CONTENTS

• INTRODUCTION
• ANATOMY
• PHYSIOLOGY
• MENSTRUAL CYCLE
• TYPES
• CLINICAL PRESENTATION
• COMPLICATIONS
• DIAGNOSIS
• PHYSIOTHERAPY ASSESSMENT
• INVESTIGATIONS
• MANAGEMENT
• MEDICAL MANAGEMENT
• PHYSIOTHERAPY MANAGEMENT
• OCCUPATIONAL THERAPY
• ALTERNATIVE THERAPY
• RESEARCH
• SUMMARY
• BIBILIOGRAPHY
• REFERENCES
 WOMENS HEALTH-MENOPAUSE MANAGEMENT

1.INTRODUCTION

1a) Women's health refers to the health of women, which differs from that of
men in many unique ways. Often treated as simply women's reproductive health,
many groups argue for a broader definition pertaining to the
overall health of women, better expressed as "The health of women".

MENOPAUSE

Menopause, also known as the climacteric, is the time in most women's

lives when menstrual periods stop permanently, and they are no longer able to
bear children. Menopause typically occurs between 49 and 52 years of
age. Medical professionals often define menopause as having occurred when a
woman has not had any vaginal bleeding for a year. It may also be defined by a
decrease in hormone production by the ovaries. In those who have had surgery to
remove their uterus but still have ovaries, menopause may be viewed to have
occurred at the time of the surgery or when their hormone levels fell. Following
the removal of the uterus, symptoms typically occur earlier, at an average of 45
years of age.

Incidence of Post menopause

• The symptoms of menopause can be distressing ,particularly as they occur
at a time when women have important roles in society,within family and at
the workplace.

• Hormonal changes that begin during the menopausal transition affect

many biological systems.

• Menopause is the time at which a woman permanently stops

menstruating,usually between 45 an 55 years of age,and is diagnosed after
12 months of amenorrhea.

• It is preceded by the climacteric period,sometimes referred to as

perimenopause or menopausal transition,which is the transition period in a
woman’s life from the time of full sexual maturity to the onset of
menopause

• Accordingly,the signs and symptoms of menopause include central nervous

system related disorders,metabolic weight,cardiovascular and
musculoskeletal changes ,urogenital and skin atrophy,and sexual
dysfunction.

• The physiological basis of these manifestations is emerging as complex and

related,but not limited to,oestrogen deprivation.

• The physical manifestations are caused by hormonal changes(primarily a

drop in progesterone and estrogen levels ) that occur during the
climacteric period.
• Clinical features leading upto menopause include irregular
menses,autonomic symptoms(e.g.,hot flashes),mental
symptoms(e.g.,mood swings).and atrophic features(e.g.,reduced breast
size,vaginal atrophy).

• Middle –aged and elderly women may experience a variety leading to

death or hampering their quality of life.

• According to the Global Burden of Diseases,the top causes of death in

women in developed countries worldwide are cardiovascular
diseases(CVD’s including ischemic heart disease and stroke),cancer,chronic
obstructive pulmonary disease(COPD) and diabetes.

• Disease prevalence differs between women aged 50-69 and women aged
over 70.Notably the top 5 causes of death for women aged 50-69 has not
changed since 1990.All these diseases cause disability at different levels.

• Menopausal transition is a natural phase of the aging process in

females,and as such does not usually warrant treatment .However
,treatment is warranted in the cases of severe symptoms or early onset
menopause.

• The choice of treatment is decided on a case-by-case basis and includes

conservative methods,hormone replacement therapy and non hormonal
therapy.
 ANATOMY OF FEMALE REPRODUCTIVE SYSTEM

The female reproductive system is designed to carry out several functions. It

produces the female egg cells necessary for reproduction, called the ova or
oocytes. The system is designed to transport the ova to the site of
fertilization. Conception, the fertilization of an egg by a sperm, normally occurs in
the fallopian tubes. The next step for the fertilized egg is to implant into the walls
of the uterus, beginning the initial stages of pregnancy. If fertilization and/or
implantation does not take place, the system is designed to menstruate (the
monthly shedding of the uterine lining). In addition, the female reproductive
system produces female sex hormones that maintain the reproductive cycle.

What Parts make up the Female Anatomy?

The female reproductive anatomy includes parts inside and outside the body.
The female reproductive system functions to produce gametes and reproductive
hormones, just like the male reproductive system; however, it also has the
additional task of supporting the developing fetus and delivering it to the outside
world. Unlike its male counterpart, the female reproductive system is located
primarily inside the pelvic cavity. Recall that the ovaries are the female gonads.
The gamete they produce is called an oocyte. We’ll discuss the production of
oocytes in detail shortly. First, let’s look at some of the structures of the female
reproductive system.

Figure 1. The major organs of the female reproductive system are located inside
the pelvic cavity.

