This document discusses menopause and hormone replacement therapy. It begins by defining menopause as the permanent stoppage of menstruation due to declining ovarian function. It then discusses the stages of menopause including perimenopause and the changes in hormones like FSH and estrogen that occur. The document notes that menopause is a natural process but can cause both short term symptoms and long term health issues if estrogen is not replaced. It evaluates the risks and benefits of different treatment options for menopause including lifestyle changes, alternative therapies, medical treatments, and hormone replacement therapy.

1. MD, DGO
Doctor House,
Una Pani Road,
SURAT (Gujarat)
395 003

2.  What is it?
-and why do we care?
And WHY there is so much controversy?

3.  Menopause – Cessation of Menstruation.
 Its derived from a Greek words “Menos and Pause”
Meaning Cessation of Menstruation.
 Definition: Permanent stoppage of Menstruation as a
result of declining ovarian function leading to
deficient ovarian hormonal secretions.

4. FSH & LH
Estrogen and
Progesterone

5. Fertile Years:
Fairly Predictable
Teen years:
Perimenopause:
+/- Rough
Variable
Menopause:
Menses “Pause”
Age
0 10 20 30 40 50 60 70 80 90 100
Menarche:
The Beginning
SPC SURAT 9825356080/31-07-11

6. “Ideal” monthly cycles:
smooth hormonal balance
d d d d d d d d d d d d

7.  Menopause strictly means the end (pause) of menses.
 Menopause is a hypo-estrogenic state.
 Estrogen surges have caused growth of the
endometrium.
 Now no growth = no shedding = no period
 ~ FSH over 40
 Average age 51-52.

8.  By definition means the time around menopause.
 (Could mean anytime from birth to death. )
 Usually refers to the transitional years leading
from regular menses to the end of menses and the
symptomatic years.
 Ages 35 to 60.
 Low, unreliable Progesterone & Fluctuating
Estrogen.

9. Age related depletion of ovarian follicles

Degeneration of Granulosa & Theca cells

Degenerating Theca cells fail to respond to Gn

Leads to fall in estrogen levels

Decrease in negative feedback on HPA axis

Consequent rise in Gn attempting to stimulate ovaries
Sharman et al 1976

10.  These process begins 5 year before actual menopause
 At this time FHS  and Estradiol 
 LH and Progesterone levels remain unchanged,
indicating that cycle probably continue to be ovulatory.
 Estradiol  – Hot flushes

11.  In contrast to follicular cells, the stromal cells continue to
produce androgens in response to  LH after Menopause,
 The adrenals continue to produce androgens
 The physiologic  in Estrogen / Androgen ratio accounts
for  increase in facial hair growth after menopause.
 In obese women androgens are converted by peripheral body
fat to a weak estrogen – estrone
 Hence they are less prone to menopausal symptoms and
osteoporosis but increase chance of endometrial hyperplasia
and malignancy.

12.  30 to 50 years of your life.
 Uncomfortable Symptoms.
 Possibly disruptive
 Possible increase PMS (mood changes,
sadness, lack of concentration).
 More abnormal bleeding – iron deficiency.
 Decline in general health.
 Huge impact on reproductive system.

13. ● 200 years ago, fewer than 30% of women lived
long enough to experience menopause.
● 100 years ago the average women‟s life expectancy
just reached 50 years of age.
● NOW-Average life expectancy is 80 and most of
you will far surpass that.
● Ready or not, you can already expect a better
QUANTITY of life.
● So the question really becomes - “How can I
maintain the best QUALITY of life?”

