obstetrics & gynecology,

1. MenopauseMenopause
Sayed Muhammad HussainiSayed Muhammad Hussaini
Batch KBatch K
08-19208-192

2. 1-Introduction1-Introduction
- The term menopause is derived from Greek Meno- The term menopause is derived from Greek Meno
(months) and pause (cessation). The word means(months) and pause (cessation). The word means
cessation of menstruation.cessation of menstruation.
-- Climacteric:Climacteric: which is by dictionary definition is periodwhich is by dictionary definition is period
of life when fertility and sexual activity decline. It occursof life when fertility and sexual activity decline. It occurs
due to the dwindling function of ovaries which isdue to the dwindling function of ovaries which is
manifested by physical and psychological changes inmanifested by physical and psychological changes in
the body. It is a wide term leading to:the body. It is a wide term leading to:
*Pre Menopause*Pre Menopause
**Peri MenopausePeri Menopause
*Post Menopause*Post Menopause

3. Definitions:Definitions:
-- Perimenopause:Perimenopause:
It is 3-5 years period before menopause with increaseIt is 3-5 years period before menopause with increase
frequent irregular anovulatory bleeding followed byfrequent irregular anovulatory bleeding followed by
episodes of ammenorrhea and intermittent menopausalepisodes of ammenorrhea and intermittent menopausal
symptoms.symptoms.
Menopause:Menopause:
-- The point in time at which menstrual cycles permanentlyThe point in time at which menstrual cycles permanently
cease. It is a retrospective diagnosis after 12 months ofcease. It is a retrospective diagnosis after 12 months of
ammenorrhea women classified as being menopause.ammenorrhea women classified as being menopause.
-- Smokers experience menopause up to 2 years earlier.Smokers experience menopause up to 2 years earlier.
- Mean age – 51 years.- Mean age – 51 years.

4. Definitions:Definitions:
 Premature menopause:Premature menopause:
It occurs b/w ages 30 and 40 years and is mostlyIt occurs b/w ages 30 and 40 years and is mostly
idiopathic, but can also occur after radiation therapy andidiopathic, but can also occur after radiation therapy and
oophorectomy.oophorectomy.
- Premature ovarian Failure:Premature ovarian Failure:
- It occurs before age 30 years and may be associated withIt occurs before age 30 years and may be associated with
autoimmune disease or Y chromosome mosaicism.autoimmune disease or Y chromosome mosaicism.

5. ..
..
The Reproductive CycleThe Reproductive Cycle

6. Hormonal changesHormonal changes
::
FSH
Ovary
Hypothalmus
Inhibin B
+
GnRH
Normal Ovary

7. Hormonal changesHormonal changes
..
FSH
Ovary
Hypothalamus
Estradiol / Inhibin B
+
GnRH
Aging Ovary

8. ..
..
FSH
Ovary
Hypothalmus
Estradiol / Inhibin B
+
GnRH
Menopausal Ovary
Hormonal changesHormonal changes
.

9. II. PathophysiologyII. Pathophysiology
 The number of primordial follicle decline even before birth butThe number of primordial follicle decline even before birth but
dramatic just before menopause.dramatic just before menopause.
 Increase FSH, LH from about 10 years before menopause.Increase FSH, LH from about 10 years before menopause.
 Close to menopause: There will beClose to menopause: There will be
-anovulation-anovulation
-inadequate Leuteal phase →-inadequate Leuteal phase →
decrease progesterone but not estrogen level → lead todecrease progesterone but not estrogen level → lead to
DUB and endometrial HyperplasiaDUB and endometrial Hyperplasia
- at menopause dramatic decrease of estrogen→menstruation- at menopause dramatic decrease of estrogen→menstruation
ceases and symptoms of menopause started.ceases and symptoms of menopause started.
 But still ovarian stroma produceBut still ovarian stroma produce →small androstenedione and→small androstenedione and
testosterone due to increase LH action on stromal cells. But, maintestosterone due to increase LH action on stromal cells. But, main
postmenopausal estrogen is estrone produced by Peripheral fat.postmenopausal estrogen is estrone produced by Peripheral fat.