External Female Genitals

The external female reproductive structures are referred to collectively as

the vulva. The mons pubis is a pad of fat that is located at the anterior, over the
pubic bone. After puberty, it becomes covered in pubic hair. The labia
majora (labia = “lips”; majora = “larger”) are folds of hair-covered skin that begin
just posterior to the mons pubis. The thinner and more pigmented labia
minora (labia = “lips”; minora = “smaller”) extend medial to the labia majora.
Although they naturally vary in shape and size from woman to woman, the labia
minora serve to protect the female urethra and the entrance to the female
reproductive tract.

The superior, anterior portions of the labia minora come together to encircle
the clitoris (or glans clitoris), an organ that originates from the same cells as the
glans penis and has abundant nerves that make it important in sexual sensation
and orgasm. The hymen is a thin membrane that sometimes partially covers the
entrance to the vagina. An intact hymen cannot be used as an indication of
“virginity”; even at birth, this is only a partial membrane, as menstrual fluid and
other secretions must be able to exit the body, regardless of penile–vaginal
intercourse. The vaginal opening is located between the opening of the urethra
and the anus. It is flanked by outlets to the Bartholin’s glands (or greater
vestibular glands).
Figure 2. The external female genitalia are referred to collectively as the vulva.

Vagina

The vagina is a muscular canal (approximately 10 cm long) that serves as the

entrance to the reproductive tract. It also serves as the exit from the uterus
during menses and childbirth. The outer walls of the anterior and posterior vagina
are formed into longitudinal columns, or ridges, and the superior portion of the
vagina—called the fornix—meets the protruding uterine cervix. The walls of the
vagina are lined with an outer, fibrous adventitia; a middle layer of smooth
muscle; and an inner mucous membrane with transverse folds called rugae.
Together, the middle and inner layers allow the expansion of the vagina to
accommodate intercourse and childbirth. The thin, perforated hymen can
partially surround the opening to the vaginal orifice. The hymen can be ruptured
with strenuous physical exercise, penile–vaginal intercourse, and childbirth. The
Bartholin’s glands and the lesser vestibular glands (located near the clitoris)
secrete mucus, which keeps the vestibular area moist.
The vagina is home to a normal population of microorganisms that help to protect
against infection by pathogenic bacteria, yeast, or other organisms that can enter
the vagina. In a healthy woman, the most predominant type of vaginal bacteria is
from the genus Lactobacillus. This family of beneficial bacterial flora secretes
lactic acid, and thus protects the vagina by maintaining an acidic pH (below 4.5).
Potential pathogens are less likely to survive in these acidic conditions. Lactic acid,
in combination with other vaginal secretions, makes the vagina a self-cleansing
organ. However, douching—or washing out the vagina with fluid—can disrupt the
normal balance of healthy microorganisms, and actually increase a woman’s risk
for infections and irritation. Indeed, the American College of Obstetricians and
Gynecologists recommend that women do not douche, and that they allow the
vagina to maintain its normal healthy population of protective microbial flora.

Ovaries

The ovaries are the female gonads. Paired ovals, they are each about 2 to 3 cm in
length, about the size of an almond. The ovaries are located within the pelvic
cavity, and are supported by the mesovarium, an extension of the peritoneum
that connects the ovaries to the broad ligament. Extending from the mesovarium
itself is the suspensory ligament that contains the ovarian blood and lymph
vessels. Finally, the ovary itself is attached to the uterus via the ovarian ligament.

The ovary comprises an outer covering of cuboidal epithelium called the ovarian
surface epithelium that is superficial to a dense connective tissue covering called
the tunica albuginea. Beneath the tunica albuginea is the cortex, or outer portion,
of the organ. The cortex is composed of a tissue framework called the ovarian
stroma that forms the bulk of the adult ovary. Oocytes develop within the outer
layer of this stroma, each surrounded by supporting cells. This grouping of an
oocyte and its supporting cells is called a follicle. The growth and development of
ovarian follicles will be described shortly. Beneath the cortex lies the inner
ovarian medulla, the site of blood vessels, lymph vessels, and the nerves of the
ovary. You will learn more about the overall anatomy of the female reproductive
system at the end of this section.

The Ovarian Cycle

The ovarian cycle is a set of predictable changes in a female’s oocytes and ovarian
follicles. During a woman’s reproductive years, it is a roughly 28-day cycle that
can be correlated with, but is not the same as, the menstrual cycle (discussed
shortly). The cycle includes two interrelated processes: oogenesis (the production
of female gametes) and folliculogenesis (the growth and development of ovarian
follicles).

