Menopause

1
Menopause

• Dr. Ahmed Al Harbi
• Obstetrics/Gynecology
• Consultant

2

• An event in the whole range of anatomical,
  physiological and psychological events that
  contribute to the climacteric.
• The change , this is the transition from
  fertility to infertility and occupies that decade
  from 45-55 years when a woman passes from her
  reproductive in to her post-reproductive years.

3
(No Transcript)
4
Pathophysiology
5

• Common causes
• Premature Ovarian Failure
• Secondary Amenorrhea due to a failure of the
  ovaries to generate sufficient oestrogen may
  occur at any age and if below the of 45 years, is
  described as premature.
• Such patients exhibit low plasma oestradiol (E2)
  (usually lt150 pmol/L), high levels of
  follicle-stimulating hormone (FSH) and
  luteinizing hormone (LH) and a symptom pattern
  suggestive of oestrogen deficiency.

6

• The cessation of cyclic bleeding takes many
  forms.
• The mentrual cycle may stop abruptly or may cause
  after a prolonged stage of oligomenorrhea.
• Even after a substantial period of amenorrhea, a
  further cycle may occur which, if more than 6
  months from the last, will be correctly classed
  as postmenopausal bleeding and will therefore
  require investigation.

7
(No Transcript)
8

• Other Causes Of Menopause
• Therapeutically, the use of gonadotrophin-releasi
  ng hormone agonist (GnRH analogues) in the
  treatment of endometriosis or in the preoperative
  containment of leiomyomata (fibroids) results in
  virtually complete suppression of ovarian steroid
  output.
• The management of malignant disease in young
  women may provoke menopause in two ways.

9

• In premenopausal women with breast cancer
  radiation, menopause may still be used to
  suppress oestrogen output.
• Although this management may be superseded by
  pure oestrogen antagonists.
• The use of chemotherapeutic agents in conditions
  such as breast cancer or lymphoma may suppress
  and indeed arrest ovarian cyclic activity.

10
Symptoms of Menopause
11

• The physical symptoms of menopausal include the
  classical vasomotor symptoms of hot flushing and
  night sweats.
• Hot flushes are not contemporaneous with LH
  pulses and are essentially a vascular response to
  a central disturbance of the thermoregulatory
  centre in the hypothalamus.

12

• Physical
• Tiredness
• Hot flushes
• Night sweats
• Insomnia
• Vaginal dryness
• Urinary frequency

• Psychological
• Mood swings
• Anxiety
• Loss of short-term memory
• Loss of self-confidence
• Depression

13

• Vaginal dryness is a vitally important symptom of
  menopause.
• Dyspareunia
• The vaginal skin is dependent on oestrogen for
  the depth and lubrication of its squamous
  epithelium.
• With loss of plasma oestrogen, the skin becomes
  thin and poorly moisturized.

14

• Urinary Symptoms
• Menopausal women often complain of frequency,
  dysuria and urgency.
• Symptoms which suggest urinary tract infection
  (UTI) but which are not associated with a
  positive urine culture.
• Skeletal System
• The skeleton consists of 203 bones but only 2
  types of bone.
• Some 80 of the skeleton is compact bone, which
  is found, for example, in the shafts of the long
  bones.
• It is relativity insensitive to oestrogen.

15

• The remaining 20 of the bone is, in contrast,
  highly oestrogen sensitive and is named after its
  trabecular structure.
• It is found at such sites as the vertebrae, the
  distal radius, the femoral neck and the
  calcaneus.
• The relationship between oestrogen and trabecular
  bone is complex and intimate.
• Oestrogen acts as a physiological restraint on
  bone turnover and to hold the balance between
  bone resorption and bone formation.

16

• The loss of circulating oestrogen after
  menopause, a decoupling takes place that is
  characterized the background of a general
  increase in the activation of new bone turnover
  sites on bone surfaces.
• Trabecular bone is shock-absorbing bone.
• It is central function is to absorb, dissipate
  and dispense incident kinetic energy.
• This it accomplishes by means of the vast network
  of interconnecting trabeculae or struts that
  comprise its internal architecture.

17

• When this network is degraded by the progressive
  loss of trabecular number, thickness and
  interconnection, the bone becomes more liable to
  fracture after minimal or moderate trauma.
• The net result is that after menopause there is
  a progressive rise in the incidence of fracture
  of the trabecular sites.
• Traumatic fracture affects the distal radius and
  femoral neck, whereas non-traumatic fracture
  affects the vertebrae.

18
(No Transcript)
19
(No Transcript)
20
(No Transcript)
21

• Cardiovascular System
• Total Cholesterol ?
• High - density lipoprotein (HDL) Cholesterol ?
• Low - density lipoprotein (LDL) Cholesterol ?
• Triglycerides ?
• Loss of oestrogen can thus result in a promotion
  of both atherogenesis and vasoconstriction.

