Menopause typically occurs between ages 50-52 as ovaries stop producing eggs and estrogen levels decline. Symptoms include hot flashes, night sweats, and vaginal dryness. Management includes lifestyle changes and various hormonal and non-hormonal treatments to relieve symptoms and prevent long-term issues like osteoporosis and heart disease. Hormone replacement therapy (HRT) effectively treats short-term menopausal issues but carries risks if used long-term like an increased risk of breast cancer. Careful screening and use of the lowest effective dose for the shortest time is recommended for HRT.

1. Menopause
Gaya 

2. Cessation of menstruation in a average age of
50-52 years.
Peri-menopause (climacteric) period ovary
activity fluctuates often leading to irregular
mensus.
Surgical menopause occurs when functioning
ovaries are removed surgically.

3. Premature menopause
occurrence of menopause before the age of 45
years. causes are
• Primary (unknown etiology)
• Autoimmune disorder
• Radiotherapy
• Chemotherapy
• Surgical removal

4. Ovaries produce following steroid hormones
• Oestradiol
• Progesterone
• Testosterone
• androstenedione

5. • In developing follicles granulosa cellls
androstenedione and testosterone convert to
oestradiol.
• Around age of menopause the follicles stop
developing and oestradiol levels fall.
• Ovary also produce inhibin it inhibit
production of FSH in pituitary .
• Fall of inhibin and oestradil level cause araise
of FSH.

6. Menopause diagnosis by serum FSH level
which is more than 30iu/L
If woman still menstruating serum FSH have to
be done on day 2 or 3

7. Menopausal symptoms
Short term Intermediate Long term
Vasomotor symptoms
Night sweating
hot flushes
Vaginal dryness and
dyspareunia
osteoporosis
Psychological symptoms
Irritability/mood change
anxiety
Recurrent UTI Cardiovascular effects
Psychosexual problems
Loss of libido (female sexual
dysfunction
Urge incontinence (due to
atrophy of the trigonal and
distal urethra)
Pelvic organ prolapse due
to weakness of muscles
and ligaments
Dementia
irritability
anxiety

9. Management
• Lifestyle change
Dietary advice
Regular exercise prevent excessive weight gain
and osteoporosis
Calcium supplement also given

10. Non hormonal treatment
Phyto-oetrogens
Plant substance similar to oestrogen manage short
term effect.
Propranolol , clonidine
Used in patient with vasomotor symptoms
Bisphosphonate
Prevent osteoporosos

11. Hormonal replacement therapy
Most effective component of HRT is
replacement of oestrogen but it can lead to
endometrial hyperplasia
Therefore need to combine with progesterone

12. Oestrogen replacement routes
• Oral tablet-oestrodiol valerate
• Dermal patches (oestradiol)- avoid 1sr pass
effect
• Subcutaneous implants (oestrodiol)-
useful patient after hysterectomy
• Vaginal cream (oestriol)- manage urogenital
symptoms

13. Progesterone
Always need to added to avoid the effect of
hyperplasia of endometrium by the oestrogen
.
Can be given cyclically for 10-14 days in every cycle
to -mimic the natural cycle
cause regular withdrawal bleeding
avoid hyperplasia
Giving low dose continuously prevent bleeding

14. Available preparation
• C-19 nortestosterone derivatives –
norethisterone , levonorgestrel
• C-21 progesterone derivatives –
dydrogesterone , medroxyprogesterone
acetate , cyptoterone acetate
• C-17 derivatives – drospirenone
• Progesterone – micronized progesterone
vaginal suppository

15. Testosterone
50% of testosterone are produced in the ovaries in
women , and menopause does not affect on
testosterone production
Its play in important role in
• Maintaining the libido
• Sexual activity
• Feeling of well being after menopause
In surgical menopause –testosterone level reduce

16. Benefits of HRT
• Prevent short term effect
• Vaginal dryness and urogenital symptoms
responds well to local oestrogen cream
• Effective in prevention of
osteoporosis(recommend in women of
premature ovarian failure )
• Cardiovascular protective effects is
controversial

17. • Some studies has shown that oestrogen
replacement can make slow development of
dementia and Alzheimer’s disese (not
confirmed )
• Some studies has shown HRT reduce risk of
colon cancer

18. Side effects
Oestrogen related
• Nausea vomiting
• Headache and triggering migraine
• Breast tenderness
Progesterone related
• Fluid retention
• Feeling bloating
• Headache

19. • Acne
• Depression
So when prescribing minimal effective does
ahold be given for the shortest necessary
duration.
Premature menopause –longer duration
treatment

20. Risk of HRT
• Increasing risk of breast cancer (when using
more than 5 year n postmenopausal period
increase risk of breast CA /risk mostly
associated with progesterone )
• Venous thromboembolism ( more in women
who smoke ,obese or have underlying
thrombophilia)
• Coronary heart disease -mostly in premature
menopausal women

21. • Stroke – more in older women
Contraindication
• Breast cancer
• Endometrial cancer
• Active liver disease
• DVT
• Thrombophilia

22. Contraception in menopausal women
• Spontaneous ovulation can occur even after
menopause
• Women who under 50 –contraception method
have to use for 2 yrs
• Women over 50 -for 1 yrs

23. Selective estrogen receptor
modulators (SERM)
• These agents exert their action only on
specific tissue such as bones to be effective for
prevention osteoporosis
Ex : Raloxifine

24. Following advice are given in
menopause clinic
• Breast USS and mammography
• Endometrial assessment – for abnormal
uterine bleeding (hysteroscopy and
endometrial biopsy)
• CVS risk assessment
• DEXA scan foe bone density assessment