10. III. Symptoms of Menopause:III. Symptoms of Menopause:
1. Hot flushes: cutaneous vasodilation1. Hot flushes: cutaneous vasodilation
- occurs in 75% of women- occurs in 75% of women
- more severe after surgical menopause- more severe after surgical menopause
- continue for 1 year- continue for 1 year
- 25% continue more than 5 years- 25% continue more than 5 years
2. Cardiovascular Symptoms2. Cardiovascular Symptoms
- Hypertension: has no direct relation with menopause,- Hypertension: has no direct relation with menopause,
just a coincidence.just a coincidence.
- Palpitation- Palpitation
- Heart disease: the incidence of coronary thrombosis- Heart disease: the incidence of coronary thrombosis
increases rapidly after menopause.increases rapidly after menopause.

11. Symptoms……Symptoms……
3. Psychological/Neurological symptoms:3. Psychological/Neurological symptoms:
Anxiety, depression, loss of libido, Alzheimer, insomnia.Anxiety, depression, loss of libido, Alzheimer, insomnia.
4. General Symptoms:4. General Symptoms:
fatigue, weakness, headache, vertigo, breast tendernessfatigue, weakness, headache, vertigo, breast tenderness
skin pigmentation. She may complain of dyspareunia.skin pigmentation. She may complain of dyspareunia.
Gastrointestinal symptoms in the form of increase orGastrointestinal symptoms in the form of increase or
decrease appetite.decrease appetite.

12. ..
 ,,
Vasomotor SymptomsVasomotor Symptoms
 Most often begin in perimenopauseMost often begin in perimenopause
 Sudden onset reddening of the skinSudden onset reddening of the skin
(head/neck/chest), feeling of intense(head/neck/chest), feeling of intense
body heat, profuse perspirationbody heat, profuse perspirationSperoffSperoff
 Intervals vary (minutes to hours)Intervals vary (minutes to hours)
 More frequent and severe at nightMore frequent and severe at night
 Generally stop spontaneouslyGenerally stop spontaneously
w/in few years, may persistw/in few years, may persist
for many yearsfor many years
– 12-15 % of women in 60’s12-15 % of women in 60’s
– 9% of women after age 709% of women after age 70 CasperCasper

13. After menopauseAfter menopause
Atrophic changes:Atrophic changes:
 VaginaVagina
*vaginitis due to thinning of epithelium, ↓ PH and*vaginitis due to thinning of epithelium, ↓ PH and
lubrication.lubrication.
*dyspareunia→due to decrease vascularity and*dyspareunia→due to decrease vascularity and
drynessdryness
 Decrease size of cervix and mucus with retract ofDecrease size of cervix and mucus with retract of
segumocolumnar (SC) junction into the endocervicalsegumocolumnar (SC) junction into the endocervical
canal.canal.
 Decrease size of the uterus, shrinking of myoma &Decrease size of the uterus, shrinking of myoma &
adenomyosis.adenomyosis.
 Decrease size of ovaries, become non palpable.Decrease size of ovaries, become non palpable.
 Pelvic floor - relaxationPelvic floor - relaxation →prolapse.→prolapse.
 Urinary tract →atrophy →lose of urethral tone →caruncleUrinary tract →atrophy →lose of urethral tone →caruncle
Hypertonic Bladder - detrusor instabilityHypertonic Bladder - detrusor instability

14. After menopauseAfter menopause
 Decrease size of breast and benign cysts.Decrease size of breast and benign cysts.
Skin Collagen –Skin Collagen – ↓ collagen &↓ collagen & thicknessthickness →→ ↓↓
elasticity of the skin.elasticity of the skin.