22
Hormone Replacement Therapy
23

• Strong and opposing views on HRT are held by
  professional and lay groups.
• Extending from the view that the menopause is
  natural and physiological, thus requires no
  intervention.
• The view that it is a true hormonal deficiency
  state and thus should be treated with replacement
  therapy for life.

24

• Consultation
• A full history is taken, with concentration on
  those symptoms that are, or are likely to be, due
  to oestrogen deficiency.
• The family history should include any history
  of
• Cardiovascular disease
• Particularly angina pectoris
• Myocardial infarction and stroke
• Skeletal disease
• Particular osteoporosis manifested in relatives
  through height loss and low-trauma fracture to
  wrist

25

• Hip and other sites.
• Alzheimers disease or other neurogenerative
  disease in the family is of relevance.
• The history of any gastrointestinal or liver
  disease that might interfere with the normal
  pharmacodynamics of oestrogen therapy must also
  be sought.
• A history of benign or malignant breast disease
  must be sought.
• Histological reports on any breast biopsy
  material should be scrutinized to determine
  whether or not cellular atypia was present, as
  this may affect future management.

26

• The patients mammographic record should be
  ascertained and she should be encouraged to
  accept all triennial recalls from age 50 to 64 in
  the National Breast Screening Campaign.
• Any heavy or persistently irregular, bleeding
  should be further investigated by pelvic
  ultrasonic examination, proceesing, if requiredto
  hysterpscopy and endometrial biopsy.

27

• Examination
• Breast examination
• Pelvic examination
• The blood pressure should be checked in
  semi-recumbent position.
• Modes of treatment
• Oestrogen and the progestogens may be delivered
  by many routes.
• Most common in the UK is the oral route.

28

• Oestradiol is largely converted in the liver
  parenchyma into oestrone, which is then released
  via the hepatic veins.
• This results in an E2oesterone ration of 12,
  which is the reverse of the normal premenopausal
  position.
• The oral oestrogens common use are
• Oestradiol Valerate 1 mg or 2 mg
• Conjugated Equine Oestrogen 0.625 mg or 1.25 mg
• Oesterone 1.25 mg

29

• Transdermal Oestrogen
• The advent of transdermal oestrogen, first by
  reservoir and now by matrix patches.
• The oestrogen, which, being lipid soluble, may
  transit across the epidermis, passes directly
  into the systemic circulation, thus avoiding the
  hepatic first pass which is an obligatory feature
  with the oral route.
• This maintains the E2oesterone ration of 21 and
  is thus highly physiological.
• With therapeutic plasma levels of E2 being
  achieved within 4 hours.

30

• Pathches are available in varying strengths,
  usually delivering 28, 50, 75 or 100 µg of E2 per
  day, and can be tailored to the individual
  patients needs.
• Seven day patches are now also available.
• Subcutaneous Implamentation
• This mode of delivery is restricted in the UK to
  patients who have undergone hysterectomy with or
  without oophorectomy.
• The procedure involved the positioning of a
  pellet of E2 in the subcutaneous tissue, usually
  of the lower abdomen, under sterile conditions
  and local anaesthetic.

31

• Implants are available at 25, 50 and 100 mg
  strengths and are usually reviewed at intervals
  of 6 months.
• Progestogens
• Early attempts to give oestrogen alone resulted
  in a significant degree of endometrial
  hyperplasia and neoplasia, and it was realized,
  again, the physiology of the premenopause would
  have to be mimicked.
• To this end, studies showed that the
  administration of a progesterone for 12 days per
  month resulted in the secretory transformation of
  the endometrium and in satisfactory shedding.

32

• Tibolone
• This is a synthetic steroid that exhibits
  oestrogenic, progestogenic and androgenic
  activity.
• Given in a dose of 2.5 mg per day to women at
  least 1 year after menopause.
• It results in suppression of symptoms and the
  prevention of bone loss.
• Mild androgenic side effects may occur, but in
  general the preparation is well tolerated and the
  amenorrhoea that is present in 80 of patients by
  6 months is usually warmly welcomed.
• Some patients report a significant increase in
  libido with tibolone.

33
Contraindications To HRT
34

• Absolute
• Present or suspected pregnancy
• Suspicion of breast cancer
• Suspicion of endometrial cancer
• Acute active liver disease
• Uncontrolled hypertension
• Confirmed VTE

35

• Relative
• Presence of uterine fibromyomata
• Past history of benign breast disease
• Unconfirmed VTE
• Chronic stable liver disease
• Migraine

36
THE END