Approach to menopause

1. MENOPAUSE PRESENTATION
PRESENTED BY;
NIWASIIMA PATIENCE 2021-08-06938

2. OUTLINE:
• DEFINITION
• CLINICAL DIAGNOSIS
• ENDOCRINOLOGY OF MENOPAUSE TRANSITION
• ORGAN CHANGES AND SYMPTOMS
• MANAGEMENT
• ABNORMAL MENOPAUSE

3. DEFINITIONS
• Menopause is a natural biological process that marks the end of a
woman's reproductive years. It is defined as the permanent cessation
of menstruation, and it usually occurs around the age of 45 to 55.
• Menopause is a result of hormonal changes, primarily a decline in the
production of estrogen and progesterone by the ovaries. It signifies
the end of a woman's ability to conceive naturally and typically occurs
in midlife.

4. • Contn;
• It is the point of time when last and final menstruation occurs.
• The clinical diagnosis is confirmed following stoppage of
menstruation (amenorrhea) for twelve consecutive months
without any other pathology
• Menopause transition is the period of time during which a woman passes
from the reproductive to the non reproductive stage. This phase covers
4–7 years on either side of menopause.
• Menopause transition is associated with elevated serum FSH
levels and variable length of menstrual cycle and/or missed
menses.
• Postmenopause is the phase of life that comes after the
menopause

5. Other definitions:
WHO definition: Period of permanent cessation of menstruation at
the end of reproductive life due to loss of ovarian follicular activity.
STRAW:Stades of Reproductive Aging Workshop
Menopause is the anchor point that is defined after 12months of
amenorrhea following the final menstrual period, which reflects a near
complete but natural diminution of ovarian function
CAMS:council of Affiliated Menopause Societies
‘Menopause occurs after 12 months of amenorrhea for which there is
no other obvious pathologic or physiologic causes’
Simply menopause aka the climacteric is the time in most women’s
lives when menstrual periods stop permanently and they are no
longer able to bear children.

6. AGE OF MENOPAUSE
• The age of menopause ranges between 45–55 years,
average being 50 years.
• The age of menopause is not related to age of menarche
or age at last pregnancy but is genetically predetermined.
• However, cigarette smoking and severe malnutrition may
cause early menopause.
• Thinner women have early menopause.

7. Cont’d
• Menopause before the age of 40years is called
premature ovarian failure (POF).
PHASES OF MENOPAUSE
• Premenopausal…..Perimenopause…..menopause….p
ostmenopausal.
PREMENOPAUSE
• This phase is the part of the climacteric when the
menstrual cycle is to be irregular and it is the time prior
to menopause which occurs before 40years .

8. PERIMENOPAUSE
• This is the period around menopause (40-55)years
• This phase is also known as climacteric and in this phase
physiological changes associated with end of
reproductive capacity and terminating with completion of
menopause take place.
MENOPAUSE
• In this phase end of menstruation occur.
• It occurs between the age of 45 to 55yrs
• And the average age =50yrs

9. POSTMENOPAUSAL PHASE
• This phase is the period after which a woman has
experienced 12 consecutive months of amenorrhea
without period.

10. Diagnosis of menopause
• Age –around 50 years is average (range =45to 55yrs)
• Amenorrhea =12 months
• Menopausal symptoms.
• Vaginal cytology—showing maturation index of at least
10/85/5 (features of low estrogen
• Serum estradiol: < 20 pg/mL
• Serum FSH and LH:> 40 mlU/mL (three values at
weeks interval required)

11. Clinical diagnosis for confirmation
• Following stoppage of menstruation (amenorrhea)for 12
consecutive months without any pathology, as such a
woman is declared to have attained menopause only
retrospectively

12. ENDOCRINOLOGY OF MENOPAUSE TRANSITION
• Few years prior to menopause, along with depletion of the ovarian
follicles, the follicles become resistant to pituitary gonadotropins.
• As a result, effective folliculogenesis is impaired with diminished
estradiol production.
• There is a significant fall in the serum level of estradiol from 50–
300 pg/mL before menopause to 10–20 pg/mL after menopause.
• This decreases the negative feedback effect on
hypothalamopituitary axis resulting in increase in FSH. The
increase in FSH is also due to diminished inhibin.

