MenopauseMenopause By By

Dr. Khattab Omar Dr. Khattab Omar

Prof. & Head of Obstetrics and Prof. & Head of Obstetrics and Gynaecology DepartmentGynaecology Department

Faculty of Medicine, Al-Azhar University, Faculty of Medicine, Al-Azhar University, DamiettaDamietta

Menopause is permanent cessation of Menopause is permanent cessation of menstruation due to failure of ovarian menstruation due to failure of ovarian

function. function.

““PermanentPermanent”” means cessation of means cessation of menstruation for at least 12 months. menstruation for at least 12 months.

Menopause is a manifestation Menopause is a manifestation ofof climacteric. 'Climacteric' is a wider climacteric. 'Climacteric' is a wider

term of events leading up to and term of events leading up to and following the menopause, the pre- following the menopause, the pre-

peri- and post-menopause. peri- and post-menopause.

Definition

Life expectancy of women is increasing Life expectancy of women is increasing and about 1/3 of womenand about 1/3 of women’’s life is spent s life is spent

oestrogen deficient. oestrogen deficient.

The mean age of menopause is about 50 The mean age of menopause is about 50 (48-53). (48-53).

95% of women will be menopausal by the 95% of women will be menopausal by the age of 55. age of 55.

About 25% of women experience About 25% of women experience menopause before the age of 45. menopause before the age of 45.

In most cases menstruation gradually In most cases menstruation gradually decreases in amount & frequency. decreases in amount & frequency.

In about 10% menstruation stops In about 10% menstruation stops suddenly. suddenly.

Physiology of the menopause

TypesTypes

1- Natural. 1- Natural.

2- Premature: Before the age of 40. 2- Premature: Before the age of 40.

3- Delayed: After the age of 55. 3- Delayed: After the age of 55.

4- Artificial: surgical or radiation. 4- Artificial: surgical or radiation.

Phases Phases 1- 1- Partial ovarian failure: Partial ovarian failure: Ovulatory & Ovulatory &

corpus luteum failure starts 10-15 y before corpus luteum failure starts 10-15 y before the menopause.the menopause.

2- 2- Compensated ovarian failure: Compensated ovarian failure: HypothalamicHypothalamic––pituitary hyperactivity starts pituitary hyperactivity starts 5-10 y before the menopause. 5-10 y before the menopause.

3- 3- Follicular failureFollicular failure starts at the menopause. starts at the menopause.

Diagnosis Diagnosis Diagnosis is almost confirmed if FSH 30U/ Diagnosis is almost confirmed if FSH 30U/ L level is demonstrated in 2 occasions 2 L level is demonstrated in 2 occasions 2 w apart to avoid the mid-cycle surge. w apart to avoid the mid-cycle surge. Cessation of menstruation for 1 y >50; Cessation of menstruation for 1 y >50; Cessation of menstruation for 2 y <50. Cessation of menstruation for 2 y <50. Cessation of menstruation for 1 y <50 if Cessation of menstruation for 1 y <50 if associated with high levels of FSH.associated with high levels of FSH.In general, hormonal assay is not In general, hormonal assay is not necessary as levels fluctuate in the peri-necessary as levels fluctuate in the peri-menopausal period & they may not cor-menopausal period & they may not cor-relate well with the clinical picture. relate well with the clinical picture. Diagnosis is best made clinically. Diagnosis is best made clinically. Hormonal assay is of value in cases of Hormonal assay is of value in cases of premature menopause & in hysterectomi-premature menopause & in hysterectomi-zed women. zed women.

Events Events 1- The response of Gn to GnRH increases! 1- The response of Gn to GnRH increases! 2- There is increase in the amplitude, but not the 2- There is increase in the amplitude, but not the

frequency of Gn pulses. The amount is similar to frequency of Gn pulses. The amount is similar to that of the mid-cycle surge. Rise in FSH levels that of the mid-cycle surge. Rise in FSH levels precedes the rise in LH levels. precedes the rise in LH levels. While LH raises by While LH raises by 3-x, FSH raises by 13-x. After 5-10 y, levels of 3-x, FSH raises by 13-x. After 5-10 y, levels of both Gn begin to decline. both Gn begin to decline.

