A slide presentation on aspects of menopause for medical students. The presentation, and hormonal changes resulting in the presenting symptoms and signs. For year 3/4 students

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 results from:
1.Follicular depletion ("natural" menopause) or
2. Surgical removal of the ovaries
Both ovarian E & P declines.
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
11. Poor libido
12. Any medications
13. Exercise and diet

9. DIFFERENTIAL DIAGNOSIS
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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
• EARLYAND ACUTE SYMPTOMOF E DEFICIENCY.
• BEGIN INTHE PERIMENOPAUSE SO MORE RELATEDTO CLIMACTERIC
THANTO MENOPAUSE.
• IT ISTHE RAPID FALL IN E LEVELTHAT PRECIPITATESTHE
SYMPTOMS.
• THE CAUSEOF FLUSHES REMAINS ILLUSIVE.THE EPISODES RESULT
FROM A HYPOTHALAMIC RESPONSE (PROBABLY MEDIATED BY
CATECHOLAMINES) INDUCED BY A CHANGE IN ESTROGEN STATUS.

13. 3. VISION
• IDIOPATHIC FULL-THICKNESS MACULAR DEGENERATION IN
WOMEN > 60YEARS.
• SYMPTOMS BECOME MORE SEVERE POSTMENOPAUSE.

14. 4. COLLAGEN
E HAS A POSITIVE EFFECT ON COLLAGEN, -
IMPORTANT FOR BONE AND SKIN. ABOUT 30% OF
SKIN COLLAGEN IS LOSTWITHINTHE FIRST 5YEARS.
YEARS.THE RATE IS 2% PERYEAR FORTHE FIRST 10
FIRST 10YEARS AFTER MENOPAUSE.
SAME AS FOR BONE LOSS AND STRONGLY
SUGGESTS A LINK BETWEEN SKINTHICKNESS, BONE
LOSS, AND OSTEOPOROSIS.
ATROPHY OFTHEVAGINAL AND URETHRAL MUCOSA
UTERINE PROLAPSE, URINARY INCONTINENCE
SKIN CHANGES

15. 5. UROGENITAL ATROPHY
• ONE THIRD AFFECTED.
• E DEFICIENCY RESULTS IN:
• THIN AND PALERVAGINAL MUCOSA. LOW MOISTURE CONTENT .
DRYNESS
• PH INCREASES (USUALLY PH > 5).
• INFLAMMATIONAND SMALL HEMORRHAGES-PETECHIAE.
• LOSS IN SUPERFICIALCELLS ANDAN INCREASE OF BASAL AND
PARABASALCELLS.
• UTI (E.G. COLIFORM BACTERIA), AS A RESULT OFTHE REDUCED
ACIDITY.
• DECREASE IN LACTOBACILLI, YEAST, AND BACTERIALVAGINOSIS-
ASSOCIATED BACTERIA ALSO MAY EXPLAINTHE LOWER
INCIDENCEOF BACTERIALVAGINOSISANDYEASTVAGINITISTHAN
INYOUNGWOMEN.
• VAGINAL DISCOMFORT, ITCHING, DYSPAREUNIA,AND RECURRENT
RECURRENTVAGINITIS , AND URINARY SYMPTOMSAS FREQUENCYAND
DYSURIA.
• PELVIC LAXITY AND STRESS INCONTINENCE.

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- IMPROVE
RELATIONSHIPS
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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 FORWOMEN AT RISK FOR
OSTEOPOROSISWHO CANNOT USE HRT.

27. D) SERM
• SELECTIVEAGONISTICOR STIMULATORY EFFECTS (I.E., ESTROGENIC)
ON ONE ORGAN SYSTEMAND NEUTRALOR ANTAGONISTIC (I.E.,
ANTIESTROGENIC) EFFECTS ON OTHER ORGAN SYSTEMS.

28. TIBOLONE -
• TIBOLONE,A SYNTHETIC
STEROIDANALOGUE, IS A
FORM OF HRTTHAT CAUSES
LESS BLEEDING.
• IT IS EFFECTIVE IN
MAINTAININGAN IN-ACTIVE
ENDOMETRIUMWHILE
PROVIDINGAN
ESTROGENIZATIONOFTHE
LOWER GENITALTRACT 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 REDUCINGTHE RISKOF ALZHEIMER'S DISEASE,
HOWEVER,ARE REMARKABLY CONSISTENT (RR, 0.4-0.6).
•ALTHOUGH ESTROGEN APPEARSTO HAVE A PROTECTIVE EFFECT ON
ALZHEIMER'S DISEASE, IT IS STILL 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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