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Uploaded byMini Sood
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Menopause overview

Menopause marks the end of menstrual cycles for women, usually occurring in their 50s, and is characterized by hormonal changes leading to various physical and psychological symptoms. A significant percentage of women experience severe symptoms like hot flushes, sleep disturbances, and sexual issues, which may persist for years. Treatment options include hormone replacement therapy (HRT), lifestyle changes, and supplements, but these must be approached cautiously due to associated risks.

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Differential Diagnosis•
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MENOPAUSE: and HRT Mini Sood
Timing Menopause is defined as the time when the woman's final period stops. Usual age – 50’s "menopause" refers to the menopause transition years, or the climacteric or "peri- menopause”. The word menopause is also used to mean all the years of post- menopause .
Early menopause 3
Symptoms and stages 4
Physiology of climacteric Ovarian decline..... Change Reproductive decline..... Change Hormonal changes...... Change Estrogen decline... this is the problem Menopause symptoms are due to 1.Follicular depletion ("natural" menopause) or 2. Surgical removal of the ovaries Perimenopause the cycles become irregular with symptoms. At this time, transient and episodic bursts of ovarian activity may occur, and the decreased hormones may result in some vaginal bleeding.
Symptoms 6
symptoms 7
History taking suggestions 8 Ask about 1. Hot flushes 2. Tiredness 3. Weakness 4. Dizzy spells 5. Crying spells and irritability 6. Headaches and body aches 7. Joint pains 8. Eye symptoms 9. Urinary and vaginal symptoms 10. Dyspareunia, prolapse, incontinence 11. Poor libido 12. Any medications 13. Exercise and diet
Differential diagnosis Pregnancy- in early perimenopause state , where there is amenorrhoea Hypothyroid – features of fatigue, skin changes, weight gain, mood changes and menstrual irregularity 9
incidence 1 in 4 women experience severe vasomotor symptoms. 1 in 3 experience severe psychological symptoms ( depression, anxiety) 1 in 2 women report moderate to severe symptoms of sleep disturbance, joint pain or headache. 1 in 4 women have sexual problems. Women who experience severe symptoms, may continue to experience severe symptoms for several years. 10
1. Brain and CNS Mood Changes and Cognitive Function Est role in depression, declining cognitive function, dementia, and Alzheimer's disease is unclear. Migraine ◦ E and progestins affect central serotoninergic and opioid neurons, causing a change in the prevalence or intensity of headaches.
2. Hot Flushes Early and acute symptom of E deficiency. Begin in the perimenopause so more related to climacteric than to menopause. It is the rapid fall in E level that precipitates the symptoms. The cause of flushes remains illusive. The episodes result from a hypothalamic response (probably mediated by catecholamines) induced by a change in estrogen status. A typical description is that of waking in the night with sweats and discomfort, or having flashes of feeling hot and sweaty and unable to function well – feeling very fatigued and with added moody spells.
3. Vision Idiopathic full-thickness macular degeneration in women > 60 years. symptoms become more severe post-menopause.
4. Collagen E has a positive effect on collagen, -important for bone and skin. About 30% of skin collagen is lost within the first 5 years.The rate is 2% per year for the for the first 10 years after menopause.  Same as for bone loss and strongly suggests a link between skin thickness, bone loss, and osteoporosis. Atrophy of the vaginal and urethral mucosa Uterine prolapse, Urinary incontinence Skin changes
5. Urogenital Atrophy One third affected. E deficiency results in: ◦ Thin and paler vaginal mucosa. Low moisture content . dryness ◦ pH increases (usually pH > 5). ◦ Inflammation and small hemorrhages-petechiae. ◦ Loss in superficial cells and an increase of basal and parabasal cells.
6. Bone Loss One third of women > 65 years suffer from osteopenia/ osteoporosis. E deficiency is a dominant pathogenic factor in bone loss. From 1.5 years before to 1.5 years after menopause, spine bone mineral density (BMD) decreases by 2.5% per year, compared with a premenopausal loss rate of 0.13% per year.
