menopause

menopause

• 1.
  MENOPAUSE PRESENTED BY: MS VRUTI PATEL,
• 2.
  MEANING OF MENOPAUSE The transition from reproductive to non- reproductive .  The word "menopause" literally means the "end of monthly cycles" from the Greek word pausis (cessation) and the root men- (month).  Menopause is an unavoidable change that every woman will experience.  The date of menopause in human females is formally medically defined as the time of the last menstrual period.
• 3.
  DEFINITION  Menopause meanspermanent cessation of menstruation at the end of reproductive life due to loss of ovarian follicular activity. It is the point of time when last and final menstruation occurs. OR  Menopause is the permanent cessation of the primary functions of the human ovaries.
• 4.
  AGE OF MENOPAUSE Age at which menopause occurs is genetically predetermined and not related to age of menarche or age at last pregnancy, lactation, use of oral pill, socioeconomic condition, race, height or weight.  In India and the Philippines, the median age of natural menopause is considerably earlier, at 44 years.
• 5.
   Additional factors: Smoking  Surgical menopause/ Artificial menopause
• 6.
  ABNORMAL MENOPAUSE  Prematuremenopause : A woman's ovaries stop working at a very early age, ranging anywhere from the age of puberty to age 40, and this is known as premature ovarian failure (POF).  Delayed menopause : if the menopause fail to occur even beyond 55 years it is called delayed.
• 7.
  TERMINOLOGY RELATED TOMENOPAUSE  The word "menopause" usually refers not to one day, but to the whole of the menopause transition years. This span of time is also commonly called the change of life, the change, or the climacteric and more recently is known as "per menopause", (literally meaning "around menopause").  Perimenopause : perimenopause is technically defined as the time from which menses start to become irregular and FSH levels have increased, until the time when it is known that periods have ceased completely.
• 8.
   Premenopause :Premenopauseis a word used to describe the years leading up to the last period, when the levels of reproductive hormones are already becoming lower and more erratic, and the effects of hormone withdrawal may be present.  Postmenopause : The term postmenopause is applied to women who have not experienced a menstrual bleed for a minimum of 12 months.
• 9.
  ENDOCRANIOLOGY OF CLIMACTRICAND MENOPAUSE  In younger women, during a normal menstrual cycle the ovaries produce estradiol, testosterone and progesterone in a cyclical pattern under the control of FSH and luteinising hormone (LH) which are both produced by the pituitary gland.  Estradiol: there is a significant fall in the level of serum estradiol from 50-300 pg/ml before menopause to 10-20 pg/ml after menopause.  Oestrogen: The sources fail to supply the precursor of oestrogen and about 5-10 years after menopause, there is a sharp fall in oestrogen and also the trophic hormones.
• 10.
   Androgens: aftermenopause, the stromal cells of overy continue to produce androgens because or increase in LH.  Progesterone: A trace amount of progesterone detected is probably adrenal in origin.  Gonadotrophins: The secretions of both FSH and LH are increased due to absent negative feedback effect of oestradiol and inhibin or due to enhanced responsiveness of pituitary to GnRH.
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   Indications andsigns: Menstruation pattern prior to menopause – any of the following patterns are observed: 1. Abrupt cessation of menstruation (rare) . 2. Gradual decrease in both amount and duration. It may be spotting or delayed and ultimately lead to cessation. 3. Irregular with or without excessive bleeding. One should exclude genital malignancy prior to declare it as the usual premenopausal pattern.