13. CONTD.
• Disturbed folliculogenesis during this period may result in
anovulation, oligoovulation, premature corpus luteum or
corpus luteal insufficiency.
• The mean cycle length is significantly shorter.
• This is due to shortening of the follicular phase of the cycle.
Luteal phase length remains constant.
• In late menopausal transition, there is accelerated rate of
follicular depletion.
• Ultimately, no more follicles are available and even some
exist, they are resistant to gonadotropin.

14. cont
• Estradiol production drops down to the optimal level of 20 pg/mL
→no endometrial growth → absence of menstruation.
• Following menopause, the predominant estrogen is estrone and
to a lesser extent estradiol
• The major source of estrone is peripheral conversion
(aromatization) of androgens from adrenals (mainly) and
ovaries.
• The aromatization occurs at the level of muscle and adipose
tissue
• After menopause, the stromal cells of the ovary continue
to produce androgens because of increase in LH

15. CONTD
• The main androgens are androstenedione and
testosterone
• A trace amount of progesterone detected is probably
adrenal in origin. Anti-Müllerian hormone (AMH) levels are
decreased markedly due to loss of ovarian reserve

16. SYMPTOMS OF MENOPAUSE

17. ORGAN CHANGES
• Skin
Loses its elasticity due to loss of elastin and collagen and becomes thin
and fine
• Weight-
increases due to irregular food habits secondary to mood swings
• Hair-
becomes dry, coarse and there is hair loss due to decrease in the level
of estrogen
• Voice
Becomes deeper due to thickening of vocal cords
• Fat
Increased fat deposition around the hips, waist and buttocks.

18. CHANGES IN THE VASOMOTOR SYSTEM
HOT FLUSHES
Starts in face and quickly
spreads all over the neck and
upper body
Occurs any time in the day and
night
They vary in number from 1
per hr to as 1 in every 15mins
Often associated with profuse
sweating
NIGHT SWEATS
• Related to hot flushes
and occur simultaneously
• Occur any time
• Sufficient to wake up the
women from sound sleep
and insomniac
• Sudden wake up can
cause palpitations and
panic attacks

19. Changes due to metabolism of the body
• Cholesterol levels
cholesterol Increases in blood ,this leads to gradual rise in
the risk of heart disease and stroke after menopause
• Calcium levels-calcium levels from the bones is increased
in 1st
5 yrs after onset of menopause resulting in loss of
bone density
Bone loss=3.5% per year due to low levels of estrogen
Calcium shifts out of bones leaving them weak and liable to
fracture at the smallest stress(osteoporosis).

20. Cont’d
Digestive stress
• More activity of entire system is diminished and intestines
tend to be sluggish leading to constipation
Urinary system
• Due to low estrogen levels, tissues lining the bladder and
urethra become drier and thinner and less elastic and
causes increased frequency of passing urine as well as
increased tendency to develop UTI

21. Changes in Genital Organs
• Uterus
Atrophy of uterine muscles
Small and fibrotic uterus
• Cervix
The cervix becomes smaller and appears to flush with the vagina
The vaginal and cervical discharge decreases in amount and later
disappears completely--vaginal dryness
• Ovaries:
Become smaller and shriveled
Increase in amount 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 body fat which leads to more secretion of
androgens and are more prone to endometrial hyperplasia and endometrial
carcinoma

22. Changes in genital organs cont’d
• Vagina
Thinning of mucous membrane
Menstrual index=10/85/5(feature of low estrogen)
No glycogen-
Absence of doderlein’s bacilli
dyspareunia