15. IV. Late effect of MenopauseIV. Late effect of Menopause
A. Osteoporosis:A. Osteoporosis:
- bone mass reach peak at the end of their 3- bone mass reach peak at the end of their 3rdrd
decade of life.decade of life.
- After 40years bone resorption exceeds bone- After 40years bone resorption exceeds bone
formation by 0.5% per year.formation by 0.5% per year.
- This negative balance increase after- This negative balance increase after
menopause to a lose of 5% of bone permenopause to a lose of 5% of bone per
year.year.

16. ..
 ..
Osteoporosis is a systemic skeletal disease characterized by low
bone mass and microarchitectural deterioration with a
consequent increase in bone fragility with susceptibility to
fracture’
Normal…..VS.…Osteoporotic Bone
Normal iliac crest Osteoporotic iliac crest

17. Risk factorsRisk factors
..
Age Race Oestrogen Wt Diseases
Diet Drugs Lifestyle
Low Ca.
Low Vit D
Alcohol
Smoking
Sedentary
Osteoporosis

18. ..
..
Pathogenesis of EstrogenPathogenesis of Estrogen
Deficiency and Bone LossDeficiency and Bone Loss
 Estrogen loss triggers increasesEstrogen loss triggers increases
in IL-1, IL-6, and TNF.in IL-1, IL-6, and TNF.
 Increased cytokines lead to increasedIncreased cytokines lead to increased
osteoclast development and lifespan.osteoclast development and lifespan.
 Increased turnover of osteoblasts.Increased turnover of osteoblasts.
 Impacts vitamin D metabolismImpacts vitamin D metabolism
 Impacts on renal and intestinal handlingImpacts on renal and intestinal handling
of calciumof calcium

19. ..
..
Consequences of OsteoporosisConsequences of Osteoporosis
 Spinal (vertebral)
compression fractures
– Back pain
– Loss of height and
mobility
– Postural deformities
 Colles’ (forearm)
fractures
 Hip Fractures
 Tooth loss

20. Diagnosis – (DEXA-Dual Energy X-ray Absorptometry)Diagnosis – (DEXA-Dual Energy X-ray Absorptometry)
-for Assessment of bone densmetry to demonstrate if bone-for Assessment of bone densmetry to demonstrate if bone
density above or below fracture threshold.density above or below fracture threshold.
 Prevention – improve lifestylePrevention – improve lifestyle
- regular exercise- regular exercise
- eliminate smoking & alcohol- eliminate smoking & alcohol
 MedicationMedication
a. ERT (Estrogen Replacement Therapy)a. ERT (Estrogen Replacement Therapy)
b. Biphosphonate (Fosamax) that inhibitb. Biphosphonate (Fosamax) that inhibit
osteoclastic activity & minimal S/Eosteoclastic activity & minimal S/E
c. Raloxifene (Evista) is selective oestrogen receptorsc. Raloxifene (Evista) is selective oestrogen receptors
moderator [SERMs] that bind with a high affinity to estrogenmoderator [SERMs] that bind with a high affinity to estrogen
receptors. It has some estrogen like effect e.g. ↑ bone density, ↓LDLreceptors. It has some estrogen like effect e.g. ↑ bone density, ↓LDL
Cholesterol [cardioprotective] but act as estrogen antagonist onCholesterol [cardioprotective] but act as estrogen antagonist on
endometriam and breast.endometriam and breast.
d. Calcitonin inhibit osteoclastic activity + analgesic effect ofd. Calcitonin inhibit osteoclastic activity + analgesic effect of
e. Calcium Supplement & Vit D.e. Calcium Supplement & Vit D.