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   Vascular instability 1.Hot flashes or hot flushes, including night sweats and, in a few people, cold flashes 2. Possible but contentious increased risk of atherosclerosis 3. Migraine 4. Rapid heartbeat
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   Urogenital atrophy,also known as vaginal atrophy 1. Thinning of the membranes of genitals 2. Itching 3. Dryness 4. Bleeding 5. Watery discharge 6. Urinary frequency 7. Urinary incontinence 8. Urinary urgency 9. Increased susceptibility to inflammation and infection, for example vaginal candidiasis and urinary tract infections 10. Vaginal dryness and vaginal atrophy
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   Skeletal 1. Backpain 2. Joint pain, Muscle pain 3. Osteopenia and the risk of osteoporosis gradually developing over time
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   Cardiovascular andcerebrovascular effects 1. Risk of Ischemic heart disease 2. Coronary artery disease and stoke increased 3. Atherosclerotic changes 4. Vasoconstriction 5. Thrombus formation
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   Skin, softtissue 1. Breast atrophy 2. breast tenderness +/- swelling 3. Decreased elasticity of the skin 4. Formication (itching, tingling, burning, pins and needles, or sensation of ants crawling on or under the skin) 5. Skin thinning and becoming drier
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   Sexual 1. Dyspareuniaor painful intercourse 2. Decreased libido 3. Problems reaching orgasm
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  PSYCHOLOGICAL CHANGES  Depressionor unstable mood  Anxiety  Fatigue  Irritability  Memory loss and problems with concentration  Mood disturbance : specially mood swing is common.  Sleep disturbances
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   Insomnia  Sleepiness Aggressiveness  Tension  Phobias  Low self-esteem  Tearfulness
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   Causes ofmood swing : 1. Hormonal changes 2. Sleeplessness 3. Stresses 4. sexual dysfunction 5. changes in the body and negative attitude towards aging
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   Who experiencesmood swings during menopause?  Peri-menopausal period exceeds 27 month  Moderate to severe hot flushes. Experiencing hot flushes is associated with a 4-6 times increased risk of developing depression  History of depression are 4–9 times more likely to experience depressed mood in the menopausal transitionWomen with other factors that increase the risk of depression, including:  Poor relationship satisfaction; Significant life stress; Low self-esteem; Negative body image; Lack of exercise  Excessive alcohol intake
• 22.
  SOCIAL ASPECTS  Thecultural context within which a woman lives can have a significant impact on the way she experiences the menopausal transition.  Social location affects the way women perceive menopause and its related biological effects.  The way she views menopause  Ethnicity and geographical location
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  DIAGNOSIS OF MENOPAUSE Cessation of menstruation for consecutive 12 months during climacteric.  Appearance of menopausal symptoms ‘hot flush’ and ‘night sweats’.  Vaginal cytology – showing menstruation index of at least 10/85/5 (features of low oestrogen).  Serum oestradiol : < 20 pg/ml.  Serum FSH and LH: 40 mlU/ml (three values at weeks interval required.
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  MANAGEMENT  Prevention  Counselling Treatment
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   Non-hormonal treatment: 1. Nutritious diet 2. Supplementary calcium – daily intake of 1-1.5 gm 3. Exercise – weight bearing exercises, walking, jogging. 4. Vitamin D – supplementation of vitamin D3 (400-800 IU/day) along with calcium can reduce osteoporosis and fractures. 5. Cessation of smoking and alcohol. 6. Bisphosphonates pre vent osteoclastic bone resorption. Commonly used drugs are etidronate and alendronate. It is taken in empty stomach. Nothing should be taken by mouth for at least 30 minutes after after oral dosing. 7. Fluoride prevents osteoporosis and increases bone matrix
• 26.
   Calcitonin inhibitsbones resorption.  Selective oestrogen receptor modulators (SERMs) are tissue specific in action. Of the SERMs, raloxifene has many mineral density, reduce serum LDL and to raise HDL2 level.  Clonidine, an alpha adrenergic agonist may be used to reduce the severity and duration of hot flushes.  Thiazides reduce urinary calcium excretion.  Paroxetine is effective to reduce hot flushes both the frequency and severity.  Gabapentine is an analogue of gamma-amino-butyric acid. It is found also to be effective.  Phytoestrogens containing isoflavones are found to lower the incidence of vasomotor symptoms, osteoporosis and cardiovascular disease.  Soy protein is also found effective to reduce vasomotor symptoms. Soy protein acts as SERMs.
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   Hormonal replacementtherapy (HRT) The HRT is indicated in menopausal woman to overcome the short term and long term consequence of oestrogen deficiency.
