Perimenopause /menopause

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Perimenopause/menopause
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What is ?

• Hot flushes
• Night sweats

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Definitions

• Menopause
• last menstrual period
• One complete year without a menstrual cycle
• Perimenopause
• transition into menopause. It can last for 2 to 8
  years prior to menopause and includes the first
  year after menopause

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Three-step

• Pre-menopause
• Peri-menopause
• Post-menopause

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perimenopausal syndrome

• Definition
• In about 2/3 of the women in perimenopausal
  period ,there appear a series of symptoms due to
  deficiency of sexual hormone.
• usually occurring in women ageing from 45 to 55.

Menopause affects the women who suffer from it as
well as their loved ones!
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Signs and Symptoms

• Vasomotor symptomshot flashes, night sweats
• Vaginal drynesspainful intercourse,Vulvae
  pruritus
• Insomnia
• Weight gain
• Sexual changes
• Irregular menses
• Moon changes Irritability,depression

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Menopause Etiology

• Natural
• Surgical
• Premature
• Post-chemotherapy/radiation
• cancer

• cyst ,EMs
• cancer

• lt40ys

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Health Issues

• Osteoporosis
• Cardiovascular risk
• Breast Disease
• Diet modification
• Exercise
• Calcium intake, Vitamin D
• Family history

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CommonlyAsked Questions

• Is hormone replacement therapy (HRT) safe?
• What can I do about my lack of sex drive?

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What is HRT?

• Combination of estrogen, progesterone and
  sometimes testosterone
• Estrogen is given for relief of hot flashes,
  night sweats and vaginal dryness
• Other advantages of estrogen
• Improvement of sexual functioning
• Improvement with sleep
• Improvement with cognition
• Improvement of mood
• Prevents osteoporosis
• Decreases risk of fractures
• Decreases risk of colon and rectal cancer
• ? Improves skin

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What is HRT?

• Progesterone is given with estrogen to prevent
  cancer and hyperplasia (pre-cancer) of the lining
  in the uterus (endometrium)
• Estrogen alone is generally given to those women
  who dont have a uterus
• Testosterone is given to improve sexual
  dysfunction

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Is HRT Safe?

• Disadvantages of estrogen - based on the WHI
  study (Womens Health Initiative)
• Coronary heart disease
• Stroke
• Venous Thromboembolism - clotting that occurs in
  the deep veins (usually the legs, pelvis or
  lungs)
• Breast cancer
• Endometrial cancer and hyperplasia (known)

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WHI Study

• Mission does Prempro (combo of premarin and
  provera) or premarin alone reduce cardiovascular
  risk
• (premarin is a conjugated estrogen and provera is
  medroxyprogesterone acetate)

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WHI Study

• Results
• Prempro trial was halted prematurely after only
  5.2 years due to the increased risk of CHD,
  stroke, VTE, and breast cancer
• Premarin-alone trial was halted prematurely due
  to the increased risk of stroke
• Due to these findings the number of HRT
  prescriptions dropped by 50 from 1995 to 2003

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WHI Study

• The Headlines
• 41 increase in strokes
• 29 increase in heart attacks
• Greater than 100 increase in VTE
• 22 increase in total CVD
• 26 increase in breast cancer

• 37 decrease in colorectal cancer
• 33 decrease in hip fracture
• 24 decrease in total fractures

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• Not in the media about WHI
• Average age was 63
• Only 16 were within 5 years of their last menses
• Most were an average of 12 years after their last
  menses
• Most already had silent CVD
• 50 current or former smokers
• Average Body Mass Index 28.5, many obese
• Average participant was older, overweight smoker

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Is HRT Safe?Take Home Message

• HRT is safer for younger menopausal women
• HRT is intended for relief of vasomotor symptoms
  only (hot flashes, night sweats, vaginal dryness)
• Flushing is worse between the transition from
  pre-menopause to perimenopause
• Vaginal dryness, sweating, insomnia is most
  prominent during the transition from
  perimenopause to post-menopause
• WHI study tested only premarin and provera
• Many other forms of estrogen and progesterone

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What can I do about my lack of sex drive?

• Definition
• decreased interest in sexual activity or lack of
  sexual satisfaction.
• 40 of women between ages 18 to 59 report some
  sort of sexual dysfunction.
• Sexual functioning is a very important part of a
  womans relationship with her partner.
• Sexual dysfunction is very common during the
  perimenopausal and post-menopausal years.