Oogenesis

Gametogenesis in females is called oogenesis. The process begins with the

ovarian stem cells, or oogonia. Oogonia are formed during fetal development,
and divide via mitosis, much like spermatogonia in the testis. Unlike
spermatogonia, however, oogonia form primary oocytes in the fetal ovary prior to
birth. These primary oocytes are then arrested in this stage of meiosis I, only to
resume it years later, beginning at puberty and continuing until the woman is
near menopause (the cessation of a woman’s reproductive functions). The
number of primary oocytes present in the ovaries declines from one to two
million in an infant, to approximately 400,000 at puberty, to zero by the end of
menopause.
The initiation of ovulation—the release of an oocyte from the ovary—marks the
transition from puberty into reproductive maturity for women. From then on,
throughout a woman’s reproductive years, ovulation occurs approximately once
every 28 days. Just prior to ovulation, a surge of luteinizing hormone triggers the
resumption of meiosis in a primary oocyte. This initiates the transition from
primary to secondary oocyte. However, as you can see in Figure 3, this cell
division does not result in two identical cells. Instead, the cytoplasm is divided
unequally, and one daughter cell is much larger than the other. This larger cell,
the secondary oocyte, eventually leaves the ovary during ovulation. The smaller
cell, called the first polar body, may or may not complete meiosis and produce
second polar bodies; in either case, it eventually disintegrates. Therefore, even
though oogenesis produces up to four cells, only one survives.
Figure 3. Click for a larger image. The unequal cell division of oogenesis produces
one to three polar bodies that later degrade, as well as a single haploid ovum,
which is produced only if there is penetration of the secondary oocyte by a sperm
cell.

How does the diploid secondary oocyte become an ovum—the haploid female
gamete? Meiosis of a secondary oocyte is completed only if a sperm succeeds in
penetrating its barriers. Meiosis II then resumes, producing one haploid ovum
that, at the instant of fertilization by a (haploid) sperm, becomes the first diploid
cell of the new offspring (a zygote). Thus, the ovum can be thought of as a brief,
transitional, haploid stage between the diploid oocyte and diploid zygote.

The larger amount of cytoplasm contained in the female gamete is used to supply
the developing zygote with nutrients during the period between fertilization and
implantation into the uterus. Interestingly, sperm contribute only DNA at
fertilization —not cytoplasm. Therefore, the cytoplasm and all of the cytoplasmic
organelles in the developing embryo are of maternal origin. This includes
mitochondria, which contain their own DNA. Scientific research in the 1980s
determined that mitochondrial DNA was maternally inherited, meaning that you
can trace your mitochondrial DNA directly to your mother, her mother, and so on
back through your female ancestors.

Folliculogenesis

Again, ovarian follicles are oocytes and their supporting cells. They grow and
develop in a process called folliculogenesis, which typically leads to ovulation of
one follicle approximately every 28 days, along with death to multiple other
follicles. The death of ovarian follicles is called atresia, and can occur at any point
during follicular development. Recall that, a female infant at birth will have one to
two million oocytes within her ovarian follicles, and that this number declines
throughout life until menopause, when no follicles remain. As you’ll see next,
follicles progress from primordial, to primary, to secondary and tertiary stages
prior to ovulation—with the oocyte inside the follicle remaining as a primary
oocyte until right before ovulation.
Folliculogenesis begins with follicles in a resting state. These small primordial
follicles are present in newborn females and are the prevailing follicle type in the
adult ovary. Primordial follicles have only a single flat layer of support cells,
called granulosa cells, that surround the oocyte, and they can stay in this resting
state for years—some until right before menopause.

After puberty, a few primordial follicles will respond to a recruitment signal each
day, and will join a pool of immature growing follicles called primary follicles.
Primary follicles start with a single layer of granulosa cells, but the granulosa cells
then become active and transition from a flat or squamous shape to a rounded,
cuboidal shape as they increase in size and proliferate. As the granulosa cells
divide, the follicles—now called secondary follicles—increase in diameter, adding
a new outer layer of connective tissue, blood vessels, and theca cells—cells that
work with the granulosa cells to produce estrogens.

Within the growing secondary follicle, the primary oocyte now secretes a thin
acellular membrane called the zona pellucida that will play a critical role in
fertilization. A thick fluid, called follicular fluid, that has formed between the
granulosa cells also begins to collect into one large pool, or antrum. Follicles in
which the antrum has become large and fully formed are considered tertiary
follicles (or antral follicles). Several follicles reach the tertiary stage at the same
time, and most of these will undergo atresia. The one that does not die will
continue to grow and develop until ovulation, when it will expel its secondary
oocyte surrounded by several layers of granulosa cells from the ovary. Keep in
mind that most follicles don’t make it to this point. In fact, roughly 99 percent of
the follicles in the ovary will undergo atresia, which can occur at any stage of
folliculogenesis.
Figure 4. Click for a larger image. (a) The maturation of a follicle is shown in a
clockwise direction proceeding from the primordial follicles. FSH stimulates the
growth of a tertiary follicle, and LH stimulates the production of estrogen by
granulosa and theca cells. Once the follicle is mature, it ruptures and releases the
oocyte. Cells remaining in the follicle then develop into the corpus luteum. (b) In
this electron micrograph of a secondary follicle, the oocyte, theca cells (thecae
folliculi), and developing antrum are clearly visible. EM × 1100. (Micrograph
provided by the Regents of University of Michigan Medical School © 2012)