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   Indications ofhormonal replacement therapy: 1. Relief of menopausal symptoms 2. Prevention of osteoporosis 3. To maintain the quality of life in menopausal years
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   Special groupof woman to whom HRT should be prescribed: 1. Premature ovarian failure 2. Gonadal dysgenesis 3. Surgical or radiation menopause
• 30.
   Benefits ofhormone replacement therapy: 1. Improvement of vasomotor symptoms (70- 80%). 2. Improvement of urogenital atrophy. 3. Increase in bone mineral density (2-5%). 4. Decreased risk in vertebral and hip fractures (25-50%). 5. Reduction in colorectal cancer (20%). 6. Possibly cardio protection.
• 31.
   Risks ofhormonal replacement therapy:  Endometrial cancer : when oestrogen is given alone to a woman with intact uterus.  Breast cancer : combined oestrogen and progestin replacement therapy.  Venous thrombolic (VTE) disease : use of combined oral oestrogen and progestin.  Coronary heart disease : combined HRT therapy  Lipid metabolism: gallbladder disease  Dementia, Alzheimer disease are increased.
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   Contraindications tohormonal replacement therapy: 1. Undiagnosed genital tract bleeding 2. Oestrogen dependent neoplasm in the body 3. History of venous thromboembolism 4. Active liver disease 5. Gallbladder disease
• 33.
  Available preparation forhormone replacement therapy  Commonly used oestrogens are conjugated oestrogen (0.625-1.25 mg/day) or micronized oestradiol (1-2 mg/day).  Progestins used are medroxyprogestone (100-300 mg/dl)or ndydrogestrone (5-10 mg/day).  Oral oestrogen regimen: oestrogen – conjugated equine oestrogen 0.3 mg or o.625 mg is given daily for woman who had hysterectomy.  Oestrogen and cyclic progestin: for a woman with intact uterus oestrogen is given continuously for 25 days and progestin is added for last 12-14 days.  Continuous oestrogen and progestin therapy: continued combined therapy can prevent endometrial hyperplasia. There may be irregular bleeding with this regimen.
• 34.
   Subdermal implants:implants are inserted subcutaneously over the anterior abdominal wall using local anaesthesia. 17β oestradiol implants 25 mg, 50 mg or 100 mg are available and can be kept for 6 months.  Percutaneous oestrogen gel: 1 gm applicator of gel, delivering 1 mg of oesradiol daily.  Trans dermal patch: it contains 3.2 mg of 17β oestradiol, releasing about 50 µg of oestradiol in 24 hours. It should be applied below the waist line and changed twice a
• 35.
   Vaginal cream:conjugated equine vaginal oestrogen cream 1.25 mg daily is very effective specially when associated with atrophic vaginitis. It also reduces urinary frequency, urgency and recurrent infection.  Progestins: patients with history of breast cancer or endometrial carcinoma, progestin may be used. It may be effective in suppressing hot flushes and it prevents osteoporosis.  Tibolone: Tibolone is a steroid having weakly oestrogenic, progestogenic and androgenic properties. It prevents osteoporosis, atrophic changes of vagina and hot flushes. It increases libido. Endometrium is atrophic. A dose of 2.5 mg per day is given.
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   Duration ofHRT use: A short period of 3-5 years has been advised. Reduction of dosage should be done as soon as possible.
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  ROLE OF MIDWIFERYNURSE PRACTISNOR
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  MCQS 1. The agewhen women are likely to enter menopause is usually A. 35 - 40 years B. 40 - 45 years C. 45 - 50 years D. None of the above
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  2. During menopauseovaries stop producing A. Estrogen B. Progesterone C. Both A & B D. Androgen
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  3. A dietrich in the following controls menopause symptoms A. Carbohydrates B. Soya items C. Fruits and veggies D. Eggs and meat
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  4. Symptoms ofmenopause include A. Hot flushes B. Loss of sex drive C. Mood swings D. All of the above
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  5. The followinghelps to control the symptoms of menopause A. Diet and exercises B. Medication C. Lifestyle changes D. All of the above
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  ANSWER KEY 1. C 2.C 3. B 4. D 5. D