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  1. AGE:- around50 years is average (range = 45-55 yrs.) 2. Genetically predetermined 3. Thinner women have early menopause 4. Cigarette smoking & severe malnutrition will leads to early menopause 5. Amenorrhea = 12 months 6. Menopausal symptoms DIAGNOSIS OF MENOPAUSE
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   Following stoppageof menstruation (Amenorrhea) for 12 consecutive months without any pathology.  As such, a woman is declared to have attained menopause only retrospectively. CLINICAL DIAGNOSIS FOR CONFIRMATION
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  When ovaries aretotally depleted of eggs and no amount of stimulation from the regulating hormones can force them to work. CAUSES OF MENOPAUSE
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  OTHER CAUSES  Prematureovarian failure (POF)  Surgeries that removes both ovaries and uterus.  Some types of chemotherapy.  Stress Usual onset: 49 and 52 years of age.
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  PHYSIOLOGICAL CHANGES IN MENOPAUSE
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  CHANGES IN GENERALAPPEARANCE SKIN: Loosesits elasticity due to loss of elastin and collagen from the skin. Become thin and fine Weight: Increases due to irregular food habits due to mood swings. Hair: Dry, coarse and hair loss due to decrease level of estrogen.
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  Voice: Become deeper dueto thickening of vocal cords Fat: Increase deposition of fat around the hips, waist & buttocks. CHANGES IN GENERALAPPEARANCE
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  CHANGES IN THEVASOMOTOR SYSTEM HOT FLUSHES NIGHT SWEATS  Starts in face & quickly spread all over the neck & upper body.  Related to hot flushes occur simultaneously  Occur anytime in day & night  Occur anytime  They vary in number from 1 in every hour to as one in every 15 minutes.  Enough to wakeup the women from sound sleep and insomniac.  Often associated with profuse sweating.  Sudden wakeup can cause palpitations & panic attacks.
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  Cholesterol levels: Increases inthe blood. This leads to gradual rise in the risk of heart disease & stroke after menopause. Calcium levels: Calcium loss from the bone is increased in 1st 5 years after onset of menopause resulting in loss of bone density. Bone loss = 3-5%/yr. due to low level of estrogen. Calcium moves out of bones, leave them weak & liable to fracture at the smallest stress (osteoporosis). CHANGES DUE TO METABOLISM OF BODY:
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  Digestive stress: More activityof entire digestive system is diminished. Intestines tends to be sluggish leads to constipation. Urinary system: Due to low level of estrogen; tissue lining the urethra & bladder become drier, thinner & less elastic and causes increase frequency of passing urine as well as increase tendency to develop UTI. CHANGES DUE TO METABOLISM OF BODY:
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  Uterus: Atrophy of muscles Small& fibrotic uterus Cervix: Smaller appear to flush with vagina In older women it become impossible to differentiate with vagina The vaginal & cervical discharge decreases in amount & later disappears completely. CHANGES IN GENITAL ORGANS
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  Ovaries: smaller & shriveled Increaseamount of androgen secretion leads to secretion of androstenedione and testosterone. Which leads to facial hair growth and change in voice In obese women, there is more fat in the body which leads to more secretion of androgen & are more prone to endometrial hyperplasia and endometrial carcinoma. CHANGES IN GENITAL ORGANS
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  Vagina: Mucous membrane becomethin Menstrual index = 10/85/5 (feature of low estrogen) No glycogen Absence of doderlein’s bacilli Dry, alkaline pH Dyspareunia CHANGES IN GENITAL ORGANS
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  Vulva & externalgenital organs: Fat in labia majora Decrease in mons pubis Sparse pubic hair Narrow introitus Breast :  Become flat in thin built women & shriveled Remain flabby & pendulous in heavy built women. CHANGES IN GENITAL ORGANS
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  Are mainly manifestedby: Frequent headache Irritability, mood disturbance, aggressiveness, tension Fatigue, memory loss & problem with concentration Depression, anxiety & instable mood Sleepiness, insomnia, phobias, tearfulness ad low self-esteem. All are occur due to changes in hormonal levels. PSYCHOLOGICAL CHANGES IN MENOPAUSE
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  Diminished change ininterest due to;  Emotional upset Secondary to dyspareunia Dry vagina PSYCHOLOGICAL CHANGES IN MENOPAUSE
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   The feelingthat a women holds about herself and her social relationship as well as the symptoms she experiences can be defined by the culture in which she live.  Social location affects the way women perceive menopause & its related biological effects.  The way she view menopause.  Ethnicity & geographical location. SOCIAL CHANGES IN MENOPAUSE
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  HORMONE REPLACEMENT THERAPY (HRT) Itis a treatment used to relieve symptoms of the menopause. It replaces female hormone (estrogen) that is at a lower level as women approaches the menopause.