Hormonal Control of the Ovarian Cycle

The process of development that we have just described, from primordial follicle
to early tertiary follicle, takes approximately two months in humans. The final
stages of development of a small cohort of tertiary follicles, ending with ovulation
of a secondary oocyte, occur over a course of approximately 28 days. These
changes are regulated by many of the same hormones that regulate the male
reproductive system, including GnRH, LH, and FSH.

As in men, the hypothalamus produces GnRH, a hormone that signals the anterior
pituitary gland to produce the gonadotropins FSH and LH. These gonadotropins
leave the pituitary and travel through the bloodstream to the ovaries, where they
bind to receptors on the granulosa and theca cells of the follicles. FSH stimulates
the follicles to grow (hence its name of follicle-stimulating hormone), and the five
or six tertiary follicles expand in diameter. The release of LH also stimulates the
granulosa and theca cells of the follicles to produce the sex steroid hormone
estradiol, a type of estrogen. This phase of the ovarian cycle, when the tertiary
follicles are growing and secreting estrogen, is known as the follicular phase.
The more granulosa and theca cells a follicle has (that is, the larger and more
developed it is), the more estrogen it will produce in response to LH stimulation.
As a result of these large follicles producing large amounts of estrogen, systemic
plasma estrogen concentrations increase. Following a classic negative feedback
loop, the high concentrations of estrogen will stimulate the hypothalamus and
pituitary to reduce the production of GnRH, LH, and FSH. Because the large
tertiary follicles require FSH to grow and survive at this point, this decline in FSH
caused by negative feedback leads most of them to die (atresia). Typically only
one follicle, now called the dominant follicle, will survive this reduction in FSH,
and this follicle will be the one that releases an oocyte. Scientists have studied
many factors that lead to a particular follicle becoming dominant: size, the
number of granulosa cells, and the number of FSH receptors on those granulosa
cells all contribute to a follicle becoming the one surviving dominant follicle.
Figure 5. Click for a larger image. The hypothalamus and pituitary gland regulate
the ovarian cycle and ovulation. GnRH activates the anterior pituitary to produce
LH and FSH, which stimulate the production of estrogen and progesterone by the
ovaries.

When only the one dominant follicle remains in the ovary, it again begins to
secrete estrogen. It produces more estrogen than all of the developing follicles
did together before the negative feedback occurred. It produces so much
estrogen that the normal negative feedback doesn’t occur. Instead, these
extremely high concentrations of systemic plasma estrogen trigger a regulatory
switch in the anterior pituitary that responds by secreting large amounts of LH
and FSH into the bloodstream. The positive feedback loop by which more
estrogen triggers release of more LH and FSH only occurs at this point in the cycle.

It is this large burst of LH (called the LH surge) that leads to ovulation of the
dominant follicle. The LH surge induces many changes in the dominant follicle,
including stimulating the resumption of meiosis of the primary oocyte to a
secondary oocyte. As noted earlier, the polar body that results from unequal cell
division simply degrades. The LH surge also triggers proteases (enzymes that
cleave proteins) to break down structural proteins in the ovary wall on the surface
of the bulging dominant follicle. This degradation of the wall, combined with
pressure from the large, fluid-filled antrum, results in the expulsion of the oocyte
surrounded by granulosa cells into the peritoneal cavity. This release is ovulation.

In the next section, you will follow the ovulated oocyte as it travels toward the
uterus, but there is one more important event that occurs in the ovarian cycle.
The surge of LH also stimulates a change in the granulosa and theca cells that
remain in the follicle after the oocyte has been ovulated. This change is called
luteinization (recall that the full name of LH is luteinizing hormone), and it
transforms the collapsed follicle into a new endocrine structure called the corpus
luteum, a term meaning “yellowish body”. Instead of estrogen, the luteinized
granulosa and theca cells of the corpus luteum begin to produce large amounts of
the sex steroid hormone progesterone, a hormone that is critical for the
establishment and maintenance of pregnancy. Progesterone triggers negative
feedback at the hypothalamus and pituitary, which keeps GnRH, LH, and FSH
secretions low, so no new dominant follicles develop at this time.
The post-ovulatory phase of progesterone secretion is known as the luteal phase
of the ovarian cycle. If pregnancy does not occur within 10 to 12 days, the corpus
luteum will stop secreting progesterone and degrade into the corpus albicans, a
nonfunctional “whitish body” that will disintegrate in the ovary over a period of
several months. During this time of reduced progesterone secretion, FSH and LH
are once again stimulated, and the follicular phase begins again with a new cohort
of early tertiary follicles beginning to grow and secrete estrogen.