15.  They welcome Menopause – freedom from bleeding and risk of
pregnancy
 Feel free to participate in religious and social activities.
 Psychological symptoms are fewer – joint family strong support
 Lifestyle of rural India – more physical activities fiber rich diet, low
fat, good intake of milk and exposure to sun shine
 Hot flushes are common in the white Caucasian women then
Indian. Urogenital symptoms common in Indians.
 Decreased libido – shy to discuss

16.  Survey of knowledge attitude and symptomatology
menopause and HRT in qualified nurses – revealed
substantial degree of paucity of knowledge amongst
them.
 66.6% - only were familiar in premenopausal group
 48.5% - in menopausal group
KEM hospital – Mumbai (Kansaria et al 2000)

17.  Survey (on the basis of questionnaire) of knowledge attitude
and symptomatology of menopause, HRT and Cancer in
qualified 352 educated working class women.
 40% of them had read about menopause in newspapers.
 48% considered it as media hype, and the despite of the fact
that 26% of them being postmenopausal, only 2.9% were on
HRT.
 This survey emphasizes the need for enhancing public
awareness of menopause and its implications.
Monali Desai 2003, Vadodara

18. Menopausal impacts can be divided into two categories -
short term and long term
Estrogen Withdrawal Symptoms-short term (Resolve with time)
hot flashes
night sweats
 sleeplessness
 fatigue
 mental lapses
 moodiness
 irritability
 palpitations
 headaches
 many others
MOST DISAPPEAR WITH TIME.

19. Estrogen Deficiency -- ( Worsen with time)
● Vaginal effects (dryness, atrophy) ● Genitalia (atrophy)
● Brain (cognitive decline) ● Loss of libido
● Bone (loss of mineral density) ● Joints (tightness)
● Blood vessels (atherosclerosis) ● Metabolic ( insulin
● Skin (wrinkling) resistance)
● Mucus membranes (dryness) ● Macular degeneration
● Others
THESE IMPACTS DO NOT FADE - THEY GET WORSE.

20. ● Questions to resolve:
● A. Could anything be done? --- YES
● B. What would be the options?
● C. How safe are they?

21. 1) NATURAL - Live a Healthy Lifestyle
 Enhance and accept what nature has given you.
2) ALTERNATIVE – use supplements, vitamins, naturopathic and
homeopathic remedies.
3) MEDICAL TREATMENTS – treat specific symptoms or problems
with medications as they arise.
4) HORMONAL – replace the original substance that is missing -
prevention. (Similar to treatment of low thyroid)

22. 1. Detail personal and family history, physical examination
including height, weight and BP
2. Breast examination, pelvic examination & PAP‟s test
3. Evaluation of symptoms and need for medication
4. Evaluation of individual risk Vs benefits from treatment
5. Routine screening test: CBC, Urine analysis, blood sugars,
RFT, LFT
6. Lipid profile and CVS risk assessment

23. 7. TVS and Assessment of Endometrial thickness
8. Routine mammography
9. Assessment of BMD – DEXA (Dual Energy X-ray
Absorptiometry) test is preferable
10. Endometrial biopsy – in postmenopausal bleeding or F/H/O
cancer or P/H/O late menopause, infertility and PCOD.
11. Stool test for occult blood [for colorectal disease]
12. TSH, and free T3, T4
13. FHS, LH in women on OC pills with secondary amenorrhea or in
hysterectomised patients.

24. ● Medical treatments begin after a problem develops.
● Traditionally, this is what most of us choose.
● We seem to assume that disease is inevitable.
“Eventually we all will get something.”
● This refers to specific drug therapies to treat
conditions or disease states as they arise, or even
before that.

25.  Improves vasomotor stability, reducing hot flashes.
 Helps maintain elasticity of skin and tissues.
 Improves sleep patterns, decreases fatigue.
 Increased „sense of well being‟.
 Better recall, memory, problem solving.

26.  Cardiovascular Risk  Insomnia
 Osteoporosis  Ovarian cancer
 Colon cancer  Diabetes
 Endometrial cancer  Breast cancer
 Dementia  Clotting – Deep Vein
Thrombosis & Stroke
 Macular degeneration
 Arthritis

27.  Timing of treatment - It‟s important to start early to
get the full benefit.
 Many of the benefits persist if you continue therapy
for longer periods of time.
 Mode of delivery –Various routes
 NON-ORAL Have advantages over oral.

