The document discusses menopause in Indian women. It notes that the average age of menopause in India is 46.2 years, younger than Western countries. Menopause causes various symptoms like hot flashes, mood swings, and sexual dysfunction. Premature menopause before age 40 increases risks of cardiovascular disease, diabetes, and osteoporosis due to the loss of estrogen's protective effects. Management includes lifestyle changes, herbal remedies, and potentially hormone therapy with caution due to risks. The menopausal population in India is projected to reach over 100 million by 2026. Quality of life is impacted by loss of estrogen during menopause.

1. The core of Indian menopause:
Challenges&Prospective
Dr Sharda Jain
Secretary general
Delhi Gynaecologist forum

2. The transition from reproductive to
nonreproductive phase
The word "menopause" literally means
the "end of monthly cycles" from the
Greek word pausis (cessation) & the root
men-(month)
• Menopause is an unavoidable Universal & Natural change
that every woman will experience.

3. 3

4. Transitioning: Menopause and
its Life-long Sequela
4

5. PERIMENOPAUSE
• HARMONE BEGIN TO CHANGE--- AT 40 YRS
• HOT FLUSHES
8/10

6. Perimenopause& Menopausal symptoms
• CHANGES IN PERIODS
• MOOD SWINGS—(HARMONE SENSITIVE)
• CHANGE IN SLEEP( 85 % )
• NIGHT SWEATS
• SEXUAL DYSFUNCTION.( 30 % ) .VAGINAL DRYNESS
• WEIGHT GAIN ( 80 % ) bcz RULES OF BODY
CHANGE, METABOLISM SLOWS DOWN
• DEPRESSION ,ANXIETY ( 70 % )..Sp in
women with H/O PMS, POSTPARTUM BLUES

7. Menopausal Distress (70 %)
• Menopause distress is defined as
An emotional response
characterised by extreme apprehension,
discomfort or dejection ,due to perceived
inability in coping with the biomedical &
psychological challenges & demands of
living with MENOPAUSE
Kalra B, Kalra S ,Dhingra A ,Bhattacharya S

8. *HAIR
*ACNE
*Aches & pain
*Myalgia, Fatigue
*Hurting Joints
NAVIGATING CHALLENGES &
SYMPTOMS is Great task

9.  Premature menopause : A woman's ovaries stop working
at a very early age, ranging anywhere from the age of
puberty to age 40, and this is known as premature ovarian
failure (POF)—1.5 – 20 %
 Delayed menopause : if the menopause fail to occur even
beyond 55 years it is called delayed
Abnormal menopause
Jadhav A & Bavaskar Y. Int J Community Med Public Health. 2017 Sep;4(9):3088-93

10. 2.1 2.8
5.2
6.7
13.4
0
2
4
6
8
10
12
14
16
30-32 33-34 35-36 37-38 39-40
Age in Years
Premature Menopause (%)
Health & Social Work Volume 42, Number 2 May 2017
20.1% of the women between the 37-40 years age group suffer from
Premature Menopause

11. SEQUELAE OF POI OR
PREMATUREMENOPAUSE
• MATERNITY
• MECHANICAL
• CARDIO METABOLIC
• MOOD
• MICTURITION
• MORTALITY

12. Endocr Rev. The role of estrogens in control of energy balance and glucose
homeostasis.2013; 34 (3): 309-338
Detrimental
Effects of Estrogen
Deficiency
on Metabolism
PrematureMenopause

13. Premature Menopause & Cardiovascular
Disease
If menopause occurs early
CARDIOPROTECTIVE effect of
estrogen is gone & increases
the risk of CVD

14. Menopause & Diabetes—WHIStudy
• PREMATURE MENOPAUSE INCREASES THE RISK OF
*DIABETES
*PREDIABETES
*METABOLIC SYNDROME
• WOMEN WITH LESS THAN 30 YEARS REPRODUCTIVE
LIFESPAN HAD 40 % INCREASE THAN WOMEN WITH
Reproductive lifespan of 36 to 40 years

15. INDIAN SURVEY ON MENOPAUSE

16. Age of menopause
Age at which menopause occurs is genetically
predetermined and not related to age of
menarche or age at last pregnancy, lactation,
use of oral pill, socioeconomic condition, race,
height or weight
Jadhav A & Bavaskar Y. Int J Community Med Public Health. 2017 Sep;4(9):3088-93

17. Social problems
It is a taboo to discuss reproductive health,
Menopause & sexual problems

18. Today
 We are 1.3 billion Life
expectancy 71 years
Unni J. J Midlife Health. 2010 Jan-Jun; 1(1): 43–47
Unni
Menopause : 47.5 years

19. ICMR
2007---2008
49 Years

20. 2.4
6.5
20.3
44.8
0
10
20
30
40
50
30-34 35-39 40-44 45-49
Age in Years
Menopause (%)
Health & Social Work Volume 42, Number 2 May 2017
65.1% of the women between the 40-49 years age group suffer
from Menopause

21. INDIA & Menopausal problem
The rural urban divide (72% rural & 28% urban)
An economic imbalance between the poor,
middle class, affluent and the multicultural,
multiethnic, multireligious composition of the
population makes it difficult to formulate
generalized recommendations
Unni J. J Midlife Health. 2010 Jan-Jun; 1(1): 43–47.