The Uterine Tubes

The uterine tubes (also called fallopian tubes or oviducts) serve as the conduit of
the oocyte from the ovary to the uterus. Each of the two uterine tubes is close to,
but not directly connected to, the ovary and divided into sections. The isthmus is
the narrow medial end of each uterine tube that is connected to the uterus. The
wide distal infundibulum flares out with slender, finger-like projections
called fimbriae. The middle region of the tube, called the ampulla, is where
fertilization often occurs. The uterine tubes also have three layers: an outer
serosa, a middle smooth muscle layer, and an inner mucosal layer. In addition to
its mucus-secreting cells, the inner mucosa contains ciliated cells that beat in the
direction of the uterus, producing a current that will be critical to move the
oocyte.

Following ovulation, the secondary oocyte surrounded by a few granulosa cells is

released into the peritoneal cavity. The nearby uterine tube, either left or right,
receives the oocyte. Unlike sperm, oocytes lack flagella, and therefore cannot
move on their own. So how do they travel into the uterine tube and toward the
uterus? High concentrations of estrogen that occur around the time of ovulation
induce contractions of the smooth muscle along the length of the uterine tube.
These contractions occur every 4 to 8 seconds, and the result is a coordinated
movement that sweeps the surface of the ovary and the pelvic cavity. Current
flowing toward the uterus is generated by coordinated beating of the cilia that
line the outside and lumen of the length of the uterine tube. These cilia beat more
strongly in response to the high estrogen concentrations that occur around the
time of ovulation. As a result of these mechanisms, the oocyte–granulosa cell
complex is pulled into the interior of the tube. Once inside, the muscular
contractions and beating cilia move the oocyte slowly toward the uterus. When
fertilization does occur, sperm typically meet the egg while it is still moving
through the ampulla.

Figure 6. This anterior view shows the relationship of the ovaries, uterine tubes
(oviducts), and uterus. Sperm enter through the vagina, and fertilization of an
ovulated oocyte usually occurs in the distal uterine tube. From left to right, LM ×
400, LM × 20. (Micrographs provided by the Regents of University of Michigan
Medical School © 2012)
The open-ended structure of the uterine tubes can have significant health
consequences if bacteria or other contagions enter through the vagina and move
through the uterus, into the tubes, and then into the pelvic cavity. If this is left
unchecked, a bacterial infection (sepsis) could quickly become life-threatening.
The spread of an infection in this manner is of special concern when unskilled
practitioners perform abortions in non-sterile conditions. Sepsis is also associated
with sexually transmitted bacterial infections, especially gonorrhea and
chlamydia. These increase a woman’s risk for pelvic inflammatory disease (PID),
infection of the uterine tubes or other reproductive organs. Even when resolved,
PID can leave scar tissue in the tubes, leading to infertility.

The Uterus and Cervix

The uterus is the muscular organ that nourishes and supports the growing
embryo. Its average size is approximately 5 cm wide by 7 cm long (approximately
2 in by 3 in) when a female is not pregnant. It has three sections. The portion of
the uterus superior to the opening of the uterine tubes is called the fundus. The
middle section of the uterus is called the body of uterus (or corpus). The cervix is
the narrow inferior portion of the uterus that projects into the vagina. The cervix
produces mucus secretions that become thin and stringy under the influence of
high systemic plasma estrogen concentrations, and these secretions can facilitate
sperm movement through the reproductive tract.

Several ligaments maintain the position of the uterus within the abdominopelvic
cavity. The broad ligament is a fold of peritoneum that serves as a primary
support for the uterus, extending laterally from both sides of the uterus and
attaching it to the pelvic wall. The round ligament attaches to the uterus near the
uterine tubes, and extends to the labia majora. Finally, the uterosacral ligament
stabilizes the uterus posteriorly by its connection from the cervix to the pelvic
wall.

The wall of the uterus is made up of three layers. The most superficial layer is the
serous membrane, or perimetrium, which consists of epithelial tissue that covers
the exterior portion of the uterus. The middle layer, or myometrium, is a thick
layer of smooth muscle responsible for uterine contractions. Most of the uterus is
myometrial tissue, and the muscle fibers run horizontally, vertically, and
diagonally, allowing the powerful contractions that occur during labor and the
less powerful contractions (or cramps) that help to expel menstrual blood during
a woman’s period. Anteriorly directed myometrial contractions also occur near
the time of ovulation, and are thought to possibly facilitate the transport of sperm
through the female reproductive tract.

