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Menopause

This document discusses menopause and hormonal changes in menopausal women. It defines menopause as the permanent cessation of menstruation from loss of ovarian activity, determined after 12 months of amenorrhea. The document outlines the stages of menopause including perimenopause and climacteric, and discusses premature ovarian failure. It also discusses estrogen replacement therapy and management of menopausal symptoms like vasomotor symptoms, urogenital atrophy, and osteoporosis. The document lists contraindications to hormone replacement therapy and discusses alternative therapies.

Health & Medicine◦
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Menopause Resident Lecturer: Abigail Polintan, MD Consultant Facilitator: Divina Rojas, MD, FPOGS
Menopause • Defined by the WHO as the permanent cessation of menstruation resulting from loss of ovarian follicular activity • Determined retrospectively from the date of the last menstrual period, after 12 months of amenorrhea, with no other attributable cause
Perimenopause • Menopausal transition • Includes the years prior to menopause that encompasses the change from normal ovulatory cycles to cessation of menses • Hallmark: Skipped periods, or longer duration between periods (40-60 days)
Climacteric • Refer to the period of time when a woman passes from a reproductive stage of her life to a non-reproductive stage • Includes menopausal transition, menopause, and the post-menopausal years
Premature Ovarian Failure • Refers the cessation of menstruation due to depletion of ovarian follicles before the age of 40 • Also known as premature menopause.
Estrogen Replacement Therapy (ERT) • Refers to the administration of physiologic doses of estrogen by oral or topical routes to postmenopausal women without addition of progesterone
Menopause • Genetically programmed • Between 51-52 years of age • Average menopause age for Filipinas is 47
Hormonal Changes in Menopause •  Reduction in E2 and E1(Estrone) •  FSH and LH - Normal Growth Hormone (GH) - Normal Thyroid Stimulating Hormone (TSH) - Normal ACTH - Continued production of androstenedione, DHEA,DHEA-S by the adrenals -  Testosterone
Systemic Effects of Menopause • Central Nervous System • Vasomotor Symptoms (hot flush) • Due to the fall in estrogen level  precipitates • Results from a hypothalamic response probably mediated by cathecolamines. • Depression • Irritability
Systemic Effects of Menopause • Integument • Decrease in collagen • Reproductive System • Genital atrophy • Skeletal System • Bone Loss • Cardiovascular System • Accelerated rise in total cholesterol
Management of Perimenopausal and Postmenopausal Women • Vasomotor symptoms • lifestyle changes: cool body temperature • regular exercises • paced respiration • avoidance of hot flush trigers • Maintain a healthy weight • low-dose HRT/ERT • Transdermal estradiol • Tibolone
Management of Perimenopausal and Postmenopausal Women • Urogenital atrophy • HRT/ERT and vaginal moisturizers • Low-dose vaginal products are the treatment of choice • Regular sexual activity • Tibolone
Management of Perimenopausal and Postmenopausal Women • HRT/ERT have beneficial effects in maintaining skin thickness, prevention of dementia, and improving mood disorders
Osteoporosis • HRT/ET; Tibolone • Calcium(1200-1500mg/day) • Calcium carbonate has 40% elemental Ca • Calcium lactate has 10% elemental Ca • Vitamin D (400-600 IU) • Engage in regular weight-bearing exercises like walking
Perimenopausal Bleeding • Should always be investigated to rule out organic causes • Medical management may be recommended if the endometrium is normal • NSAIDS may be used to minimize abnormal bleeding in the absence of menopausal symptoms
Postmenopausal Phase • Osteoporosis • Calcium and vitamin D • HRT/ERT • Alendronate, Risedronate, raloxifene,parathyroid hormone
Cardiovascular Disease • There is significant increase in cardiovascular events after HRT use, its use should only be reserved for those experiencing severe menopausal symptoms and the recommendation should include only the low-dose HRT/ERT.
Congraindications to HRT/ERT • Current, past or suspected breast cancer • Known or suspected estrogen-dependent malignant tumors(e.g. endometrial cancer) • Undiagnosed genital bleeding • Previous idiopathic or current venous thromboembolism(deep venous thrombosis, pulmonary embolism)
Congraindications to HRT/ERT • Active or recent arterial thrombolic disease(e.g. angina, myocardial infarction) • Untreated hypertension • Known hypersensitivity to the active substances or to any of the excipients • Porphyria cutanea tarda(absolute contraindication)
Hormonal Therapy 1. Estrogens Oral= oral CEE – 0.625 mg Transdermal patch Vaginal cream 2. Progestins Oral= medroxyprogesterone acetate -10mg 3. Combinations CEE+ MPA
Hormonal Therapy 4. Androgens Oral- Esterified estrogen and methyl testosterone Transdermal 5. Biphosphanates Alendronates,Risedronate, Ibandronate, Eridronate
Hormonal Therapy 6. SERM(Selective Estrogen Receptor Modulators) Raloxifene,Tibolone,Human parathyroid Hormone
Alternative Therapy • Phytoestrogens • plant-derived estrogen-like compounds that can produce estrogen-like effects
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