This newsletter article discusses predicting a woman's age at menopause. It explains that predicting age at menopause can help women plan their families and target health interventions. While difficult, several markers can be used including estradiol, FSH, inhibin, and AMH levels. AMH in particular decreases steadily with age and can provide insights into ovarian reserve years before menopause. The article provides ranges for these markers in the reproductive, early transition, late transition, and post-menopausal stages. References are also included to support the discussion.

1. NEWSLETTER
Issue 5 December, 2011
Holistic, Compassionate and Quality Healthcare
Advisory Group Predicting Age at Menopause
Prof. U Thein Aung
Dr. Nyein Moe Thaw
Prof. U Khin Maung Aye
M.B.,B.S, M.Med.Sc (OG), Dr. Med.Sc (OG)
Dr. Tin Nyunt
Prof. U Saw Win
P redicting age at menopause and ovarian reserve is of great interest in women who
wish to delay childbearing and who wish to know their ovarian reserve. Age at menopause may
Prof. Daw Mya Thidar also be of relevance because many health conditions are linked to age at menopause. Lower
Prof. U Ne Win age at menopause is linked to an increased risk for cardiovascular disease and osteoporosis.
Older age at menopause is linked to an increased risk for breast cancer, endometrial cancer,
Editorial Board
and possibly ovarian cancer. So, women may be able to target certain interventions for
Dr. Myint Lwin
reducing risk earlier in life if they have this information about when they are likely to go
Dr. Shwe Baw
through menopause.
Dr. Zay Ya Aye A valid prediction of the time to menopause is still a challenge for a practising
Dr. Tin Moe Phyu physician. Ovarian aging is dictated by decreasing quantity and quality of the resting follicles
Dr. Khin Than Htay and depletion in the oocyte stock, after which menopause occurs. Because it is not feasible
Dr. Thidar Oo to directly assess the oocyte or follicle pool, endocrinologic and sonographic markers are
used as an indirect measure. A woman’s fertility ends ten years prior to the final menstrual
Dr. Nyein Moe Thaw
period (FMP) and can even occur around the age of thirty. With regard to family planning
Dr. Hnin Thuzar Aung
and a career, it is extremely valuable for women to know the expected length of their fertility.
Contact Us This knowledge will enable women who are predicted to become infertile at an early age to
No-60, G-1, choose the option of having their eggs frozen. This means that they will still be able to have
New Parami Road, children if it turns out that they can no longer get pregnant spontaneously.
Mayangone Tsp,
Prediction of age at menopause can be enhanced by using markers of ovarian reserve;
Yangon, Myanmar.
estradiol, follicular stimulating hormone (FSH), inhibin , and antimüllerian hormone (AMH).
Tel : 651674, 660083,
While one cannot use a single test to determine time to FMP, the menstrual cycle pattern and
657228 to 657232
hormonal characteristics can be used to generate rough estimates for counseling patients.
info@paramihospital.
The reproductive stage is generally characterized by regular menstrual cycles, early
Free Distribution follicular phase FSH levels less than 10 mIU/mL, and AMH levels greater than 0.3 ng/mL.
The contents of the The early menopausal transition begins approximately 7 to 8 years prior to the FMP. FSH
newsletter are not to be values are generally greater than 10 mIU/mL, and AMH levels are less than 0.4 ng/mL in
reproduced in any form this group of women.1,2 The late menopausal transition begins approximately 3 to 4 years
without prior written prior to the FMP. Occurrence of the late menopausal transition stage is confirmed when
approval of the
early follicular phase estradiol levels are greater than 100 pg/mL or FSH values are greater
editorial board.
