This document discusses menopause and postmenopause. It defines menopause as the permanent cessation of menstruation due to loss of ovarian activity, usually occurring between ages 45-50. The document describes the hormonal changes, symptoms, risks, diagnosis, and treatment options associated with menopause including hormone replacement therapy and lifestyle modifications.

1. 1

2. 2
Post
menopause

3. DEFINITION
• Menopause means permanent cessation of
menstruation at the end of reproductive life due
to loss of ovarian follicular activity. It is the point
of time when last and final menstruation occur”
• “Clinical diagnosis is confirmed following
stoppage of menstruation for twelve consecutive
months without any other pathology”

4. • PERIMENOPAUSE
– A period of 3years before menopause &
followed by 1 year of amenorrhoea
– Assosiated with mild ovarian hormonal
deficiency
– Leads to anovulation, menorrhagia
4

5. • CLIMACTERIC:
– Phase of waning ovarian activity
– 2-3yrs before and 2-5 yrs after menopause
5

6. Age
• Usual age 45 to 50yrs average being 47yrs.
• Premature menopause - before 40 yrs
• Late menopause – menstruation beyond
52 yrs
6

7. • Delayed menopause
– Due to good health and better nutrition.
– Also seen in women with uterine fibroids .
– Also in women with high risk of endometrial
cancer
• Menopausal age is directly associated with smoking
and genetic disposition.
• Smoking induces premature menopause.
7

8. Pathophysiology
• During climacteric, ovarian activity declines
• Initially, ovulation fails, no corpus luteum forms
and no progesterone is secreted by the ovary
• Later, graffian follicle fails to develop, estrogenic
activity decreases leading to amenorrhea
• Increased secretion of FSH and LH by anterior
pituitary (due to negative feed back mechanism )
8

9. 9

10. Hormone levels
• 50% reduction in androgen production and 66%
reduction in estrogen production
• Some estrogen produced by ovary (oestrone, E1)
• FSH appears in large concentrations.
• Low estrogen levels(below 20pg/ml) predisposes
to osteoporosis and ischemic heart disease.
10

11. Risk factors for menopausal related
problems are as follows:
• Early menopause
• Surgical menopause or radiation.
• Chemotherapy.
• smoking., caffeine, alcohol.
• Family history of menopausal diseases.
• Drugs related such as GnRH, heparin,
corticosteroids and clomiphene(anti- oestrogen)
when given over prolonged peiod can cause
oestrogen deficiency.
11

12. LATE ONSET
• High parity
• Use of oral contraceptive
• Obesity
• Alcohol consumption

13. DIAGNOSIS OF MENOPAUSE
 Cessation of menstruation for consecutive 12 months
during climateric
 Appearance of menopausal symptoms
 Serum oestradiol<20pg/ml
 Serum FSH and LH >40 IU /ml

14. Anatomical changes
SITE CHANGES
Genital organs Atrophy and regression
Ovary Shrink,surfaces:grooved
Size of ovary <2*1.5*1cm
fallopian tube Atrophy
Cilia Disappear
Uterus Smaller
Endometrium As basal layer: deeply stained
stroma
14

15. SITE CHANGES
Cervix Smaller
Vaginal fornices Disappears
Vagina Narrow
Epithelium Pale, thin,and dry: senile vaginitis
Vulva Atrophy (+narrow
vagina:dyspareunia)
Skin of labia minora and vestibule Pale,thin,dry
Labia majora Reduction in fat
Pubic hair Reduced and grey
Breast More pendulous(fat dep)
Glandular tissue <5%
Pelvic cellular tissue Becomes lax
Ligaments supporting the uterus and
vagina
Lose their tone:prolapse of genital
organs, stress incontinence of urine,
and fecal incontinence
15