7. CardioVascular CVD risk in women aged 50-59 was 4X that in premenopausal women .The relative risk of CVD depended on the age and smoking. Aging and E deficiency contribute to the increased risk of CVD in older women. Premature menopause, <age 35, has a 2- to 3-fold increased risk of myocardial infarction; oophorectomy (< 35) increased the risk by 7- fold. Cholesterol rises after menopause. Increases in low-density lipoprotein cholesterol (LDL-C), very-low-density lipoprotein (VLDL) and lipoprotein a (LP(a)). The oxidation of LDL-C is also enhanced. However, most of these changes occur in a variable degrees with aging
7.Sexuality The urogenital atrophy, affects sexual function. - decline in sexual interest, AND ability to become sexually aroused . Postmenopausal women become androgen deficient; which lead to reduced libido. Clinicians have proposed adding androgen to HRT for complaints relating to sexual desire and arousal and energy level.
Family support- improved relationships- she needs the support and love- her breakfast in Bed!! 19
Women’s Perceptions of Menopause An aging process ???? Cessation of menstrual cycles End of reproductive ability A time of hormonal changes A change of life, a changing body A time of changing emotions A time of symptoms and disease 51% reported that more happiness with more fulfilled lives in the postmenopausal years than in their 20’s (10%), 30’s (17%), or 40’s (16%). 75% had better lifestyle changes at midlife
If she does not have any of these symptoms, why not to leave her alone??
How to Manage? The ultimate question is:Will any of the available options improve the overall quality of life for the woman?
Lifestyle change 23
2. Supplement Calcium and vitamin D are important adjuncts to treatment and preventive health programs. Calcium should begin before menopause. Calcium carbonate (500 mg daily), in premenopausal women prevent bone loss, which may reduce the risk of later bone fracture. Supplement is good for bone physiology.
3. Estrogen for vasomotor Natural E supplements are popular Black kohosh, genistein, and soy-based for hot flushes. There are no convincing data about efficacy for vaginal health, lowering CVD risk, or improving brain function. Because phytoestrogens bind to ERs (ER-beta > ER-alpha), large doses THAT may pose risk for estrogen-responsive cancers.
4. Bisphophonate for osteoporosis Bisphosphonate may be appropriate for women at risk for osteoporosis who cannot use HRT.
d) SERM Selective agonistic or stimulatory effects (i.e., estrogenic) on one organ system and neutral or antagonistic (i.e., antiestrogenic) effects on other organ systems.
Tibolone - Tibolone, a synthetic steroid analogue, is a form of HRT that causes less bleeding. It is effective in maintaining an in- active endometrium while providing an estrogenisation of the lower genital tract over 6 years. Tibolone (2.5 mg/day) can safely relieve menopausal symptoms
Women perception Awareness of HRT is determined by race, educational level, and the perception of going or having gone through menopause. Many women express fear regarding HRT, especially because of the associated risk of breast cancer. Use of HRT markedly decreased after Women’s Health Initiative . Breast cancer risk It was controversial but after WHI; it is not. In earlier calculations of HRT related risk, a RR of 1.1 was ascribed, suggesting a 10% increase in risk relative to no ERT. It is also possible that ERT use causes breast cancer to occur earlier in some women.
Benefits and risks of HRT  Vasomotor Osteoporosis CVD Urogenital Cognitive diseases Alzheimer's disease Unscheduled bleeding in any postmenopausal woman should be investigated regardless of results of US endometrial thickness, because abnormalities may be present even when the endometrial thickness is less than 4 mm. Recurrent bleeding during sequential HRT regimens causes many patients to stop treatment.
Improve Mood and Cognitive functions • E has a positive effect on mood, memory, and quality of life scales. • The data on estrogen reducing the risk of Alzheimer's disease, however, are remarkably consistent (RR, 0.4-0.6). • Although estrogen appears to have a protective effect on Alzheimer's Alzheimer's disease, • it is still with an uncertain benefit.
Contraindications to HRT Absolute contraindications ◦ Breast cancer, family ◦ Endometrial cancer ◦ Vascular thrombosis ◦ Unexplained vaginal bleeding. Relative contraindications ◦ Hyperlipidemia. ◦ > 5 yrs treatment. 32 32
To sum up For Climacteric symptoms, HT is the most effective but it is not always necessary. First line is other options < 50 means < 5years treatment is not hazardous. Intervention is effective for specific symptoms. Not every woman will respond the same to a given therapy. Be flexible in prescribing patterns, for traditional HRT or alternative approaches. Short-term treatment with hormone therapy is preferred to long-term treatment. The lowest effective estrogen dose should be given for the shortest duration required, because risks for hormone therapy increase with (1) advancing age, (2) time since menopause, (3) duration of use
Message for all menopausal women 34