(To Page - 2 _____)
>

2. Issue - 5, December 2011 Page - 2 Parami Hospital - Yangon, Newsletter
Continued from Predicting Age At Menopause (Page - 1) Picture Quiz
Dr. Tin Moe Phyu
than 30 to 40 mIU/mL.1,3 AMH values are generally less M.B.,B.S, MMedSc ( Paediatrics ), MRCPCH (UK),
4 Assistant Lecturer, Department of Paediatrics,
than 0.1 ng/mL (or below assay sensitivity). While the
term Menopause appears easy to define as “12 months of Yangon Children Hospital, University of Medicine ( 1 ) Yangon
amenorrhoea,” differentiating women in the late menopausal
transition from those in early postmenopause can be difficult
A n eight years old boy, body weight 21 kg,
came to Parami Hospital-Yangon OPD with the complaint
within the first 12 months following the FMP.
of gradual increase in weakness of lower limbs since 3
Among these various markers, serum AMH has years ago. He also had history of frequently falls during
several unique characteristics that emphasize its robustness playing. He was previously well and there was no history
as a biologic marker of ovarian aging. AMH is secreted of hospitalization. Birth history (Including both antenatal
exclusively in ovarian follicles and is independent of the and natal history) was uneventful.
menstrual cycle; its level remains almost constant from one There was no similar problem among family
cycle to another. 5 AMH seems to regulate the early follicular members . His developmental milestones are normal. He
development,6 and its serum concentration decreases with started to walk at about 1 year and 3 months. He is currently
attending 4th standard and he is doing well in school lessons
advancing age before changes in other markers such as
and examinations. Immunization history was said to be
follicular-stimulating hormone and inhibin B become
complete.
apparent.7,8
On examination, currently he is well, alert and
References
f happy. He does not have any dysmorphic feature. However,
1. Burger HG, Dudley EC, Hopper JL, et al. The endocrinology of the
his legs are big compared to his upper limbs. The following
menopausal transition: a crosssectional study of a population-based sample.
pictures showed his funny big legs and his activities in trying
J Clin Endocrinol Metab. 1995;80 (12):3537-3545.
2. Gracia CR, Sammel MD, Freeman EW, et al. Defining menopause status: to stand up from lying position.
creation of a new definition to identify the early changes of the menopausal
transition. Menopause. 2005;12(2):128-135.
3. Santoro N, Brockwell S, Johnston J, et al. Helping midlife women predict
the onset of the final menses: SWAN, the Study of Women’s Health Across
the Nation. Menopause. 2007;14(3 pt 1):415-424.
4. Sowers MR, Eyvazzadeh AD, McConnell D, et al. Anti-mullerian hormone
and inhibin B in the definition of ovarian aging and the menopause transition.
J Clin Endocrinol Metab. 2008;93(9):3478- 3483.
5. Hehenkamp WJ, Looman CW, Themmen AP, de Jong FH, Te Velde ER,
Broekmans FJ. Antimüllerian hormone levels in the spontaneous menstrual
cycle do not show substantial fluctuation. J Clin Endocrinol Metab
2006;91:4057–4063.
6. Durlinger AL, Visser JA, Themmen AP. Regulation of ovarian function: the
role of antimüllerian hormone. Reproduction 2002; 124:601–609.
7. Van Rooij IA, Broekmans FJ, Scheffer GJ, et al. Serum antimüllerian hormone
levels best reflect the reproductive decline with age in normal women with
proven fertility: a longitudinal study. Fertil Steril 2005;83:979–987.
l
8. de Vet A, Laven JS, de Jong FH, Themmen AP, Fauser BC. Antimüllerian
hormone serum levels: a putative marker for ovarian aging. Fertil Steril
2002;77:357–362. (To Page - 3 _____)
>

3. Issue - 5, December 2011 Page - 3 Parami Hospital - Yangon, Newsletter
Continued from Picture Quiz Leisure Reading
(Page -2)
Control of You r
Your
Respiratory system, cardiovas- Heart
cular system and locomotor system
examinations are normal. His A wise and understanding
heart does not repay a hurt with a hurt.
neurological examination is normal
In doing so, the heart is diminished.
apart from slight decrease in tone of
Fissures form. Love leaks out. Every
both lower limbs and difficulty to stand
pain given in return for one received,
up from sitting and lying position.
changes the contents of the heart. It
All laboratory investigations is no longer defined by love, wisdom
( CP, U&E, Calcium ) are within normal and understanding. It is redefined by
range. However, serum creatine kinase the bearers of hurt and hate, pain and
( CK ) is 15632 IU/L ( normal <160 prejudice, meanness and madness,
IU/L ). Chest X-ray and ECG are sorrow and sadness. You give away
normal. control of your very own heart.
