MENOPAUSE

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MENOPAUSE

• 1.The cessation of menses is menopause.The
  climacteric and perimcnopausal are the periods of
  waning ovarian function.

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90
2.Female life expectancy
90
80
80
70
70
60
60
50
50
Age of menopause
40
40
1850
1900
1950
2000
Age of menopause and female life expectancy.
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3.SYMPTOMS AND SIGNS OF OVARIAN FAILURE

• (1) Menstrual Cycle Alterations
• Soon after an adolescentwoman has her first
  menstrual cycle, regular, predictable menstrual
  cycles are established that continue until
  approximately 40 years of age. Around 40 years,
  the number of ovarian follicles becomes
  substantially depleted and subtle changes occur
  in the frequency and length of menstrual cycles.

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• A woman may note shortening or lengthening of her
  cycles. The luteal phase of the cycle remains
  constant at 13 to 14 days, whereas the variation
  of cycle length is related to a change in the
  follicular phase. Women in their 20s and 30s
  ovulate 13 to 14 times per year. Several years in
  advance of menopause, the frequency of ovulation
  decreases to 11 to 12times per year and, with
  advancing reproductive age, may decrease to 3 to
  4 times per year.

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• With the change in reproductive cycle length and
  frequency ,there are concomitant changes in the
  plasma concentration of FSH and LH . More FSH is
  required to stimulate follicular maturation
  .Beginning in the late 30s and early 40s, the
  concentration of FSH begins to increase . This is
  the frist chemical evidence of ovarain failure.

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• The 5- to 10-year period before menopause is
  termed perimvenopause.During the perimenopausal
  years, women begin to experience symptoms and
  signs of estrogen deficiency as reproductive
  function becomes increasingly inefficient.
  Realative change in FSH as a function of life are
  presented in Table 38.1.

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(2)Hot Flushes and Vasomotor Instability
Coincident with the change in reproductive cycle
length and frequency, the hot flush is the first
physical manifestation of ovarian failure.
Occasional hot flushes begin several years before
actual menopause. The hot flush is the most
common symptom of impending ovarian failure. More
than 95 of perimenopausal women experience hot
flushes.
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(3)Sleep Disturbances

• Ovarian failure with consequent declining
  estradiol induces a change in a womans sleep
  cycle so that restful sleep becomes difficult and
  for some, impossible. The latent phase of
  sleep(I.e,the time required to fall asleep) is
  lengthened the actual period of sleep is
  shortened.

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• Therefore,perimenopausal and postmenopausal women
  complain of having difficulty falling asleep and
  of waking up soon after going to sleep. This is
  one of the most disabling and least appreciated
  adverse effects of menopause. The sleep cycle is
  restored to the premenopausal state by the
  administration of replacement estrogens.

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(4)Vaginal Dryness and Genital Tract Atrophy

• The vaginal mucosa, cervix, endocervix,
  endometrium, myometrium, and uroepithelium are
  estrogen-dependent tissues. With decreasing
  estrogen production, these tissues become
  atrophic, resulting in various symptoms. The
  vaginal epithelium becomes thin and cervical
  secretions diminish.

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• Women experience vaginal dryness while attempting
  or having sexual intercourse, leading to
  diminished sexual enjoyment and dyspareunia.
  Atrophic vaginitis also may present with itching
  and burning. The thinned epithelium is also more
  susceptible to becoming infected by local flora.
• Therapy with replacement estrogens restores the
  integrity of the vaginal epithelium,relieving
  symptoms of vaginal dryness and
  dyspareunia.Sexual pleasure is often restored.

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(5)Mood Changes

• Perimenopausal and postmenopausal women often
  complain of volatility of affect. Some women
  experience depression, apathy, and crying
  spells. These may be caused directly by estrogen
  deficiency, by estrogen-deficiency associated
  sleep disturbance, or by both. Not only are these
  emotional symptoms disturbing to a woman but also
  her inability to control these feeling is equally
  of concern.

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• The physician should provide counseling and
  emotional support as well as medical therapy. The
  role of estrogons in central nervous system
  function is unknown. However, it is well
  established that sex steroid hormone receptors
  are present in the central nervous system.
  Estrogen replacement in perimenopausal and
  postmenopausal women often diminishes these mood
  swings.

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(6)Skin,Hair,and Nail Changes

• Estrogen influences skin thickness. With
  declining estrogen production, skin tends to
  become thin, less elastic, and eventually more
  susceptible to abrasion and trauma. Estrogen
  replacement helps restore the thickness and
  elasticity of skin. Estrogen therapy also helps
  to slow the formation of wrinkles.

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(7)Osteoporosis

• Bone demineralization is a natural consequence of
  aging. Diminishing bone density occurs in both
  men and women. However, the onset of bone
  demineralization occurs 15 to 20 years earlier in
  women than in men by virtue of acceleration after
  ovarian function ceases. Bone demineralization
  not only occurs with natural menopause but also
  has been reported in association with decreased
  estrogen production in certain groups of young
  women.

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(8)Cardiovascular Lipid Changes

• With approaching ovarian failure, changes occur
  in the cardiovascular lipid profile. Total
  cholesterol increases, high-density lipoprotein
  (HDL) cholesterol decreases and low-density
  lipoprotein (LDL) cholesterol increases.

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4.Management of Menopause

• All of the signs and symptoms, and adverse
  effects, of menopause result from declining
  estradiol-17B production by the ovarian
  follicles. Exogenous estrogen adminstration to
  the perimenopausal and postmenopausal woman
  obviates most of these changes. Estradiol-17B and
  its metabolic byproducts, estrone and estriol,
  are used for replacement.

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5.Cautions in Estrogen Replacement

• Patients with unexplained abnormal vaginal
  bleeding should not receive estrogen-replacement
  therapy untile the cause of the bleeding is
  ascertained and treated appropriately. In
  addition, patients with active liver disease or
  chronically impaired liver function should
  generally not receive estrogen replacement.

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(1)Carcinoma of the Breast

• Carcinoma of the breast has been a
  contraindication to estrogen replacement. In
  light of the benefits of estrogen-replacement
  therapy in regard to osteoporosis and
  cardiovascular disease, selected patients may not
  be considered inappropriate for
  estrogen-replacement therapy.

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(2)Thromboembolic disease

• Oral estrogens stimulate the production of
  clotting factors,but estradiol administered by
  the transdermal route has no effect on clotting.
  Therefore, women with a history of thromboembolic
  disease can safely receive transdermal estradiol
  therapy.

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(3)Endometrial Carcinoma

• There is litter evidence to suggest that
  estrogens should be withheld from women with a
  history of carcinoma of the endometrium if the
  tumor was limited to the endometrium and
  myometrium. Women with metastatic endometrial
  carcinoma should not receive exogenous estrogens.