The innermost layer of the uterus is called the endometrium. The endometrium
contains a connective tissue lining, the lamina propria, which is covered by
epithelial tissue that lines the lumen. Structurally, the endometrium consists of
two layers: the stratum basalis and the stratum functionalis (the basal and
functional layers). The stratum basalis layer is part of the lamina propria and is
adjacent to the myometrium; this layer does not shed during menses. In contrast,
the thicker stratum functionalis layer contains the glandular portion of the lamina
propria and the endothelial tissue that lines the uterine lumen. It is the stratum
functionalis that grows and thickens in response to increased levels of estrogen
and progesterone. In the luteal phase of the menstrual cycle, special branches off
of the uterine artery called spiral arteries supply the thickened stratum
functionalis. This inner functional layer provides the proper site of implantation
for the fertilized egg, and—should fertilization not occur—it is only the stratum
functionalis layer of the endometrium that sheds during menstruation.

Recall that during the follicular phase of the ovarian cycle, the tertiary follicles are
growing and secreting estrogen. At the same time, the stratum functionalis of the
endometrium is thickening to prepare for a potential implantation. The post-
ovulatory increase in progesterone, which characterizes the luteal phase, is key
for maintaining a thick stratum functionalis. As long as a functional corpus luteum
is present in the ovary, the endometrial lining is prepared for implantation.
Indeed, if an embryo implants, signals are sent to the corpus luteum to continue
secreting progesterone to maintain the endometrium, and thus maintain the
pregnancy. If an embryo does not implant, no signal is sent to the corpus luteum
and it degrades, ceasing progesterone production and ending the luteal phase.
Without progesterone, the endometrium thins and, under the influence of
prostaglandins, the spiral arteries of the endometrium constrict and rupture,
preventing oxygenated blood from reaching the endometrial tissue. As a result,
endometrial tissue dies and blood, pieces of the endometrial tissue, and white
blood cells are shed through the vagina during menstruation, or the menses. The
first menses after puberty, called menarche, can occur either before or after the
first ovulation.

PHYSIOLOGY

The Menstrual Cycle

Now that we have discussed the maturation of the cohort of tertiary follicles in
the ovary, the build-up and then shedding of the endometrial lining in the uterus,
and the function of the uterine tubes and vagina, we can put everything together
to talk about the three phases of the menstrual cycle—the series of changes in
which the uterine lining is shed, rebuilds, and prepares for implantation.

The timing of the menstrual cycle starts with the first day of menses, referred to
as day one of a woman’s period. Cycle length is determined by counting the days
between the onset of bleeding in two subsequent cycles. Because the average
length of a woman’s menstrual cycle is 28 days, this is the time period used to
identify the timing of events in the cycle. However, the length of the menstrual
cycle varies among women, and even in the same woman from one cycle to the
next, typically from 21 to 32 days.

Just as the hormones produced by the granulosa and theca cells of the ovary
“drive” the follicular and luteal phases of the ovarian cycle, they also control the
three distinct phases of the menstrual cycle. These are the menses phase, the
proliferative phase, and the secretory phase.

Menses Phase

The menses phase of the menstrual cycle is the phase during which the lining is
shed; that is, the days that the woman menstruates. Although it averages
approximately five days, the menses phase can last from 2 to 7 days, or longer. As
shown in Figure 7, the menses phase occurs during the early days of the follicular
phase of the ovarian cycle, when progesterone, FSH, and LH levels are low. Recall
that progesterone concentrations decline as a result of the degradation of the
corpus luteum, marking the end of the luteal phase. This decline in progesterone
triggers the shedding of the stratum functionalis of the endometrium.
Figure 7. Click for a larger image. The correlation of the hormone levels and their
effects on the female reproductive system is shown in this timeline of the ovarian
and menstrual cycles. The menstrual cycle begins at day one with the start of
menses. Ovulation occurs around day 14 of a 28-day cycle, triggered by the LH
surge.

Proliferative Phase

Once menstrual flow ceases, the endometrium begins to proliferate again,

marking the beginning of the proliferative phase of the menstrual cycle. It occurs
when the granulosa and theca cells of the tertiary follicles begin to produce
increased amounts of estrogen. These rising estrogen concentrations stimulate
the endometrial lining to rebuild.

Recall that the high estrogen concentrations will eventually lead to a decrease in
FSH as a result of negative feedback, resulting in atresia of all but one of the
developing tertiary follicles. The switch to positive feedback—which occurs with
the elevated estrogen production from the dominant follicle—then stimulates the
LH surge that will trigger ovulation. In a typical 28-day menstrual cycle, ovulation
occurs on day 14. Ovulation marks the end of the proliferative phase as well as
the end of the follicular phase.

