A slide presentation to just sensitize the undergraduate student year 3 on aspects of menopause- features, onset, diagnosis and support

1. MENOPAUSE: and HRT
Mini Sood

2. 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 .

3. Early menopause
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4. Symptoms
and stages
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5. 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.

6. Symptoms
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7. symptoms
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8. History taking suggestions
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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

9. Differential diagnosis
Pregnancy- in early perimenopause state , where there is
amenorrhoea
Hypothyroid – features of fatigue, skin changes, weight gain,
mood changes and menstrual irregularity
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10. 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.
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11. 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.

12. 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.

13. 3. Vision
Idiopathic full-thickness macular degeneration in women >
60 years.
symptoms become more severe post-menopause.

14. 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

15. 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.

16. 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.

17. 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

18. 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.

19. Family support- improved
relationships- she needs the support
and love- her breakfast in Bed!!
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20. 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

21. If she does not have any of these
symptoms, why not to leave her
alone??

22. How to Manage?
The ultimate
question is:Will
any of the
available options
improve the
overall quality of
life for the
woman?

23. Lifestyle change
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24. 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.

25. 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.

26. 4. Bisphophonate for osteoporosis
Bisphosphonate may be appropriate for women at risk for
osteoporosis who cannot use HRT.

27. 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.

28. 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

29. 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.

30. 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.

31. 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.

32. Contraindications to HRT
Absolute contraindications
◦ Breast cancer, family
◦ Endometrial cancer
◦ Vascular thrombosis
◦ Unexplained vaginal bleeding.
Relative contraindications
◦ Hyperlipidemia.
◦ > 5 yrs treatment.
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33. 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

34. Message for all menopausal
women
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