23. Cont’d
• Vulva and external genital organs
Fatty labia majora
Decrease in mons pubis
Sparse pubic hair
Narrow introitus
• Breast
• Become flat and shriveled in thin build women
• Remain flabby and pendulous in heavy built women

24. Psychological changes in menopause
Mainly manifested by
• Frequent headache
• Irritability mood disturbance and aggressiveness ,tension
• Fatigue, memory loss and problem with concentration
• Depression ,anxiety and instable mood
• Sleepiness,insomnia,phobias,tearfulnessand low self esteem
All are occurring due to changes in hormonal level
Diminished change in interest due to; emotional upset,
secondary to dyspareunia, dry vagina

25. CARDIOVASCULAR SYSTEM
• Risk of cardiovascular disease is high in postmenopausal
women due to deficiency of estrogen.
• . Estrogen prevents cardiovascular disease by several ways
1. It increases high_x0002_density lipoprotein (particularly
HDL2) and decreases low-density lipoprotein (LDL) and
total cholesterol.
2. It stimulates the release of nitric oxide (NO) and
prostacyclin from vascular endothelium to dilate the blood
vessels.
3. It prevents atherosclerosis by its antioxidant property.

26. MANAGEMENT
Non hormonal treatment
There are variety of menopausal treatments both natural and
medical that can alleviate the symptom of menopause
Dressing in light layers can alleviate hot flushes and night
sweats; avoiding caffeine ,alcohol and spicy foods can also
minimize these symptoms .
Menopause and weight gain tend to go together due to life
style changes than to the hormonal changes.
Reducing dietary fat intake and regular exercise help to
combat weight gain during menopause

27. Rx cont’d
Menopause can lead to osteoporosis so calcium and vitamin D
supplements can help restore bone density ,which naturally
deteriorates after age 30 due to reducing estrogen levels.
Menopause decreases vaginal elasticity leading to vaginal
dryness. Vitamin E can help as can kegal exercises which help
restore elasticity. Using water based lubricants during sexual
intercourse also minimizes discomfort related to vaginal dryness.
Menopause often lead to dry ,itchy skin and weak thin hair that
breaks and that has lots of split ends .flax seed oil( found in
poultry dry red meat and whole grains) can help restore hair and
skin’s healthy appearance as can vit,E.

28. Hormonal replacement therapy(HRT)
• HRT is indicated in menopausal women to over come
short term and long term consequences of estrogen
deficiency.
• It can be administered orally in pill form,vaginaly as
cream, transdermal in patch form because it replaces
female hormones produced by the ovaries.
• HRT minimizes menopause symptoms and can be used
before during and after menopause.

29. Indication of HRT
• Relief of menopausal symptoms-hot flashes by use systemic
HRT
• Prevention of osteoporosis
• Relief of genitourinary symptoms –c/o vaginal dryness by use of
local estrogen creams
• Maintain quality of life in special group of menopausal women
in whom HRT is prescribed.
• Premature ovarian failure
• Gonadal dysgenesis
• Surgical or radiation therapy

30. Evaluation before starting HRT
• History and physical examination
• Bp measurement
• Breast and pelvic examination
• Serum TSH levels-menopause associated
hypothyroidism
• Mammography
• Lipid profile-Triglyceride levels>500mg/dl is an absolute
contradiction for HRT
• Base line USG

31. Standard HRT
• If uterus is present –Estrogen+progesterone e.g( 17-beta
estradiol+Dydrogesterone ) –lowest possible/ effective dose and the
progesterone is added for endometrial protection.
• If uterus absent –use Estrogen alone EXECEPT in following cases
when estrogen and progesterone are combined
h/o supracervical hysterectomy
h/o endometrial cancer
h/o endometriosis
h/o endometrioid tumor of ovary.
• If Estrogen is contraindicated –for example in VTE,Multiplerefractory
coronary artery disease,HTN,acute liver dysfunction. then use SSRI’s
and SNRI’s(selective serotonin reuptake inhibitors- Paroxetine,
selective Norepinephrine Reuptake inhibitors-verlafaxime)