Secretory Phase

In addition to prompting the LH surge, high estrogen levels increase the uterine
tube contractions that facilitate the pick-up and transfer of the ovulated oocyte.
High estrogen levels also slightly decrease the acidity of the vagina, making it
more hospitable to sperm. In the ovary, the luteinization of the granulosa cells of
the collapsed follicle forms the progesterone-producing corpus luteum, marking
the beginning of the luteal phase of the ovarian cycle. In the uterus, progesterone
from the corpus luteum begins the secretory phase of the menstrual cycle, in
which the endometrial lining prepares for implantation. Over the next 10 to 12
days, the endometrial glands secrete a fluid rich in glycogen. If fertilization has
occurred, this fluid will nourish the ball of cells now developing from the zygote.
At the same time, the spiral arteries develop to provide blood to the thickened
stratum functionalis.

If no pregnancy occurs within approximately 10 to 12 days, the corpus luteum will

degrade into the corpus albicans. Levels of both estrogen and progesterone will
fall, and the endometrium will grow thinner. Prostaglandins will be secreted that
cause constriction of the spiral arteries, reducing oxygen supply. The endometrial
tissue will die, resulting in menses—or the first day of the next cycle.

The Breasts

Whereas the breasts are located far from the other female reproductive organs,
they are considered accessory organs of the female reproductive system. The
function of the breasts is to supply milk to an infant in a process called lactation.
The external features of the breast include a nipple surrounded by a
pigmented areola, whose coloration may deepen during pregnancy. The areola is
typically circular and can vary in size from 25 to 100 mm in diameter. The areolar
region is characterized by small, raised areolar glands that secrete lubricating fluid
during lactation to protect the nipple from chafing. When a baby nurses, or draws
milk from the breast, the entire areolar region is taken into the mouth.
Breast milk is produced by the mammary glands, which are modified sweat
glands. The milk itself exits the breast through the nipple via 15 to 20 lactiferous
ducts that open on the surface of the nipple. These lactiferous ducts each extend
to a lactiferous sinus that connects to a glandular lobe within the breast itself
that contains groups of milk-secreting cells in clusters called alveoli. The clusters
can change in size depending on the amount of milk in the alveolar lumen. Once
milk is made in the alveoli, stimulated myoepithelial cells that surround the alveoli
contract to push the milk to the lactiferous sinuses. From here, the baby can draw
milk through the lactiferous ducts by suckling. The lobes themselves are
surrounded by fat tissue, which determines the size of the breast; breast size
differs between individuals and does not affect the amount of milk produced.
Supporting the breasts are multiple bands of connective tissue called suspensory
ligaments that connect the breast tissue to the dermis of the overlying skin.

Figure 9. During lactation, milk moves from the alveoli through the lactiferous
ducts to the nipple.
During the normal hormonal fluctuations in the menstrual cycle, breast tissue
responds to changing levels of estrogen and progesterone, which can lead to
swelling and breast tenderness in some individuals, especially during the
secretory phase. If pregnancy occurs, the increase in hormones leads to further
development of the mammary tissue and enlargement of the breasts.

AGING AND THE FEMALE REPRODUCTIVE SYSTEM

Female fertility (the ability to conceive) peaks when women are in their twenties,
and is slowly reduced until a women reaches 35 years of age. After that time,
fertility declines more rapidly, until it ends completely at the end of menopause.
Menopause is the cessation of the menstrual cycle that occurs as a result of the
loss of ovarian follicles and the hormones that they produce. A woman is
considered to have completed menopause if she has not menstruated in a full
year. After that point, she is considered postmenopausal. The average age for this
change is consistent worldwide at between 50 and 52 years of age, but it can
normally occur in a woman’s forties, or later in her fifties. Poor health, including
smoking, can lead to earlier loss of fertility and earlier menopause.

As a woman reaches the age of menopause, depletion of the number of viable

follicles in the ovaries due to atresia affects the hormonal regulation of the
menstrual cycle. During the years leading up to menopause, there is a decrease in
the levels of the hormone inhibin, which normally participates in a negative
feedback loop to the pituitary to control the production of FSH. The menopausal
decrease in inhibin leads to an increase in FSH. The presence of FSH stimulates
more follicles to grow and secrete estrogen. Because small, secondary follicles
also respond to increases in FSH levels, larger numbers of follicles are stimulated
to grow; however, most undergo atresia and die. Eventually, this process leads to
the depletion of all follicles in the ovaries, and the production of estrogen falls off
dramatically. It is primarily the lack of estrogens that leads to the symptoms of
menopause.

The earliest changes occur during the menopausal transition, often referred to as
peri-menopause, when a women’s cycle becomes irregular but does not stop
entirely. Although the levels of estrogen are still nearly the same as before the
transition, the level of progesterone produced by the corpus luteum is reduced.
This decline in progesterone can lead to abnormal growth, or hyperplasia, of the
endometrium. This condition is a concern because it increases the risk of
developing endometrial cancer. Two harmless conditions that can develop during
the transition are uterine fibroids, which are benign masses of cells, and irregular
bleeding. As estrogen levels change, other symptoms that occur are hot flashes
and night sweats, trouble sleeping, vaginal dryness, mood swings, difficulty
focusing, and thinning of hair on the head along with the growth of more hair on
the face. Depending on the individual, these symptoms can be entirely absent,
moderate, or severe.