3- Ovarian function commonly fades, recovers & 3- Ovarian function commonly fades, recovers & fades again several times. fades again several times.

Perimenopause and the early menopause are Perimenopause and the early menopause are characterized by hyper-estrogenism & decreased characterized by hyper-estrogenism & decreased progesterone production. This may be progesterone production. This may be manifested by menorrhagia, fibroidmanifested by menorrhagia, fibroid……

Androstenedione decreases markedly. Androstenedione decreases markedly. Testosterone appears to be the major product of Testosterone appears to be the major product of

the postmenopausal ovary. the postmenopausal ovary.

Health problems: Symptoms may occur some years before menop.

The incidence of ischemic heart disease, osteoporosis, loss of collagen & psychological dis orders increases dramatically after menopause.

Experience of menopause differs between women; it is affected by the following factors:

Cultural factors: Attitude to menopause, ageing & to loss of fertility. Social factors: Career peak, growing children, ageing parents. Emotional and physical well-being: Lifestyle, existing medical conditions. Hormonal factors: Diet, degree of oestrogen deficiency.

Health problems could be classified as:

Short-term effects as vasomotor instability, urogenital atrophy & psychological sympt.

and

Long-term effects as arterial diseases, osteoporosis & recognition problems.

Genitourinary atrophy begins few years after menopause. Labia majora are flattened, & hence, labia minora become more evident. The vagina loses its supports & becomes tent-shaped, smooth (due to loss of rugae) & thin. The pH becomes neutral or even alkaline. These changes predispose to senile & recurrent vaginitis The portio vaginalis may flash with the vault. Utero-cervical infantile proportion may return. Senile endometritis may occur. Weakness of cervical ligaments predisposes to prolapse. Vulvovaginal changes cause superficial dyspareun Atrophy of bladder & urethral mucosa → frequen, urgency, stress incontinence & recurrent UTI.

Psychological complaints (as headache fatigue, forgetfulness, lack of concent, poor memory, insomnia, irritability & depression) affect 25-50% of women.

Peri-menopausal depression is at its worst in the 2-3 y before the periods stop. It is related to premenstrual depression as it becomes worse with age and with falling estrogen levels.

Vasomotor symptoms:

-The aura & subjective sensation of hotness precedes a mean increase in skin temp by 2-3C. -Hot flushes occur in 80% of women, & may last for 5 years in 25% of women. Symptoms are severe enough in 25% of patients to warrant ttt. -The menopausal woman experiences a sensation of heat in the upper 1/2 of her body (may spread all over the body) associated with vasodilatation, excessive sweating, palpitation & tachycardia for few minutes. There may be insomnia & headache -Hot flushes come in attacks that may be very frequent (2-4/h) or infrequent (1-2/day). -They are attributed to autonomic instability.

Arterial disease is the main cause of death. HRT reduces the risk by 40-50%.

Liability to osteoporosis. The female : male ratio of hip fractures after the age of 51 is 3:1.

Mild hirsutism.

Differential diagnosis Differential diagnosis Pregnancy. Now, pregnancy forms a little conflict be-cause of the early diagnosis by immunoassay methods.PCOS. Prolactinoma, particularly in young women. Thyrotoxicosis.

Treatment Treatment For max benefits, preventative health For max benefits, preventative health

measures should begin some 15 y before measures should begin some 15 y before menopause. menopause.

Oestrogen does not improve depression in Oestrogen does not improve depression in postmenopausal women. postmenopausal women.

For menopausal symptoms ERT is the For menopausal symptoms ERT is the treatment of choice. treatment of choice.

Treatment Treatment Alternatives include progestins & clonidine. Alternatives include progestins & clonidine.

Medroxy progesterone acetate (MPA) given Medroxy progesterone acetate (MPA) given as 10-20mg/day orally or 50-150 mg/3 as 10-20mg/day orally or 50-150 mg/3 months has been shown to be >70% months has been shown to be >70% effective in relieving hot flushes.effective in relieving hot flushes.

Clonidine 0.1-0.2 mg twice daily orally Clonidine 0.1-0.2 mg twice daily orally (Catapres) or 0.1 mg trans-dermally (Catapres) or 0.1 mg trans-dermally (Catapres-TTS-1) is 30% effective. (Catapres-TTS-1) is 30% effective.

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