32. Prevention of osteoporosis
Other drugs used
• Tibolone-(increase the risk of stroke and breast cancer)
• SERMs-selective estrogen receptor modulators e.g.
Tamoxifen,Raloxifene.
• Both tamoxifen and Raloxifene have estrogen agonistic effect on the
bones and estrogen antagonistic effect on the breast.whreas
tamoxifen increases the risk of endometrial cancer, Raloxifene does
not because unlike Tamoxifen,Raloxifene exerts an estrogen
antagonistic effect on the endometrium hence it does not increase
the risk of endometrial cancer
• Both Tamoxifen and Raloxifene increase the risk of VTE(venous
thromboembolism)

33. Types of HRT
Estrogen and progesterone-
The most common type of HRT which involves both estrogen and
progesterone. More than 8 million women currently are taking
combination HRT and its designed specifically for women who have a
uterus. During this therapy estrogen is given regularly while
progesterone is added in on a supplementary basis. These two
hormones are given in a combination in order to prevent the over
growth of uterine lining. Estrogen alone may irritate this lining which
could lead to Endometrial cancer.
Estrogen only
• Estrogen therapy alone usually is given to women who have lost
their uterus due to surgical menopause. Because no uterus is
present the need for progesterone is not as great

34. Types cont’d
• Progestin only
• Progestin -only therapy is not prescribed very often.
Progestin does seem to provide excellent relief for
women plagued with hot flashes

35. AVAILABLE PREPARATIONS FOR HRT
• The principle hormone used in HRT is ESTROGEN .this is
ideal for a woman who has had her uterus removed already.
But a woman with intact uterus, only estrogen therapy leads
to endometrial hyperplasia and even endometrial carcinoma.
Addition of progestin for last 12 -14 days each month can
prevent this problem.
• Commonly used estrogen are conjugated estrogen (o.625-
1.25 mg/day).progestin used are medroxyprogesterone(100-
300mg/day).considering the risks, hormonal therapy should
be used with the lowest effective dose and for a short period
of time. Low dose of oral conjugated estrogen 0.3mg/day is
effective and has got minimal side effects.

36. Cont’d
• Oral estrogen regimen
Estrogen conjugated equine estrogen 0.3mg or 0.625mg is given daily
for women who had hysterectomy
• Estrogen and cyclic progestin
For a woman with uterus estrogen is given continuously for 25 days
and progestin is added for last 12-14 days
• Continuous estrogen and progestin therapy
Continued combined therapy can prevent endometrial hyperplasia
Sub dermal implants-implants are inserted subcutaneously over the
anterior abdominal wall using local anaesthesia.17beta estrogen
implants 25mg or 100mg are available and can be kept for 6months.

37. Cont’d
• Percutaneous estrogen gel
• 1gm applicator of gel delivering 1mg of estrogen daily is to be applied onto
the skin over the anterior abdominal is to be applied onto the skin over the
anterior abdominal or thigh ….Effective blood level of oestrodiol(90-120
pg./ml)can be maintained.
• Transdermal patch
• It contains about 3.2mg of 17beta estradiol releasing about 50mcg of
estradiol in 24hrs it should be applied below the waist line and changed
twice a week.
• Vaginal cream
• Conjugated equine vaginal estrogen cream 1.25mg daily is very effective
when associated with atrophic vaginitis. Women with symptoms of
urogenital atrophy and urinary symptoms and do not like to have systemic
HRT are suitable for such treatments.
• Conjugated equine offers Bone protection and as well Relief of hotflashes