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Sexual Dysfunction

• Causes
• Chronic disease
• Medications
• Psychological causes
• Socio-cultural causes
• Loss of estrogen
• Loss of testosterone

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Sexual Dysfunction

• Medical problems as a cause for decreased sexual
  activity
• Endocrine disorders diabetes, kidney disease
• Vascular diseases
• Atherosclerosis
• Neurologic disorders or injuries
• Alcohol or substance abuse
• Removal of the ovaries

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Snapshot

• The number of women aged 50 and above is
  increasing as life expectancy rises
• Women can now expect to live greater portions of
  their lives postmenopausal
• Proactively managing menopause is an opportunity
  for women to prevent disease and improve their
  long-term health and quality of life
• Menopause is a perfect time to evaluate your life
  and make changes to ensure that you stay fit and
  healthy now and in the future

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Menopause

• Derived from the Greek words for month (men)
  and cessation (pausis)
• A natural event in a woman's life - this is a
  time of change

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What is menopause?

• Menopause refers to the stage in a womans life
  when her periods cease
• Menopause occurs when the ovaries stop producing
  the hormones oestrogen and progesterone
• Usually occurs between ages of 45 and 55 years
• Symptoms such as hot flushes, mood swings,
  tiredness, loss of libido and irregular bleeding
  are common

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• There are three stages of menopause that take
  place over about a decade
• Peri-menopause
• Menopause
• Post-menopause

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• Peri-menopause
• The years prior to menopause (when symptoms
  commence) and also the first year after menopause

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• Menopause
• Permanent cessation of menstruation which occurs
  when the ovaries stop producing the hormones
  oestrogen and progesterone
• Natural menopause is recognised to have occurred
  once a period of 12-months has lapsed after the
  last menstrual period, and for which there is no
  other obvious cause
• No specific indication marks the beginning of
  menopause other than the onset of symptoms

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• Post-menopause
• When one year has lapsed since the last menstrual
  period
• Some women may still continue to experience
  menopausal symptoms for several years following
  their last period

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• Hot flushes!!
• The hallmark and the most commonly associated
  symptom with menopause. This is just one of
  several symptoms that may occur letting you know
  that menopause is on its way
• Though not welcomed, these symptoms tend to be
  experienced by the majority of women and are due
  to the declining level of oestrogen in the body
  which up until now has maintained the hormonal
  balance all these years
• The body is now moving into a state of
  readjustment and learning to live without
  oestrogen

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• Hot flushes and night sweats
• Very common
• A sensation of heat spreads over your body, in
  particular your head, face and chest and is often
  accompanied by flushing and sweating, followed by
  a chill

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Menopause Western Overview

• Differentiation menopause natural (49 50
  y/o), artificial (surgery, radiation), premature
  (lt 40 y/o, smoking, radiation, chemo)

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• Diagnosis cessation of menses 1 yr, decreased
  response to LH, FSH, shorter follicular phases,
  fewer ovulations, less estrogen progesterone,
  rise of LH/FSH

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• Symptoms none hot flashes, night sweats,
  fatigue, irritability, insomnia, nervousness,
  dizziness, paresthesias, palpitations,
  tachycardia, cotton head, cystitis,
  incontinence, vaginitis, arthralgia, myalgia,
  digestive complaints, increased risk for
  osteoporosis

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Menopause Western Overview

• Treatment counseling, anti-depressants,
  tranquilizers, ERT estrone (Ogen) 17-beta
  estradiol (oral Estrace transdermals
  Estraderm, Climara vaginal Estring) estriol
  has to be compounded conjugated estrogen
  (Premarin, similar to 17-beta estradiol, may
  increase blood pressure)

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Menopause Western Overview

• Progesterone acts on osteoblasts
  medroxyprogesterone (Provera), progesterone USP
  (Prometrium, Crinone) testosterone
• Natural Treatment natural OTC estrogen
  progesterone creams, bi-est (estradiol/estriol
  mix), tri-est (80 estriol, 10 estrone, 10
  estradiol), DHEA

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Menopause Western Overview

• Lignans cereals, fruits, vegetables, flax seeds
• Calcium yoghurt, OJ, sardines, green leafy
  vegies
• Vitamin E hot flashes, vaginal dryness also
  topically

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Menopause Oriental Views

• Life begins from the dance of the opposing forces
  of Yin Yang, heaven earth, day-time
  night-time, heating cooling, moistening
  drying, contracting relaxing.