28. ● Let‟s assume for the moment that there are safe choices.
● Therapy depends on your particular situation.
● “Where you are” in this transition process.
● Depends on your goals, health conditions, budget, etc.

29. ● NO symptoms.
● It‟s great not to have symptoms , still you face the
decline in health associated with the loss of estrogen.
● This is a group of Patients that‟s harder to convince! Pt.
doesn‟t have symptoms so she doesn‟t feel “bad”. They
won‟t “feel” the slow loss of calcium in bones until it‟s
too late.
● Consider HRT to prevent some of the long term effects
of chronic estrogen deficiency.

30.  Lifestyle changes and Personal habits
 Exercises: Brisk walking for 40 – 60 min., at least 5 times /
week
 Physical workout: Wt. bearing exercises for limbs and back
strengthening.
 Yoga and Meditation: Breathing exercises  stress
 Simple Diet: Plenty of vegetables, fruits  fat,  Sugar
 Fluid Intake: Plenty of fluids to maintain hydration.
 Control or Abstain: smoking, alcohol intake, more tea and
coffee.

33. Women‟s bodies are genetically programmed to go
through a fertile phase that ends with the onset of
menopause.
Natural phenomenon - “why not accept it gracefully,
and work to improve life quality by diet, exercise, and
natural supplements.”
Much to be said for this lifestyle.
Symptoms - not everyone has them, or they may be
mild, and even if uncomfortable, will usually resolve <
5 years. Learn to “Live with it”.

34. Most of these issues will be accepted by women as
natural aging, not realizing they could have been
prevented.
Estrogen deficiency will NOT resolve, and over time the
damage will become apparent.
At some point the damage is irreversible.
Most women at this point will be switched to
”Option 3 - Medical Treatments.” because now they
have genuine medical issues.

35. Many options available. No Rx needed. OTC (Over-
the Counter).
May consist of herbal supplements, nutrients,
Homeopathic treatment, Chinese herbs and
acupuncture treatments, massage, mental imaging,
crystal treatments.

36. Alternative tx‟s give people power to make their
own choices. Especially when so many of us
have become so skeptical of our health care
system and the motives of people making
decisions and recommendations.
Draw criticism as unproven. Most are
“unproven” in truly scientifically controlled
studies, but thats not the point.
Most likely they are safe. Most have extremely
limited data on safety so remember it‟s-“Buyer
beware”.
No data regarding disease prevention.

37. Plants make chemicals that are necessary for their own
survival.
It turns out that those chemicals can have effects on
humans.
Certain plants make chemicals that will weakly stimulate
estrogen and progesterone receptors.
Supplementing with these,can frequently alleviate mild
symptoms.

38. They are extremely weak compared to
our own ovarian hormones.
They cannot be measured in available
hormonal assays.
Little risk of harm is known,but limited
data.

39. Premarin - derived from purified urine
of pregnant mares.
Longest track record of any estrogen.
Hundreds of studies have documented its effectiveness.
Study drug from the Women‟s Health Initiative (that received
such bad press in 2002).
Most of those negative findings have been totally disproved.
The negative image still lingers, but the medication is totally
valid.

40. If you are pre-menopause (perimenopause) , but
having symptoms &/or abnormal bleeding:
Rule out underlying medical disease.
The goal of therapy would be to evaluate/correct the
bleeding issue.
Suppress the symptoms, necessary changes in nutrition/life.
LOW DOSES of hormonal supplements if needed.
Frequent monitoring and adjustments due to volatility.

41.  Hormonal changes constitute a natural progression in
women‟s lives - from birth to death.
 Menses and any accompanying symptoms are driven by these
changing hormone levels.
 There are monthly cyclic changes that create fertile
reproductive cycles.
 There are plateaus that lead to months or years of milder or
stronger symptoms or suboptimal fertility.
 And then the eventual low plateau of menopause.
 Unpleasantly, there can be daily fluctuations.