This document discusses menopause, its causes, symptoms, diagnosis, and treatment options. It defines menopause and related terms, and notes that the average age of menopause is around 51 years old. Symptoms can include hot flashes, mood changes, and vaginal dryness. Diagnosis is made if a woman has not had a period in 12 months. Treatment options include lifestyle changes, hormone therapy, and medications to help with symptoms. Hormone therapy has risks but can help treat menopausal symptoms and prevent osteoporosis.

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).