CASE 10: MENOPAUSE

MENOPAUSE Change in the Peri-menopause:

 Absence of menstruation for a year
 Defined by Last Menstrual Period
 Age of menopause is genetically determined
 Filipina: 48 - 52 years old (Book: Age 47 – 48)
 Average Age: 51 y/o
Perimenopausal, Premenopausal, Climacterium
 Before the onset of menopause
 Transition period
 There is a change in the interval of the cycles to
ANOVULATORY (AUB)
 Cause: Depletion of the # of follicles
 The HPO axis is no longer be responsive which
would ↓ E. If ↓E, nothing will inhibit hypothalamus
from secretion of GnRH which also ↑
gonadotrophin hormones. This would explain one of
the criteria of menopause as ↑ FSH.

STRAW: Stages of. Reproductive Aging Workshop

Menopausal Transition DX:

Initial phase 1. CHMI
1. Irregular cycles 2. ↑ Gonadotropin FSH followed by LH
2. HOT FLUSHES 3. ↓ E (measured form: Estradiol)
3. Insomnia, Mood swings, night sweats 4. ↓ Inhibin B - More sensitive test:
Late Phase: Osteoporosis  It inhibits the secretion of GnRH & eventually
the gonadotropin so with ↓ Inhibin, it will lead
Symptomatic: 50% to continuous ↑ FSH
In 90s: all must be treated until she dies
 But now according to WHI (Women’s Health TX:
Initiative) ONLY treat the symptomatic menopause E + P (HRT)
with duration no more than 5 years because after 1. Used in patient has intact uterus because E alone
time there is presence of cardiovascular problems. may result to a hyperplastic endometrium
Try to treat symptomatic patients with shortest 2. ↑ Risk for Endometrial CA
possible time.

PELVIC EXAM:
Atrophic vagina:
 Normal menstruating woman: (+) Rugae
 In menopause: Loss of Rugae
Pale/ thin Vaginal Mucosa
 Due to effects of hormones on the vagina
 Estrogen: Thickness of the vaginal mucosa
CHMI: Cytohormonal Maturation Index:
 Count 100 vaginal cells & classify into
 Parabasal & Intermediate - Progesterone
 Superficial – Estrogen
 100/0/0: Menopausic (Shift to the Left)
 0/80/20: Pregnant or in the Secretory Phase

Work – ups
 Breast: Mammography
 TVS: Uterus
 Check for Endometrial thickness
 IF thick: Do not give E
CASE 10
52 year old G3P3 (3003) complains of pain during sexual contact for the past 4 mos. She also notes night sweats & difficulty
sleeping. LMP – March 2012, PPE: Breasts: Symmetrical, no mass, no tenderness; Speculum examination: Vaginal mucosa is
pale pink, smooth; Cervix – pale pink, smooth, no discharge. IE: cervix is firm, short, flushed to the vaginal walls; Uterus is small;
Adnexa – no mass nor tenderness

CASE:
TX: Estrogen – Oral/ Topical/ Patch
Bear in mind all the effects of E on the body, not just to
offset the symptoms of menopause.
If you are going to give E, it will be termed as ET:
Estrogen Therapy. (Past: ERT Estrogen Replacement
Therapy)
Before start of HT for menopause, make sure there are
no risk factors that may complicate use of hormones
1. NO breast conditions - do mammography,
2. NO liver pathology (metabolize by the liver)
3. NO varicosities (Look at the legs), risk for
thromboembolism

 Oral - CEE Conjugated Equine E: 0.3/ 0.625/ 1.25 mg After starting HT when do you stop?
 Principle: Start with the lowest dose 0.3 mg qd.  Perhaps after 1 year try to withdraw, & if she is
 Transdermal Patch – Pure E or E+P asymptomatic: Discontinue

What can be the problem in giving E ONLY? Do NOT give HT to prevent osteoporosis
Remember: The effect of E is proliferating the Risk for osteoporosis:
endometrial glands but that proliferation will be counter  Skinny Slim
affected by P.  Cigarette smoker
But if you have caused proliferative  Coffee Drinker
endometrium & you keep receiving E, eventually that  Sedentary Lifestyle
endometrium will become HYPERPLASTIC which is a
precursor of Endometrial CA. TX Osteopenia or Osteoporosis:
 ↑ Incidence of Endometrial Hyperplasia & Cancer  Alendronate, Biphosphanate, NOT HT

 For patients with intact uterus - give E + P to prevent
Endometrial hyperplasia & malignancy (Do Hormone
therapy: Combination of E & P)
 For patient with NO uterus – give E ONLY
 If patient age 35 had TAH then stops menstruating,
the patient is NOT menopausic:
 Why? Because ovaries were not taken out at the
time of hysterectomy. Menopause is simply
depletion of ovarian function.
 At Age 52 patient will start manifesting menopausal
symptoms because of ↑ level of FSH that woman
will just require ET. (No more uterus)
How to give it:
 Still want to have menstruation - Give cyclic HT
 Do not want to have menstruation & TX the
menopausal symptoms – Give continuous HT
(because the moment you stop the hormones will
fall & reflected as menstruation)
In Menopause: Definitely AT RISK for osteoporosis
 Fill the bone mass: Give Calcium & do weight
bearing exercise (your body should carry your
weight) by brisk walking, boxing & ZUMBA.
Before menopause, the incidence of CAD is higher
among men than women, but after menopause they are
equal.
The beneficial effect of E will ↓ LDL but without
E or after E treatment, after menopause, the incidence
of CAD is practically the same.
WHI: Asymptomatic were given E produced ↑ incidence
of stroke & ischemic heart disease.
Again: SYMPTOMATIC patients should be the only 1 to
receive TX.

Main Problem for the Case:

 Painful contact due to vaginal atropy
 Initial TX: Pure Local Estrogen Tx (local E tablets
placed in the vagina or local E cream but
supplement with oral P to counteract effects of E)

If from local E. still complains with systemic symptoms,

(night sweats or insomnia): Shift Local E to Oral HT, NOT
ET because even in Local E, some of it may be
systemically absorbed.