Yang
Yin
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Menopause Western Overview

• Lignans cereals, fruits, vegetables, flax seeds
• Calcium yoghurt, OJ, sardines, green leafy
  vegies
• Vitamin E hot flashes, vaginal dryness also
  topically

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Menopause Oriental Views

• Life begins from the dance of the opposing forces
  of Yin Yang, heaven earth, day-time
  night-time, heating cooling, moistening
  drying, contracting relaxing.

Yang
Yin
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Yin/Yang Theory

• Yin
• Female
• Cold
• Moist
• Night
• Autumn, Winter
• Earth
• Structure
• Blood
• Interior
• Sinews/Bones
• Chronic
• Solid
• Weak
• Sinking

• Yang
• Male
• Hot
• Dry
• Day
• Spring, Summer
• Sky
• Function
• Qi
• Exterior
• Skin/ Body Hair
• Acute
• Hollow
• Strong
• Rising Up

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Yin Yang Theory 8
Pathologies
Health
Pathology
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Menopause Oriental View
Yang
Yin
Qi
Blood
Examples
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5-Phase Theory
H, SI, P, SJ
LIV, GB
SP, ST
KID, BL
LU, LI
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Menopause Oriental View
Insomnia, speech probl, memory, anxiety/joy
Digestive probl, prolapses, bleeding issues, worry
FBD, fibroids, menstrual probl anger/ depression
Urology, aging, fertility, brittle bones,
hairloss, fear/fright
Respiratory, immunity -allergies, skin probl,
grief/sadness
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Collecting the information from the patient

• Questioning (history), Inspection (visual,
  tongue), Listening Smelling (voice, breathing,
  odors), Palpation (pulse, relevant)
• Disease their energetic imbalances are
  classified into an Oriental medical diagnostic
  pattern of disharmony (Bian Zheng Lun Zhi).
• Treatment focuses on correcting patterns of
  disharmony by controlling and regulating the flow
  and balance of energy to create homeostasis.

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Menopause Oriental ViewsPatterns of Disharmony

• Disease Causes Disease Mechanisms
• Kidney Yin Deficiency
• Low back pain, chronic knee pain, night sweats,
  hot flashes, irritability, vaginal dryness,
  osteoporosis, decreased libido, hairloss,
  fearful, urinary frequency

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Menopause Patterns of Disharmony

• Kidney Yang Deficiency
• Chills, cold extremities knees, cold back,
  frequent profuse urination, low back pain,
  buckling knees, chills after a hot flash,
  incontinence, decreased libido

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Menopause Patterns of Disharmony

• Liver Depression, Qi Stagnation
• Depression, anger, PMS, fibrocystic breasts,
  fibroids, polycystic ovarian disease - PCOS,
  clots, dysmenorrhea, dark blood (purple)
  menstrual blood, menstrual irregularity, possible
  diagnosis of endomitriosis for patients with
  Blood Stasis

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Menopause Patterns of Disharmony

• Spleen Qi Deficiency
• Fatigue, irritable bowel syndrome (IBS), loose
  stools, or loose stools alternating with
  constipation, prolapses (hemorrhoids, uterine),
  increased menstrual bleeding or spotting in
  between, pale menstrual blood, frequent worrying
  or over-thinking

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Menopause Patterns of Disharmony

• Heart Yin Deficiency
• Insomnia, nightmares, anxiety, sleepwalking,
  difficulty speaking, memory loss, cotton head,
  palpitations, rapid heart beat, in severe cases
  night terrors

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Treating Menopause

• 80 of menopausal women present with symptoms of
  all of the previously mentioned patterns of
  disharmony
• Helpful tips
• Bone soup osteoporosis (make your own gelatin
  from beef or lamb bones)
• Support adrenals
• Oriental medicine can be very helpful in
  alleviating the symptoms of menopause but
  treatment has to be individualized

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Menopausal State

• Causes of Morbidity
• Cardiovascular disease
• Osteoporosis
• Cancer Lung, breast, ovarian, colon, cervical
  and uterine
• Sexual Function changes

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Postmenopause

• Issues for primary care physicians and
  gynecologists
• Hormonal changes
• Cardiovascular disease
• Osteoporosis
• Post menopausal bleeding (PMB)
• Abnormal PAPs
• Sexual Function
• Depression
• Cancer screening and prevention
• Lifestyle and habits

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HRTTCM

• However, we now know that hormone replacement
  therapy carries significant risks, so many women
  and their families need safe, long-term
  strategies to treat menopausal symptoms.
  Traditional Chinese medicine has kept women
  healthy for centuries and provides a viable
  solution to this problem.