22. Prevalence of Postmenopausal Symptoms, Its
Effect on Quality of Life and Coping in Rural
Couples in Gujarat
Shukla R, Ganjiwale J, and Patel R
Conclusion:
Couples were found to be aware of menopause; however, the
symptoms arising as consequence of it seem to be accepted as
natural age-related changes
This could possibly account for not taking any active coping
strategy measures despite reporting of mild-to-moderate
menopausal symptoms
J Midlife Health. 2018 Jan-Mar; 9(1): 14–20.

23. Menopausal symptoms
Individual variations in India exist just as they do worldwide
Rural & urban menopausal
women
 Urogenital symptoms
 Fatigue and weakness
 Body aches
 Pains
Urban women
 Hot flushes
 Psychological symptoms
 Mood swings
 Sexual dysfunctions
Jadhav A & Bavaskar Y. Int J Community Med Public Health. 2017 Sep;4(9):3088-93

24. J Mid-life Health 2016;7:126-31.
A PAN India Survey was conducted in 21 cities of IMS
across all regions (South, West, East and North)
n=23 Medical practitioners participated with consent
The questionnaire was extensive
Maninder Ahuja
Director Ahuja Hospital and Infertility Centre, Faridabad, Haryana, India

25. Ahuja M. .J Midlife Health. 2016 Jul-Sep;7(3):126-131.
Results:
Average age of menopause of an Indian woman is 46.2 years much less than
their Western counter parts (51 years).
A definite rural and urban division was also seen.
There was a correlation between the age of menopause and social and
economic status, married status, and parity status.

26. 47.3
46.2
45.5
46.1
47.8
East West North South Centre
Mean natural menopause age in differentregions of
India
Avg. age of menopause of an Indian woman is 46.2 yrs
Health & Social Work Volume 42, Number 2 May 2017,
Ahuja M.J Midlife Health. 2016 Jul-Sep;7(3):126-131.
IMS
PREVALENCE

27. Associated risk in Indian Women
OSTEOPENIA & OSTEOPOROSIS RISKS
• 35–40% of women between 40 and 65 years have been detected to
suffer from osteopenia whereas 8-30% suffer from osteoporosis (
small sample studies).
• All women over 65 years have been found to have either
osteopenia or osteoporosis
• This is attributable to low calcium intake in youth and later, lack of
exercise in all ages and paradoxically, to lack of exposure to sunlight
in women living in urban areas
IMS

28. Associated risk in Indian Women
CARDIOVASCULAR DISEASE
• Projected deaths from Cardiovascular
Diseases in 2020 is estimated as 42%
• There is an increased prevalence of
metabolic syndrome/Diabetes ,
hypertension, & central obesity
• India is diabetic capital of the world
today
IMS

29. STROKE
• The annual incidence rate of stroke
is 145.3/100,000 persons with a 30-
day case fatality of 41% found to be
similar among slum and non slum
dwellers
• There is a higher incidence & case
fatality of stroke in women as a
result of fast changing lifestyles,
hypertension, and diabetes
Associated risk inIndian Women
IMS

30. Associated risk in Indian Women
CANCER
• The common cancers in women in India are those of
# Breast (12.1–27.5%),
# Cervix (13.1–35%),
# Ovary (3.5–7.8%),
# Endometrium (0.7–2.2%)
# Oral cancer
• The incidence of different cancers varies with
geographical areas.
IMS

31. Associated chronicproblems
• Sarcopenia from lack of exercise,
• Ophthalmic disease that worsens against a
backdrop of glaucoma and trachomatis,
conjunctivitis
• Oro-dental issues with the national habit of
tobacco and areca nut chewing added to the
problems of periodontitis and receding gums on
osteoporotic jaws after menopause
IMS

32. Management
*Prevention X
*Lifestyle modification is the key
*Counseling
*Treatment

33. Ancient Collective Wisdom - on
Lifestyle changes—
Think it as Positive change
LOOSING WEIGHT , PHYSICALLY ACTIVE ,DEEP BREATHING ,
GIVE UP COFFEE /TEA /SPICY FOOD
HERBS /NATURAL MEDICINE—MAY HELP
MHT IS NO LONGER A ROUTINE MEDICATION Like calcium, mini aspirin