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  INDICATIONS Symptomatic women withestrogen deficiency Premature ovarian failure Spontaneous/ post surgery Gonadal dysgenesis Surgical or radiation menopause Women demanding HRT as prophylaxis
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  DRUGS USED INHRT ESTROGEN • PROGESTERONE TIBOLONE • RALOXIFENE BISPHOSPHONATES SOYA ANDROGENS
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  TYPES OF HRT ESTROGEN& PROGESTERONE ESTROGEN ONLY PROGESTIN ONLY
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  ESTROGEN & PROGESTERONE Designedfor women who have a uterus Estrogen is given regularly while progesterone is added on supplementary basis These 2 hormones are given in combination to prevent overgrowth of uterine lining. Estrogen alone may irritate this lining which could lead to endometrial cancer.
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  ESTROGEN ONLY This preparationis given to women who have lost their uterus due to surgical menopause Because there is no presence of uterus; the need for progesterone is not as great.
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  PROGESTIN ONLY It isnot prescribed very often It provide excellent relief for women deal with hot flushed.
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  AVAILABLE PREPARATION FORHRT Principle hormone used in HRT – Estrogen for women who had already removed her uterus. But if we are giving estrogen only to the women with intact uterus it will cause endometrial hyperplasia and carcinoma. Addition of progestin for last 12-14 days each month can prevent this problem.
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  COMMONLY USED ESTROGEN& PROGESTERONE • Conjugated estrogen (0.625- 1.25mg/d) • Micronized estradiol (1-2mg/d) ESTROGEN • Medroxyprogesterone acetate (2.5-5mg/d) • Micronized progesterone (100-300mg/d) • Dydrogesterone (5-10mg/d) PROGESTIN
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  CONJUGATED ORAL ESTROGEN Dose= 0.3 mg/d having minimum side effects Dose can be changed, modified & stopped until the control of symptoms. Women who had Hysterectomy can be given Conjugated Equine Estrogen (CEE)- 0.3-0.625mg/d
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  ESTROGEN & CYCLICPROGESTIN It is given to women who have uterus Estrogen is given continuously for 25 days Addition of progestin in last 12-14 days.
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  CONTINUOUS ESTROGEN &PROGESTIN THERAPY It prevents endometrial hyperplasia This therapy may case irregular bleeding
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  SUBDERMAL IMPLANTS It needsanesthesia Implant insertion is done over the anterior abdominal wall, subcutaneously E.g. 17 β estradiol implants. 25mg, 50mg or 100mg for 6 months.
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  PERCUTANEOUS ESTROGEN GEL 1gmof applicator of gel delivering 1mg of estradiol daily. It is applied on the skin over anterior abdominal wall or thigh. Effective blood level of estradiol (90-120pg/ml) can be maintained.
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  TRANSDERMAL PATCH It contains3.2mg of 17 β estradiol releasing about 50µgof estradiol in 24hours. It should be applied below waist line and changed twice in a week.
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  VAGINAL CREAM It isvery effective in atrophic vaginitis Conjugate equine vaginal estrogen cream- 1.25mg/d is applied. Women with symptoms of urogenital atrophy, urinary symptoms & do not like to have systemic HRT, are suiable for such treatments.
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  PROGESTIN ONLY (HRT) It isgiven in women with history of Breast carcinoma, endometrial carcinoma It is effective in suppressing Hot flushes It also helps in preventing Osteoporosis E.g. Medroxyprogesterone acetate = 2.5-5mg/d
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  TIBOLONE It is asteroid having weakly estrogenic, progestogenic & androgenic properties. It prevent osteoporosis, atrophic changes of vagina & hot flushes. It increases Libido Dose = 2.5mg/d.
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  ORAL TRANSDERMAL IMPLANTS VAGINAL INJECTABLES ESTROGEN ONLY HRT
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  DOSE OF ESTROGEN ESTROGENSTANDARD DOSE LOW DOSE Conjugated equine estrogen (CEE) 0.625 mg 0.3 – 0.45mg Micronized estrogen 1-2 mg 0.5mg Ethinyl 5 µgm 2.5 µgm Overall dose of estrogen 50 µgm/day. BD. weekly 0.014mg/ day. weekly
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  ORAL ESTROGEN ADVANTAGES DISADVANTAGES CheapHigh dose Easy to take Daily intake First pass effect
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  TRANSDERMAL ESTROGEN ADVANTAGES DISADVANTAGES Lowdose estradiol Costly Avoid first pass metabolism Allergic reaction Reduces triglycerides & Thromboembolic risk Variable absorption
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  VAGINAL ESTROGEN VAGINAL ESTROGENDOSAGE DURATION Vaginal cream 0.05-2gm CEE 0.5 – 1 mg 2-3 times/week Vaginal ring (Femring) 7.5µgm/day 50-100 µgm/day Every 3 months Vaginal pessary (Vagifem) 25 µgm/day .1 tab. day Initially 2weeks/day & then twice weekly
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  DURATION OF HRT Forshort period = 3-5years Reduction of dosage should be done ASAP.
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  CONTRAINDICATIONS OF HRT Undiagnosedgenital tract bleeding Estrogen dependent neoplasm in body (uterine fibroids) History of venous thromboembolism Active liver disease Gallbladder disease
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  BENEFITS OF HRT Improvementof Vasomotor symptoms (70-80%) Improvement of urogenital atrophy Increase in bone mineral density (2-5%) Decrease risk in vertebral & hip fractures (25-50%) Reduction in colorectal cancer (20%) Possibly cardio protection.