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• Health challenges can emerge as a woman
  transitions into the second half of life. Since
  her body is no longer preparing for pregnancy
  each month, her overall hormone production ramps
  down. This shift in endocrine function can bring
  on the symptoms associated with menopause hot
  flashes and night sweats, dryness, changes in
  bone density, low libido, headaches, weight gain,
  and sleep difficulties.

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HRT RISKS

• Western doctors traditionally prescribed hormones
  to replace a womans own diminishing production.
  Since the Womens Health Initiative ended early
  in 2002, however, research has shown that this
  strategy is fraught with side effects. This
  major long-term study on hormone replacement
  therapy found that health risks include greater
  incidence of ovarian cancer, stroke, and breast
  cancer ratesespecially for women who take
  hormones for 15 years or more.

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• As the risks and benefits of hormone replacement
  therapy come to light, collaboration with
  providers of complementary approaches like
  traditional Chinese medicine becomes ever more
  valuable.

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TCM AND MENOPAUSE

• Traditional Chinese medicine creates equilibrium
  in a womans system while her body naturally
  adjusts to a different hormone balance. Success
  rates are impressiveChinese medicine has reduced
  hot flashes, decreased night sweats, and helped
  balance emotional wellbeing for centuries.

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Diagnosis

• Western medicine focuses more on structure
  component ( nervous system, musculoskeletal
  system )
• Chinese medicine concentrated on identifying body
  functions and
• ( physical, emotional ) clarifying their
  relationships to each other.
  
  

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Treatment

• Western researchers focus on
• identification of external agents
• of disease and developing
• weapons against them.
• Chinese medicine act with the bodys
  defenses. They stimulate
• the immune system by increasing related
  cellular activity and
• efficiency.

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• Although treatment originates from outside,
  healing comes from within in Chinese medicine.

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The human body exists in a state of relative
balance described by the yin and yang paradigm.
This balance relates to the individuals
constitution, stress level, emotional change, or
illness, factors that vary as widely as
fingerprints do.
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Pathogenesis

• decline of kidney Qi
• near exhaustion of reproductive
  substance(Tiangui)
• deficiency of the thoroughfare and conception
  vessels
• insufficiency of essence and blood before and
  after menopause
• asthenia of kidney Yang
• malnutrition of meridians and vessels
• frequent asthenia of blood
• multiparity and excessive sexual life
• serious disease and prolonged illness
• severe asthenia of kidney Yin that lead to
  failure of Yang to keep in latency as well as
  asthenia of yin and hyperactivity of Yang
• deficiency of kidney yin that fail to nourish
  heart and liver, leading to hyperactivity of
  heart and liver fire
• frequent asthenia of Yang and excessive intake of
  cold foods consuming kidney Yang.

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Key points of diagnosis

• symptoms
• flushed cheeks, tidal fever, sweating, aversion
  to cold after sweating, palpitation and chest
  oppression, dizziness and tinnitus ,headache and
  insomnia ,or pain in the waist, back and joist,
  dry and itching skin as well as emotional changes
  like depression ,anxiety ,susceptibility to
  irritability and even emotional disorders in
  climacterium or after removal of ovary followed
  by disorder of menstruation or menopause.
• Lab
• FSH and LH obviously increased , E2 decreased

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Differential Diagnosis

• Angina pectoris,
• primary hypertension,
• perimenopausl psychosis
• benign and malignant tumor of genitalia
• urethrocystitis

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Differentiation of Syndromes

• Chinese medicine emphasizes the
  differentiation of syndromes that means that
  even within the same disease, different stage
  (e.g. pre-menopause, menopause, post-menopause)
  will have a different treatment and with a lot of
  individual variation.

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Yang Pathogenic Factor
Yin Pathogenic Factor
Balance of Yin and Yang
Preponderance of Yin Consumes Yang. (Shi-Cold
Syndrome)
Preponderance of Yang Consumes Yin. (Shi-Heat
Syndrome)
Weakness of Yin Leads to Preponderance of
Yang (Xu-Heat Syndrome)
Weakness of Yang Leads to Preponderance of
Yin (Xu-Cold Syndrome)
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When a traditional Chinese Doctor prescribes a
specific herb, he is not depending on active
Chemical ingredients And attempting to correct a
chemical abnormality, He based on a complex
Set of rule which govern balance in the human
body and trying
restore the harmonious flow of Qi., It developed
2500 years ago, Before chemistry as we know it
was described
Ginseng, there are more than fifty different
chemicals in it.
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Syndrome differentiation and treatment

• Kidney asthenia is the root cause of this
  syndrome which is usually of asthenia, even if
  the syndrome is of sthenia, it is often mingled
  with asthenia.