21. Diagnosis and Investigations:Diagnosis and Investigations:
 The Triad of:The Triad of:
-Hot flushes-Hot flushes
-Amenorrhea-Amenorrhea
-increase FSH > 15 i.u./L-increase FSH > 15 i.u./L
 Before starting treatment: You should performBefore starting treatment: You should perform
-breast self examination-breast self examination
-mammogram-mammogram
-pelvic exam (Pap Smear)-pelvic exam (Pap Smear)
-weight, Blood pressure-weight, Blood pressure

22. Treatment:Treatment:
 Non Hormonal:Non Hormonal:
1. Calcium 1200-1500 mg per day1. Calcium 1200-1500 mg per day
2. Calcium and Vit. D every day2. Calcium and Vit. D every day
3. Calcitrol/Calcitonin3. Calcitrol/Calcitonin
4. Raloxifene4. Raloxifene
5. Biphosphonates5. Biphosphonates
6. Exercise6. Exercise
7. Phytoestrogens7. Phytoestrogens
For severe hot flushes vit. E, antidepressants orFor severe hot flushes vit. E, antidepressants or
gabapentin may be prescribed.gabapentin may be prescribed.

23. Hormonal treatmentHormonal treatment
 When hormones are prescribed forWhen hormones are prescribed for
climacteric symptoms it is calledclimacteric symptoms it is called
hormones replacement therapy.hormones replacement therapy.
 HRTHRT has benefits for the patients buthas benefits for the patients but
there are some disadvantages as well.there are some disadvantages as well.

24. ..
..
Hormone Replacement TherapyHormone Replacement Therapy
 Vagina-↑ vaginal thickness of epitheliumVagina-↑ vaginal thickness of epithelium
→↓ dysparunia & vaginitis.→↓ dysparunia & vaginitis.
 Decrease hot flashesDecrease hot flashes
 Prevents/treats osteoporosis and hip andPrevents/treats osteoporosis and hip and
vertebral fracturesvertebral fractures
 Prevents/treats urogenital atrophyPrevents/treats urogenital atrophy
Benefits

25. ..
..
Hormone Replacement TherapyHormone Replacement Therapy
 Increased risk for venous thrombosisIncreased risk for venous thrombosis
and embolism**and embolism**
 Increased risk for breast cancer withIncreased risk for breast cancer with
prolonged (>3-5yrs) use (EPT, not ET)prolonged (>3-5yrs) use (EPT, not ET)
 Increased risk for endometrial cancerIncreased risk for endometrial cancer
with ET (not EPT) (if uterus present)with ET (not EPT) (if uterus present)
****may be dependent on route of administrationmay be dependent on route of administration
Risks

26. Contraindication to HRTContraindication to HRT
 Undiagnosed vaginal bleedingUndiagnosed vaginal bleeding
 Acute liver disease.Acute liver disease.
-chronic impaired liver functions-chronic impaired liver functions
 Acute vascular thrombosisAcute vascular thrombosis
 Breast CancerBreast Cancer

27. Hormones of HRTHormones of HRT
 Following hormones may be used to control the symptoms.Following hormones may be used to control the symptoms.
 1. Estrogens only1. Estrogens only
 2. Estrogens and Progestogens2. Estrogens and Progestogens
 a. Continuous (No bleeding takes place)a. Continuous (No bleeding takes place)
 b. Cyclical (bleeding takes place)b. Cyclical (bleeding takes place)
 3. Estrogens and Androgens3. Estrogens and Androgens
 4. SERM (Selective estrogen receptor modulators)4. SERM (Selective estrogen receptor modulators)
 5. Tibolone5. Tibolone
 6. Testosterone6. Testosterone

28. 1.Estrogens1.Estrogens
 Treatment of choice for patients who had hysterectomy.Treatment of choice for patients who had hysterectomy.
 With administration of estrogens the symptoms areWith administration of estrogens the symptoms are
improved which are due to reduced production ofimproved which are due to reduced production of
estrogens by the ovary.estrogens by the ovary.
 PREPRATIONS:PREPRATIONS:
 a. Conjugated equine estrogens (premarine) is mosta. Conjugated equine estrogens (premarine) is most
commonly prescribed for those patients who hadcommonly prescribed for those patients who had
hysterectomy. Tablets:0.3-1.25 mg daily.hysterectomy. Tablets:0.3-1.25 mg daily.
 b. Less commonly prescribed due to metabolic side effectsb. Less commonly prescribed due to metabolic side effects
is ethinyl estradiol. Tablets 0.01-0.05 mg daily.is ethinyl estradiol. Tablets 0.01-0.05 mg daily.
 Routes of administration of estrogens are oral,Routes of administration of estrogens are oral,
transdermal, patches, gel, and subcutaneous insertion.transdermal, patches, gel, and subcutaneous insertion.