34. CURRENT MANAGEMENT & INDIA
Non-pharmacological
management:
Phytoestrogens
 Soy extract
 Black cohosh extract
 Cynanchum wilfordii,
Phlomis umbrosa and
Angelica gigas
https://www.mayoclinic.org/diseases-conditions/perimenopause/diagnosis-treatment/drc-20354671
Pharmacological
management:
MHT
 Antidepressants

35. MHT & RISKS
Breast Cancer Endometrial Cancer
Coronary Heart
Disease
Osteoporosis
Memory Loss &
Dementia
Venous
Thromboembolic
Disease
Should be used at lowest dose
for shortest time
Recommended for Post-
menopause only; Not for
perimenopause
International Journal of Epidemiology, Volume 30, Issue 3, June 2001, Pages 423–426
WHI LESSIONS

36. WINDOW OF OPPORTUNITY
< 60 YRS
< 10 YRS OF MENOPAUSE

37. MHT
Breast
Cancer
Endometrial
Cancer
Coronary
Heart
Disease
Osteoporosis
Memory
Loss &
Dementia
Venous
Thrombo
embolic
Disease
International Journal of Epidemiology, Volume 30, Issue 3, June 2001, Pages 423–426
Should be used at lowest dose
for shortest time
Recommended for Post-menopause
only; Not for perimenopause

38.  Individualization of MHT, i.e., the dose, type, route, is
according to the need of the individual woman
 Use unopposed estrogen only for women who have
undergone hysterectomy
 Progesterone needs to be added if prescribed for women
with an intact uterus
 The art of prescribing MHT is to use the minimum effective
dose judiciously on indication only ,that too after
appropriate counseling
Wayahead on MHT….

39. important issues before deciding on HT
• A specific indication for starting HT must be
present, and it must be documented
• Symptoms which definitely require HT are
vasomotor symptoms and symptoms as a
result of urogenital atrophy
• The main rule for giving HT is to use the
“lowest possible dose for shortest possible
duration”
Take Home Messageson MHT….

40. Contd….
• For prevention and treatment of
Osteoporosis, other modalities
(bisphosphonates) should be preferred over
estrogens
• Assessment of Risk Factors prior to starting
HT is an essential prerequisite
• LIFESTYLE MODIFICATION is an integral
component of managing postmenopausal
women
Wayahead….

41. Non-Pharmacological Management:
Limitations
 Soy isoflavones & Black Cohosh had no statistically
significant effects on Menopausal symptoms
 Soy iso flavones…no binding with estrogens
receptors
 Additionally, Black Cohosh products carry a warning
statement due to risk of liver damage

43. ERr731: Highlights
ERr 731® is a Non-hormonal Therapy to alleviate pre & post
menopausal symptoms
Well researched & studied molecule in the field of menopause
11 21
02 04
Clinical
publications
Year follow-up
PMS
Year duration clinical trial (rare
for phytopharmaceuticals)
Published Pre-clinical &
invitro studies
Chang—ERr 731 Postmarketing Surveillance Data, Integrative Medicine • Vol. 15, No. 3 • June 2016 34

44. Regulatory Approvals/Availability
(its given a ‘New Dietary Ingredient’ notification by
USFDA) Brand Name Estrovera; Marketed by Metagenics.
This brand is available via prescription route
Chang—ERr 731 Postmarketing Surveillance Data,Integrative Medicine • Vol. 15, No. 3 • June 2016 34
Germany
since
1993
USA
2008
South
Africa
2011
Canada
2012
ERr731: Special extract isolated from the roots of rhapontic
rhubarb (Rheum rhaponticum); also known as Siberian rhubarb

45. Safety & Tolerability: Across 2 Years of Use
• Liver Parameters
• Hematology, coagulation, lipid, inflammatory,
and additional parameters
• Male and Female Sex Hormones
• Sex HormoneYBinding Globulin (SHBG) in serum
• Body weight and BMI
• Vital parameters: blood pressure and pulse rate
• Vaginal smear
• PAP smear
• Endometrial thickness
• Endometrial biopsy
No significant changes observed across different parameters:
Hasper I et al. Menopause. 2009 Jan-Feb;16(1):117-31

46. • Universal Event – Why treat ?
• Protective role of - MHT
estrogen matters
• Proven Anti oxidant √
for well being of a women
at menopause like calcium tab.
“I am feeling so much
more

48. 5 POINTS BEFORE- PRESCRIBING MHT
• AGE < 60 YRS
• MENOPAUSE NOT > 5 YRS AGO
• R/O CONTRAINDICATION OF MHT
• R/O C V RISK
• R/O BREAST CANCER RISK
• UTERUS PRESENT OR NOT

49. • Projected figures in 2026 have estimated
the population in India will be
1.4 billion,
The menopausal population 103 million
over 60 years : 173 million
Unni J. J Midlife Health. 2010 Jan-Jun; 1(1): 43–47.

50. QOL –Does Matter !!
• Protective Role of Estrogen on Women can,t be
forgotten.
• Its loss matters !