The despair of being hurt is
healed by overcoming it, not clinging
Q
Question
to the hurt and inflicting more of it on
1. What is the abnormality of his the world. When darkness is added to
legs? darkness, no one can see, no one can
2. What is the important physical love. Everyone loses.
sign shown in the photograph ? Love is not always warm and
fuzzy. Sometimes it’s the integrity we
Answers To Page ( 4 )
hold on to when we’re tempted to strike
back. Sometimes it’s the honour that
keeps us from exchanging the valuable
contents of our heart for the harsh
satisfaction of lashing back.
No, the way of love is not
always easy, but when night falls, dawn
is assured. The integrity and honour of
a wise and understanding heart, rises
with the sun of a new day.
( Ref : Morning Reading Classics )

4. Issue - 5, December 2011 Page - 4 Parami Hospital - Yangon, Newsletter
.... to our Beloved Customers …. Picture Quiz Answers
Answer
If special healthcare
1. Calves pseudohypertrophy
Is what you desire,
2. Gower sign
Ready to help you —
3. Duchenne muscular dystrophy ( D/Dx Becker
Is our team '' Parami! " .
muscular dystrophy).
Should consultation by appointment,
Duchenne muscular dystrophy is the most common
Is what you seek, hereditary neuromuscular disease . Its characteristic clinical
Just give us a call features are progressive weakness, intellectual impairment,
And express your needs —
d hypertrophy of the calves, and proliferation of connective
Your choice of doctors,
r tissue in muscle. The incidence is 1 : 3,600 liveborn infant
Your choice of time ………. boys. This disease is inherited as an X-linked recessive trait.
The abnormal gene is at the Xp21 locus. Becker muscular
to receive our healthcare :
dystrophy is the same fundamental disease as Duchenne
well-specialized and highly standardized!
dystrophy, with a genetic defect at the same locus, but
For our most valued customers, clinically it follows a milder and more protracted course.
Our team “Parami” The serum CK level is consistently greatly elevated,
Will create an atmosphere even in presymptomatic stages, including at birth.
Always warm and friendly Cardiomyopathy and respiratory muscle weakness are
And fulfill your needs readily complications of disease progress. Echocardiography,
electrocardiography (ECG), and radiography of the
To make you feel at ease
chest are essential and should be repeated periodically.
And clear you of your disease
Electromyography (EMG) shows characteristic myopathic
in next to no time, indeed!
features. Blood polymerase chain reaction (PCR) for the
dystrophic gene mutation and muscle biopsy are diagnostic
Dr. Khin Than Htay tests.
There is no specific treatment. Multidisplinary
team approach including physiology is an essential part
of management. Oral prednisolone therapy may have
improvement in short term and long term prognosis.
Because of progressive muscle weakness, some
patients become wheelchair users around 7 years of age.
Death occurs usually at about 18–20 years of age. The causes
of death are respiratory failure in sleep, intractable heart
failure, pneumonia, or occasionally aspiration and airway
obstruction.
Oralon Mouth Rinse Minolac 10 mg Tablet
(Chlorhexidine Gluconate Solution 1.0%) (Ketorolac Tromethamine)
Wincetam Syrup, 400 mg Capsule and 800 mg Caplet Lefora 10 mg and 20 mg Tablet
(Piracetam) (Leflunomide)
This Newsletter is supported by Network Marketing LTD.