29. 2. Estrogens and Progestogens2. Estrogens and Progestogens
 They are prescribed for those patients who have intact uterus.They are prescribed for those patients who have intact uterus.
 PREPARATIONS:PREPARATIONS:
 a. Sequential combined (femoston)a. Sequential combined (femoston)
 Tablets are taken every day for 21 days and stopped for 7 days. TheyTablets are taken every day for 21 days and stopped for 7 days. They
contain estradiol 1-2 mg plus dihydroprogesterone 10 mg. But womencontain estradiol 1-2 mg plus dihydroprogesterone 10 mg. But women
get withdrawal bleeding every month.get withdrawal bleeding every month.
 b. Continuous combined Pill:b. Continuous combined Pill:
 Tablets are taken continuously without a break.Tablets are taken continuously without a break.
 Include climen plus estradiol plus norethisterone.Include climen plus estradiol plus norethisterone.
 There is no withdrawal bleeding.There is no withdrawal bleeding.

30. 3. Estrogens and androgens3. Estrogens and androgens
 In postmenopausal women there is reduced level ofIn postmenopausal women there is reduced level of
androstenedione.androstenedione.
 Preparations containing methyl testosterone and ethinylPreparations containing methyl testosterone and ethinyl
estradiol are available in the market.estradiol are available in the market.
 Tablets of Mixogen contain both these hormonesTablets of Mixogen contain both these hormones
 They are good for libido, the injection is effective for 3 to 6They are good for libido, the injection is effective for 3 to 6
months.months.

31. 4.SERM4.SERM
 This specifically act on bones,help to stopThis specifically act on bones,help to stop
osteoporosis. They do not cause withdrawlosteoporosis. They do not cause withdrawl
bleeding.bleeding.
 1.Tamoxifen(Nolvadex) has bone and1.Tamoxifen(Nolvadex) has bone and
endometrium agonist effect but antagonistendometrium agonist effect but antagonist
effects on breasts.effects on breasts.
 2.Raloxifene(Evista) has bone aggonist2.Raloxifene(Evista) has bone aggonist
effects but endometrial antagonist effects.effects but endometrial antagonist effects.

32. Tibolone and testosteroneTibolone and testosterone
 Tibolone tablet is taken every day. There isTibolone tablet is taken every day. There is
no withdrawal bleeding.no withdrawal bleeding.
 Testosterone implants is given by deepTestosterone implants is given by deep
intramuscular route every 4 to 6 months.intramuscular route every 4 to 6 months.
injections 50 to 100 mg .injections 50 to 100 mg .

33. Recommendations for HRTRecommendations for HRT
 TheThe only indicationonly indication for HT is vasomotor symptoms. It should notfor HT is vasomotor symptoms. It should not
be used for prevention of cardiovascular diseases. Although HT isbe used for prevention of cardiovascular diseases. Although HT is
effective for prevention of post menopausal osteoporosis consider noneffective for prevention of post menopausal osteoporosis consider non
estrogen medication first if osteoporosis prevention is the sole reasonestrogen medication first if osteoporosis prevention is the sole reason
for using HT.for using HT.
 TheThe lowest doselowest dose of HT that will treat the symptoms should beof HT that will treat the symptoms should be
used.used.
 TheThe shortest durationshortest duration of HT that will treat symptoms shouldof HT that will treat symptoms should
be used.be used.
 Optimally do not exceed 4 yearsOptimally do not exceed 4 years. The increase in. The increase in
breast cancer risk with HT was not found prior to 4 years.breast cancer risk with HT was not found prior to 4 years.

34. 