THE CLIMACTERIC Definition

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THE CLIMACTERIC Definition

• Climacteric" comes from the Greek word for rung
  of a ladder indicates the..
• passage out of the reproductive stage of life
  and into the non-reproductive phase
• Encompasses perimenopause, menopause, and the
  early postmenopausal years.
• Begins 39 to 51 years of age

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THE PERIMENOPAUSE Definition

• the period of years in which normal ovulatory
  cycles give way to cessation of menses
• marked by irregular menstrual cycles
• Cycle length begins to increase and ovulation and
  fertility decrease
• Onset 39 to 51 years
• Duration 2 to 8 years

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THE PERIMENOPAUSE

• wide-ranging symptoms that can be quite
  bothersome

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HORMONES PERIMENOPAUSE

• decrease in inhibin and an increase in
  follicle-stimulating hormone (FSH).
• estradiol levels increase initially in response
  to rising FSH levels and then begin declining 6
  to 12 months before menopause

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HORMONES POSTMENOPAUSE

• After menopause, the ovaries no longer make
  significant amounts of estrogen
• androstenedione from the adrenal glands and
  ovaries is converted to estrone, which is in turn
  converted to estradiol
• Proportionally, estradiol levels decrease more
  than do estrone, testosterone, and
  androstenedione levels

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HORMONAL SYMPTOMS

• abnormal bleeding
• vasomotor flushes (hot flashes),
• urogenital discomfort

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HORMONAL SYMPTOMSABNORMAL BLEEDING

• Anovulation in the perimenopausal years leads to
  unopposed estrogen and dysfunctional uterine
  bleeding.
• BUT may also be due to endometrial hyperplasia or
  cancer - see PMB
• TV US endometrial stripe lt 5 mm is reassuring but
  if gt4 mm endometrial sampling e.g. Pipelle
  suction needed

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HORMONAL SYMPTOMSHOT FLUSHES

• Begin with a sudden reddening of the skin of the
  head, neck, and chest accompanied by a feeling of
  intense body heat and conclude with perspiration
  that may be profuse
• Skin temperature increases but core body
  temperature actually decreases
• Last for a few seconds to several minutes
  rarely an hour. Oftennight sweats
• Occur in 10 to 40 of premenopausal And 50
  to 85 of postmenopausal women
• Occur for 2 - 5 years

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HORMONAL SYMPTOMSHOT FLUSHES

• Treatment - symptomatic - reassurance - HRT -
  Livial Tibolone - hypotensives eg clonidine
• -alternative medicines eg soy protein and black
  cohosh - modify life style-
• exercise? calories? smoking?
• Differential diagnostic considerations include
  pheochromocytoma, carcinoid, leukemias,
  pancreatic tumors, thyroid abnormalities, and
  psychosomatic disorders.

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HORMONAL SYMPTOMSABNORMAL BLEEDING

• Differential diagnosis
• endocrine tumors, liver disease,
  hyperthyroidism,hypothyroidism,
• obesity, and ovarian tumors
• BUT may also be due to endometrial hyperplasia or
  cancer

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HORMONAL SYMPTOMSUROGENITAL

• Dysuria is a result of mucosal thinning of the
  bladder and urethra and is common in
  postmenopausal women. It responds very well to
  HRT.
• Dyspareunia - atrophic vulvo-vaginitis
  reduction in vaginal lubricating fluid and
  vaginal elasticity
• R/- sex? KY jelly
• Estrogens oral,transdermal, or intravaginal

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HORMONAL SYMPTOMS OTHERS

• Hisuitism estrogen-androgen ratio?
• Wrinkles skin inelasticity collagen?
• Libido?- ?androgen therapy but check also for
  depression, dyspareunia, alcohol, and use of
  psychotropic medicines.

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HORMONAL SYMPTOMS OTHERS

• ?Insomnia - hot flushes etc
• ?Mood Changes - past history dependent -effect of
  HT variable - R/- usual therapy Symptoms tend to
  decrease at the end of menopause,
• prevalence of osteoarthritis and rheumatoid
  arthritis?

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MENOPAUSE PMB

• Definition Bldg after 12mths of amenorrhea in
  middle aged woman
• more likely to be due to pathologic disease than
  is bldg in younger women
• Causes
• exogenous hormones eg HRT
• Vaginal atrophy /or vulval dystrophy
• Tumours of reproductive tract

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MENOPAUSE PMB

• Causes cont
• Exogenous hormones
• Vaginal atrophy /or vulval dystrophy
• Tumours of reproductive tract
• endometrial hyperplasias,polyps, carcinoma
  cervical or endocervical carcinoma, uterine
  sarcomas (including mixed mesodermal and
  myosarcomas), and, rarely, tubal and ovarian
  cancer. Estrogen-secreting ovarian tumors

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MENOPAUSE VULVAL CANCER

• Age Median age at diagnosis 65 years
• ?Two groups
• Aetiology
• Younger pts HPVve smokingVIN Association
  with CIN VAIN
• Older group ??Vulvar dystrophy
• Incidence 3 of genital cancers
• Presentation Lump or ulcer often preceded by
  chronic pruritis

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MENOPAUSE VULVAL CANCER

• Signs Lump - fleshy, ulcerated, warty
• ulcer
• groin lymphadenopathy
• Diagnosis - Biopsy
• Pathology 90 Squamous Cell Carcinoma
• Spread
• Direct Extension
• Lymphatic Embolization groin nodes
• Haematogenous spread to distant sites

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