Gyny

1. MENOPAUSE & HRT
LAIQAH AL-DHAHERI

2. Definition
• The menopause is defined as the woman’s final menstrual period and the
accepted confirmation of this is made retrospectively after 1 year of
amenorrhoea
• Discreptive terms:
• Menopuse: LMP
• Perimenopause: time of life from the onset of ovarian dysfunction until 1 year
after the last period and the diagnosis of menopause is made. This time is also
known as the climacteric.
• Postmenopause: all women who have been 1 year since their last period are
deemed postmenopausal.
• The ‘change’: a colloquial description of perimenopause and postmenopause

3. Age of menopause

4. Hormonal change

5. Diagnosis
• Symptoms ?
• serum endocrine tests?
High FSH>30
Menstrual
irrgulaties e
Amenororhea E deficiency S
Vasomotor S

6. Non-physiological menopause
• Premature ovarian insufficiency
Menopause before the age of 40 years
1% of women under 40 years and 0.1% under 30 years

7. Premature ovarian insuficiency
Causes:
Idiopathic
Primary:
Chromosome anomalies (e.g. Turner’s, fragile X)
Autoimmune disease (e.g. hypothyroidism, Addison’s, myasthenia gravis)
Enzyme deficiencies (e.g. galactosaemia, 17a-hydroxylase deficiency
Secondary:
Chromosome anomalies (e.g. Turner’s, fragile X)
Autoimmune disease (e.g. hypothyroidism, Addison’s, myasthenia gravis)
Enzyme deficiencies (e.g. galactosaemia, 17a-hydroxylase deficiency

8. Iatrogenic menopause
medical treatments and menopause after cancer treatment
??
GNRH agonist
How??
surgical menopause

9. The effect of menopause
• Immediat (1st 5 year)
• Vasomotor symptoms, (e.g. hot flushes, night sweats)
• Psychological symptoms (e.g. labile mood, anxiety, tearfulness)
• Loss of concentration, poor memory
• Joint aches and pains
• Dry and itchy skin
• Hair changes
• Decreased sexual desire

10. The effect of menopause
• Intermediate (3–10 years)
• Vaginal dryness, soreness
• Dyspareunia
• Urgency of urine
• Recurrent urinary tract infections
• Urogenital prolapse

11. The effect of menopause
• Long term (>10 years)
• Osteoporosis
• Cardiovascular disease
• Dementia

12. OSTEOPROSIS
Risk factors for osteoporosis
• Family history of osteoporosis or hip fracture.
• Smoking.
• Alcoholism.
• Long-term steroid use.
• POI and hypogonadism.
• Medical treatment of gynaecological conditions with induced menopause.
• Disorders of thyroid and parathyroid metabolism.
• Immobility.
• Disorders of gut absorption, malnutrition, liver disease.

13. OSTEOPROSIS
• Definition.
' Osteoporosis is a disorder characterized by decreased bone
mineraldensity leading to compromised bone strength with increased
risk of bone fractures.

14. OSTEOPROSIS
• Clinical manifestations.
' bone demineralization is usually a silent disease that manifests years
after menopause with; decreased height, increased curvature of the
spine, silent fractures of the vertebrae, or fractures of the hip and long
bones on exposure to mild trauma

15. OSTEOPROSIS
• Diagnosis
by X-ray bone densitometry (DEXA).
Prevention of osteoporosis:
• balanced diet with calcium intake of 1500mg daily
• Vit D 600-800 IU
• Healthy life style; including weight bearing exercises, stop smoking,
and avoid long term corticosteroid therapy.

16. OSTEOPROSIS
• A) Drugs that slow bone breakdown during bone remodeling
 Biphosphonotes: orally once per week, decrease non vertebral
fractures.
Colcitonin; nasal spray increase the vertebral bone mass and reduce
fractures risk.
B)Drugs that have anabolic effect that stimulate bone remolding
C) HRT raloxifene

17. MANAGEMENT OF MENOPAUSE
• LIVE STYLE MODIFICATION:
• Stopping smoking
• Balanced healthy diet
• Normal BMI
• Symptomotic treatment ; Sedatives, tranquilizers, or antidepressants on
individual basis whenever needed.
• Periodic tesfs for early detection of premalignant and malignant lesions
including; Mammography, TVS, Pap smear cytology, and colposcopy.
• Hormone therapy (HT)in selected cases with severe menopausal symptoms

18. MANAGEMENT OF MENOPAUSE

19. MANAGEMENT OF MENOPAUSE
• Herbal/natural preparations (designed to be ingested)
• Black cohosh (Actaea racemosa)
• Dong quai (Angelica sinensis)
• Evening primrose oil (Oenothera biennis)
• Gingko (Gingko biloba)
• Ginseng (Panax ginseng)
• Kava kava (Piper methysticum)
• St John’s wort (Hypericum perforatum)
• ‘

20. MANAGEMENT OF MENOPAUSE
• Natural’ hormones (designed to be ingested or applied
• to the skin)
• Phytoestrogens such as isoflavones and
• red clover
• Natural progesterone gel
• Dehydroepiandrosterone (DHEA)

21. Non-hormonal treatments for vasomotor
symptoms
• Alpha-adrenergic agonists
• Clonidine
• Beta-blockers
• Propanolol
• Modulators of central neurotransmission
• Venlafaxine
• Fluoxetine
• Paroxetine
• Citalopram
• Gabapentin

22. HRT
• Indications of HT in menopause –
• Menopausal symptoms affecting the patient's life style and
psychologicalcondition
• Premature menopause (idiopathic or surgically induced), till age of
natural menopause.
• Prevention of osteoporosis in high risk cases. The effect is limited to
the period of HT.

23. HRT
• Contraindication to the use of HT
• Undiagnosed abnormal bleeding from the genital tract
• Known or suspected breast cancer, or oestrogen dependent
neoplasia
• History of DVT, stroke, or thromboembolic disease
• Active liver disease

24. HRT
• Hormones used in HRT
• Oestrogens:
• oestradiol (the main physiological oestrogen);
• oestrone sulphate;
• oestriol;
• congugated equine oestrogen.
• Progestogens:
• norethisterone;
• levonorgestrel;
• dydrogesterone;
• medroxyprogesterone acetate;
• drospirenone;
• micronized progesterone.

25. HRT
• Commonly used schedules for HRT
 Continuous Combined E/PRG therapy
 Cyclic Combined E/PRG therapy
Oestrogen only therapy (ET): (after hysterectomy).
Oestrogen vaginal cream preparations: for local application in cases
of vaginal atrophy

26. HRT
• Risks of Hormone Therapy
• Small but significant increase for CVS disease, stroke, and venous
thromboembolism
• Small but significant increase in the risk of breast cancer
• Endometrial cancerrisk: with prolonged oestrogen only therapy (> 5
years).