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  RISKS OF HRT Dementia& Alzheimer disease Lipid metabolism VTE Breast cancer Endometrial cancer
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  DISADVANTAGES OF HRT Bygiving estrogen & progesterone over a long period is known to stimulate cell division & this seem to increase the risk for breast cancer by up to 90%. HRT increases the risk of heart diseases by 24% One should use HRT for not more than 5 years.
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  SURGICAL MENOPAUSE  Theovaries produce estrogen, progesterone & androgens which are essential to the regulation of the menstrual cycle. When a hysterectomy occurs, these hormones get suddenly interrupted & their level falls resulting in symptoms of menopause. This is termed as surgical menopause.
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  SURGICAL MENOPAUSE  Since,there is abrupt disruption of hormones after hysterectomy, the menopausal symptoms are more severe, more frequent & last longer when compared to natural menopause.
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  SYMPTOMS OF SURGICALMENOPAUSE  Hot flushes & night sweat due to disturbance of central thermostat located in hypothalamus which is kept stable by normal circulating estrogen.  Sleepless nights  Vaginal dryness  Itching  Decrease in sexual desire  Dyspareunia
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  SYMPTOMS OF SURGICALMENOPAUSE  Depression due to low estrogen level  Thyroid dysfunction  Bladder infection  Urine incontinence  Weight gain  Migraine  Irritability
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  MANAGEMENT OF SURGICALMENOPAUSE 1. Estrogen- immediately after surgery to prevent hot flushes 2. Estrogen gel- applied to upper leg or abdomen daily 3. Vaginal ring- for women whose uterus has been removed 4. Vaginal cream- for women having vaginal atrophy, applied locally on lining of vagina. 5. HRT implants-these are small pellets inserted surgically under the skin into the fatty layers of abdomen under local anesthesia & change periodically once in 6 months
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  MANAGEMENT OF SURGICALMENOPAUSE 6. HRT patches- these are the small patches which can release hormones into blood stream transdermally; need to change twice in a week; possible side effects are- skin irritation & allergy. 7. Tablets- most common form of HRT. It is for long term use which needs to be carefully considered.
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  MANAGEMENT OF SURGICALMENOPAUSE 8. EXERCISE: - It is the another form of self-help which are positive therapy. - One should begin with small but regular walks and then gradually move over to weight bearing exercises. - It helps to release endorphins from the brain that send feel good message to the body.
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  RISKS OF SURGICALMENOPAUSE Cardiovascular disease Weight loss due to reduced bone density Gum tissues are affected.
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  GUIDANCE & COUNSELLING It is important to understand the individual’s need and priorities when providing counseling . KEY POINTS: 1. The decision – making process 2. Problems reported by women 3. Decision- making and counseling guidelines and supports
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  GUIDANCE & COUNSELLING Women at the menopausal stage need to be supported emotionally; they may need counselling to be educated about how to manage signs and symptoms of menopause. This may also help them to overcome the symptoms of anxiety and depression. Certain life style modification is necessary to prevent the occurrence or minimize the effects of the associated condition.
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  GUIDANCE & COUNSELLING Nursegives following advice to reduce menopausal symptoms:  To reduce hot flushes and hot flashes To reduce vaginal dryness To control urinary incontinence To prevent osteoporosis
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  TO REDUCE THEHOT FLUSHES & HOT FLASHES Not too warm, Lower heat.  Use cotton clothes  Use the fan Replace coffee, tea, cola beverages by natural juices  No smoking  Learn to relax Exercise on a regular basis helps to reduce anxiety Take plenty of fluids.
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  TO REDUCE VAGINALDRYNESS In sexual relations while devoting more time loving (necking) as this will increase vaginal lubrication naturally. Using specific lubricants that are sold in pharmacies, Vaseline or oil.
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  TO CONTROL URINARYINCONTINENCE Exercises to strengthen pelvic muscles (Kegal exercise): When the bladder is empty, try to cut the flow of urine for a few seconds (the muscles are contracted) and then relax. Perform this exercise several times a day.
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  TO PREVENT OSTEOPOROSIS Physicalexercise moderately and regularly, where all the joints work and thus hinders the process of decalcification of bone. A diet rich in calcium, by increasing the intake of dairy products.
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  GUIDANCE & COUNSELLING Losses(fertility, loss of roles, leaving the house by the children, lost parents, relatives and friends, etc.) The promotion of social relationships (friends, women’s groups, associations), to avoid isolation and loneliness.  Mental health referral if some pathology such as anxiety, stress, etc.
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  TO PREVENT GYNECOLOGICALCANCER Perform breast self examination. Annual clinical examination, mammography every two years. Exfoliative cervicovaginal cytology.
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  TO PREVENT CARDIOVASCULAR DISORDER Fat diet rich in olive oil helps regulate cholesterol.  Healthy diet rich in fruits and vegetables.  Control of blood pressure to rule out hypertension.  Exercise.  Hormone replacement therapy.
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  ROLE OF MIDWIFERYNURSE PRACTITIONER ASSIGNMENT