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Yin asthenia syndrome of the liver and kidney

• Main symptoms
• Dizziness and tinnitus, flushed cheeks and high
  fever, occasional sweating, symptoms of Yin
  asthenia syndrome of the liver and kidney
  (feverish sensation over the palms, soles and
  chest, insomnia and dreaminess, aching and weak
  sensation in the loins and knees, dryness and
  pruritus of skin, dry mouth and retention of
  feces, scanty and yellowish urine, or scanty
  menstruation with red menses, ) disturbance of
  menstrual disorder, alternate sudden profuse
  uterine bleeding and dripping uterine bleeding.
• Tongue red tongue with scanty fur
• Pulse thin pulse.

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• Therapeutic methods
• Nourishing the liver and kidney, fostering Yin
  and suppressing Yang
• Prescription and drugs
• Modified Zuogui Wan
• Shengdi10 Shoudi10 Gouqi10
• Shanzhuyu10 Shanyao20 Fuling10
• Mudanpi10 Guiban10 Longgu15
• Nvzhengzi15 Hanliancao15

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Yang-deficiency syndrome

• Main symptoms
• Before or after menopause
• grayish complexion, dispiritedness,
• symptoms of ( puffy face, edema of limbs, chilly
  body and aversion to cold, anorexia and abdominal
  distention, loose stool, frequent and profuse
  urine, irregular menstruation, or sudden profuse
  uterine bleeding, whitish and thin leucorrhea. )
• Tongue bulgy tongue with tooth print and whitish
  thin fur
• Pulse deep and thin

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• Therapeutic methods
• Warming the kidney and supporting Yang,
  strengthening the spleen and assisting
  transportation
• Prescription and drugs
• Modified Youguiwan
• Lujiaojiao10 Dangshen15 Baishu10
• Buguzhi10 Xianmao10
  Xianlingpi10 Shanyao15 Shanzhuyu10
  Duzhong10 Tusizi10

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Liver depression syndrome

• Main symptoms
• Before or after menopause
• mental depression, anxiety ,sentimentality,
  irritability, chest oppression , susceptibility
  to sighing ,distending pain in hypochondria
  ,feverish sweating, disturbance of menstruation,
  profuse menorrhea in the late stage with dark red
  color
• Tongue red tongue with thin and white or yellow
  fur
• Pulse taut

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• Therapeutic methods
• Soothing the liver to relieve depression and
  regulating Qi to nourish Yin
• Prescription and drugs
• Modified Xiaoyaosan
• Baishao10 Dangui10 Caihu5 Shengdi10
  Fuling10 Yujin10 Shanyao15 Chenpi6

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Syndrome of simultaneous asthenia of heart and
spleen

• Main symptoms
• Before or after menopause
• feverish sweating ,palpitation and shortness of
  breath, amnesia and insomnia ,sallow complexion,
  facial dropsy, lassitude ,epigastric and
  abdominal distension ,anorexia and loose stool,
  disturbance of menstruation, or sudden profuse
  vaginal bleeding or dripping vaginal bleeding
  with light color and thin texture .
• Tongue light colored tongue with whitish thin
  fur
• Pulse thin and weak

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• Therapeutic methods
• Strengthening the spleen and nourishing Qi ,
  nourishing heart and tranquilizing mind
• Prescription and drugs
• Modified Guipitang
• Huangqi10 Dangshen10 Baishu10
• Danggui10 Fusheng10 Yuanzhi6
  Suanzaoren10 Chenpi10 Muxiang10 Gancao5
  Dazao10

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DIET AND LIFESTYLE

• Moreover, key diet and lifestyle changes figure
  importantly in long-term menopause management.
  Specific exercises and relaxation practices help
  reduce symptoms both in the short- and long-term.
  Personalized dietary plans present another
  effective tool, especially when created by a
  health professional who understands your
  particular medical history and symptom picture.
  Point in fact those cultures with vegetable and
  fish-based diets like the Japanese do not
  technically have a word for menopause, because
  the incidence of symptoms is so low.

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• This isnt a one size fits all situation!
• All women are different and will need different
  ways to manage their menopause