16. 16

17. Menopausal symptoms
• Menstrual irregularities
• Neurological symptoms
• Libido
• Urinary tract
• Genital
17

18. Hot Flushes
• Early and acute symptom of estrogen deficiency.
• Followed by severe sweating.
• Occurring at night may disturb sleep.
• Sometimes preceded by headache.
• Mental depression due to lack of sleep, irritability and lack
of concentration.
• With passage of time severity of hot flushes decreases.
18

19. Cause of hot flushes
•Caused by noradrenalin, which disturbs the
thermoregulatory system.
•Oestrogen deficiency reduces hypothalamic
endorphins, which release more norepinephrine
and serotonin.
•This leads to inappropriate heat loss mechanism.
19

20. Neurological
• Vasomotor symptoms and paraesthesia take the
form of sensations of pins and needles in the
extremities.
• Hot flushes
• Head ache
• Faintness
• Numbness
• Itching
• Back pain 20

21. • The symptoms which develop a little
later are :
– Urinary
• Dysuria
• Stress incontinence and urge
• Recurrent infection
• Urethral curuncle
Genital
Dry vagina
Dyspareunia
Loss of libido
Faecal incontinence
21

22. Menstrual irregularities
22
• Heavy menstruation
• Scanty menstruation
• Early or delayed menstruation
• Prolonged periods

23. Mental and emotional symptoms
23
 Depression
 Irritability
 Mood swings
 Emotional out breaks
 Fatigue
 Poor memory
 Lack of concentration

24. COMPLICATIONS
– Ortho complications
• Arthritis
• Osteoporosis of vertebral bones, upper end of hip
joint,wrist
• frature
– Cardiovascular disease.
• ischaemic heart disease, MI, HTN
• Stroke
• Cardiac irregularities
• Tachycardia
24

25. – Urogenital atrophy.
• Prolape genital tract
• Stress incontinence of urine & feces
• Ano-colonic cancer
– Cognitive decline and Alzheimer's disease.
– Cataract, glaucoma
– Skin changes and Tooth decay
25

26. • A slowly progressing skeletal disorder: Detirioration of bone
mass resulting in increased fragility and predilection to
frature : due to estrogen depletion
26

27. CARDIOVASCULAR
DISEASE
• Estrogen is cardioprotective(antioxidant
property also)
• After menopause HDL,LDL, total
cholesterol ,
• Estrogen deficiencyatherosclerosis, ischemic
heart disease, MI
• Risk factors: obese women with hypertension ,
previous thromboembolic episodes 27

28. Stroke
• Incidence of stroke also increase in menopausal women
28

29. PREVENTION
• Reduce the risk factors for other problems
associated with menopause
• 1200 to 1500mg of elemental calcium and 800
units of VIT D daily
• 1000-1500 mg ca through
diet

30. Treatment
1) Counseling
2) Mild tranquillizers
3) non hormonal therapy
4) Hormone replacement therapy(HRT)
30

31. Counselling
 General advice regarding the physiological process
 The advice on contraceptives
 Diet
 Weight bearing exercise delay onset of osteoporosis.

32. NON-HORMONAL TREATMENT
 Nutritional diet
 Supplimentary calcium (1-1.5gm )
 Exercise
 Weight bearing exercise
 Cessation of alcohol and smoking
 Biphosphonates (Alendronate and etideonate)
 Fluride (to prevent osteoporesis and increase
bone density

33. Mild tranquillizers
 Anti depressants like
sulpiride,chlordiazepoxide,alprazolam
etc
 Relieves anxiety, depression,
sleeplessness

34. Hormone replacement therapy
 Not all women require
HRT
 70-85% of women remain
healthy need only good
nutrition and healthy life
style.

35. Indications of HRT
1) Women having climacteric
symptoms
 Vasomotor symptoms
 Urinary symptoms
 Sexual dysharmony
 Established osteoporosis
2) All asymptomatic high-risk women
having
Premature menopause (surgical
/ radiation )
Family history of osteoporosis
Poor diet, excess alcohol
CVD, Alzheimer's disease,
colonic cancer
Corticosteroid & other
medications
High urinary calcium / creatinine

36. HRT can be also prescribed to…
 Premature ovarian failure
 Gonadal dysgenesis

37. Contraindications of HRT
 Breast cancer, uterine cancer or family
history of cancer.
 Previous history of thromboembolic
episode.
 Liver & gall bladder disease.