38. Cont’d
• Progestin
Patients with history of breast carcinoma or endometrial
carcinoma, progestin may be used.it may be effective in
suppressing hot flushes and it prevents osteoporosis.
Medroxyprogesterone acetate 2.5-5mg /day can be used.
Tibolone
Tibolone is a steroid having weekly estrogenic,progestogenic
and androgenic properties, it prevents osteoporosis.
NB:Tibolone however causes an increased risk of
stroke,breastcancer hence its not FDA approved.
If the mother already has osteoporosis then the treatment drug of
choice should be Bisphosphonates

39. Future HRT
• Conjugated equine estrogen +BAZEDOXIFENE
• Conjugated equine estrogen offers Bone protection and
relief of hot flashes
• Bazedoxifene is a SERM which provides endometrial
protection without increasing the risk of Breast cancer and
does not lead to hot flashes as a side effect unlike
Tamoxifen and Raloxifene

40. DURATION OF HRT
• Generally use of HRT for short period of 3-5years has been
devised. Reduction od dosage should be done as soon as possible.
• RISKS OF HRT
 Endometrial cancer; when estrogen is given alone to a woman with
intact uterus, it causes endometrial proliferation, hyperplasia and
carcinoma.
 Breast cancer; combined estrogen and progestin replacement
therapy slightly increases the risk of breast cancer.
 VTE(venous thromboembolic disease) it has found to be increased
with the use of combined oral estrogen and progestin
 Lipid metabolism; an increased incidence of gallbladder disease has
been observed following HRT due to rise in cholesterol in bile
 Dementia ,Alzheimer disease are increased

41. DISADVANTAGES OF HRT
 Estrogen and progesterone over long period of time is
known to stimulate cell division and this seem to
increase the risk for breast cancer by up to 9%
 HRT appears to increase the risk of heart disease by
24%.
 Women taking HRT to reduce risk of Alzheimer disease
actually increased their risk by a small %
 In order to prevent increasing your risk of certain
disease, it is suggested that you use HRT for not more
than 5years.
 Risk of coronary artery disease is increased in older

42. Disadvantages cont’d
• Risk of endometrial cancer especially of estrogen
unopposed regimen in those with uterus present.
• Risk of gallstones and cholecystitis especially of
hyperlipidemia

43. ABNORMAL MENOPAUSE
• Premature menopause: If the menopause occurs at or below the
age of 40, it is said to be premature . Often, there is familial
diathesis. Treatment by replacement therapy is of value
• Delayed menopause: If the menopause fails to occur even
beyond 55 years, it is called delayed menopause.
The common causes are constitutional, uterine fibroids, diabetes
mellitus and estrogenic tumor of the ovary. The cases should not be
neglected. In the absence of palpable pelvic pathology, diagnostic
curettage should be done and an early decision of hysterectomy
should be taken in theface of increased incidence of endometrial
carcinoma

44. ABNORMAL MENOPAUSE
• Artificial menopause: Permanent cessation of ovarian
function done by artificial means, e.g. surgical removal of
ovaries by radiation or chemotherapy is called artificial
menopause
• Radiation menopause: The ovarian function may be
suppressed by external gamma radiation in women below
the age of 40,
• The castration is not permanent. The menstruation may
resume after 2 years and even conception is possible.

45. SURGICAL MENOPAUSE
• Surgical menopause ,type of induced menopause in
which both ovaries are surgically removed .surgical
menopause can occur at any age before natural
menopause occurs. The symptoms of surgical
menopause are generally more intense than when
menopause occurs naturally. The induced menopause
to abrupt cutoff ovarian hormones causes the sudden
onset of hot flushes and other menopausal symptoms
such as dry vagina and a decline in sex drive.
• Hormonal therapy may be used to treat the symptoms
of induced menopause.it stops or reduces the short

46. COUNSELLING & GUIDANCE
Its important to understand the individuals needs and
priorities when providing counselling
KEY POINTS
The decision- making process
Problems reported by women
Decision –making and counselling guidelines and
supports

47. REFERENCES
• Williams textbook of gynecology 3rd edition
• Dc Dutta’s text book of gynecology 7th Edition.