38. DRUGS USED IN HRT
 Oestrogen
 Progesterone
 Other drugs:
◦ Tibolone
◦ Raloxifene
◦ Soya
◦ Bisphosphonates

39. Estrogen therapy
To relieve symptoms like; hot flush, night sweats,
palpitations, disturbed sleep, osteoporosis etc
 In smallest effective dose for 3-6 months
 Oral premarin (Conjugated equine estrogen
(CEE): 0.625 mg daily)
 Ethinyl estradiol (0.01mg), Evalon(1-2mg),
micronized estrogen are effective.

40.  Medroxyprogestrone(10mg) or
primolut-N (2.5mg) daily for 10-12d
each month.
 Combined hormone therapy(femet).
2mg 17-β-oestrodiol & 1mg of
norethisterone acetate.

41. Oral Preparations of estrogen
 Oral: -
◦ Conjugated equine estrogen (CEE): 0.625
mg daily
◦ Ethinyl estradiol : 0.01mg
◦ Micronised estrogen : 1-2g

42. Transdermal Preparations of
estrogen
 Transdermal (estradiol): -
◦ Patches: contains: 3-4mg; releases 50 micro gm / 24 hour
twice weekly.
◦ Gel :for improving collagen in skin 75 micro gm / 24 hours
daily.

43. THE RISKS OF HRT
 Vaginal bleeding
 Thrombo embolism
 Endometrial cancer if E2 is taken
alone
 Breast cancer ,if HRT is taken over
5yrs.
 CHD in a women with CVD.

44. Progesterone
 Role in HRT
 Prevents endometrial hyperplasia and cancer in
non-hysterectomised women
 Implant may replace oestrogen, where estrogen is
c/I or sensitive
 Prevents breast cancer
 Improves bone mineral density
◦ medroxyprogestrone & duphaston
◦ Mirena IUCD- levonorgestrel

45. Tibolone
 Synthetic derivative of 19-nor-
testosterone.
 Weak oestrogenic, progestogenic, &
androgenic action.
 Endometrial hyperplasia
 Elevates the mood, relieves the VM
symptom, improves sex drive &
reduces bone resoption.

46. Raloxifene
 Non steroidal comp, reduses the risk
of fracture by 50%.
 It causes 10% reduction in total
cholesterol & LDL & HDL level.
 It does not raise the level of
triglycerides.so cardio protective for
long term.
 Reduces osteoporosis.

47. soya
 Isoflavone.
 phytoestrogen-oetrogenic- non steroid plant
product.
 45-60mg soya daily –protective- breast cancer,
liver disease &other side effect.
 cholesterol ,LDL,TG & marginal HDL.
 Antiviral, antifungal & ant carcinogenic.

48. DURATION OF HRT THERAPY
 3-5 years

49. SELF CARE AT HOME
HOT FLUSHES
• Regular aerobic exercise
• Avoid spicy ,caffeine and alcohol
• Vit E ,soya
HEART DISEASE
• Low fat –low cholestrol containing diets
WEIGHT GAIN
• Regular exercises
• Good nutritious food

50. OSTEOPORESIS
• Adequate calcium intake
• Weight bearing exercises
STRESS
• Meditation for 15 min
• Exercises
INSOMNIA
• Meditation just before bed
• Bath before bed
• Sedatives for short period of time

51. GOOD NUTRITION
• Plenty of fruits and vegetables
• Antioxidants and vitamins
• Add Fibre rich diet
• Avoid fat,cholestrol and spicy foods

52. VAGINAL DRYNESS AND URINARY
INCONTINENCE
• Vaginal oestrogen
• Lubricant for vaginal dryness
• Yam cream contains phytoestrogen
• VIT E
• Kegal exercise