After menopause, lower amounts of estrogens can lead to other changes.

Cardiovascular disease becomes as prevalent in women as in men, possibly
because estrogens reduce the amount of cholesterol in the blood vessels. When
estrogen is lacking, many women find that they suddenly have problems with high
cholesterol and the cardiovascular issues that accompany it. Osteoporosis is
another problem because bone density decreases rapidly in the first years after
menopause. The reduction in bone density leads to a higher incidence of
fractures.

Hormone therapy (HT), which employs medication (synthetic estrogens and

progestins) to increase estrogen and progestin levels, can alleviate some of the
symptoms of menopause. In 2002, the Women’s Health Initiative began a study to
observe women for the long-term outcomes of hormone replacement therapy
over 8.5 years. However, the study was prematurely terminated after 5.2 years
because of evidence of a higher than normal risk of breast cancer in patients
taking estrogen-only HT. The potential positive effects on cardiovascular disease
were also not realized in the estrogen-only patients. The results of other hormone
replacement studies over the last 50 years, including a 2012 study that followed
over 1,000 menopausal women for 10 years, have shown cardiovascular benefits
from estrogen and no increased risk for cancer. Some researchers believe that the
age group tested in the 2002 trial may have been too old to benefit from the
therapy, thus skewing the results. In the meantime, intense debate and study of
the benefits and risks of replacement therapy is ongoing. Current guidelines
approve HT for the reduction of hot flashes or flushes, but this treatment is
generally only considered when women first start showing signs of menopausal
changes, is used in the lowest dose possible for the shortest time possible (5 years
or less), and it is suggested that women on HT have regular pelvic and breast
exams.

Before menopause, a woman's periods typically become irregular,which

means that periods may be longer or shorter in duration or be lighter or heavier
in the amount of flow. During this time, women often experience hot flashes;
these typically last from 30 seconds to ten minutes and may be associated with
shivering, sweating, and reddening of the skin. Hot flashes often stop occurring
after a year or two. Other symptoms may include vaginal dryness, trouble
sleeping, and mood changes. The severity of symptoms varies between
women.[8]While menopause is often thought to be linked to an increase in heart
disease, this primarily occurs due to increasing age and does not have a direct
relationship with menopause. In some women, problems that were present
like endometriosis or painful periods will improve after menopause.

Menopause is usually a natural change. It can occur earlier in those

who smoke tobacco. Other causes include surgery that removes both ovaries or
some types of chemotherapy. At the physiological level, menopause happens
because of a decrease in the ovaries' production of the
hormones estrogen and progesterone. While typically not needed, a diagnosis of
menopause can be confirmed by measuring hormone levels in the blood or
urine. Menopause is the opposite of menarche, the time when a girl's periods
start.

Specific treatment is not usually needed. Some symptoms, however, may

be improved with treatment. With respect to hot flashes, avoiding smoking,
caffeine, and alcohol is often recommended. Sleeping in a cool room and using a
fan may help. The following medications may help: menopausal hormone
therapy (MHT), clonidine, gabapentin, or selective serotonin reuptake
inhibitors. Exercise may help with sleeping problems. While MHT was once
routinely prescribed, it is now only recommended in those with significant
symptoms, as there are concerns about side effects. High-quality evidence for the
effectiveness of alternative medicine has not been found. There is tentative
evidence for phytoestrogens.

Causes

Menopause can be induced or occur naturally. Induced menopause occurs

as a result of medical treatment such
as chemotherapy, radiotherapy, oophorectomy, or complications of tubal
ligation, hysterectomy, unilateral salpingo-oophorectomy or leuprorelin usage.

Age

Menopause typically occurs between 49 and 52 years of age.[3] In India and

the Philippines, the median age of natural menopause is considerably earlier, at
44 years.

In rare cases, a woman's ovaries stop working at a very early age, ranging
anywhere from the age of puberty to age 40. This is known as premature ovarian
failure and affects 1 to 2% of women by age 40.[31]

Undiagnosed and untreated coeliac disease is a risk factor for early

menopause. Coeliac disease can present with several non-gastrointestinal
symptoms, in the absence of gastrointestinal symptoms, and most cases escape
timely recognition and go undiagnosed, leading to a risk of long-term
complications. A strict gluten-free diet reduces the risk. Women with early
diagnosis and treatment of coeliac disease present a normal duration of fertile life
span.

Women who have undergone hysterectomy with ovary conservation go

through menopause on average 3.7 years earlier than the expected age. Other
factors that can promote an earlier onset of menopause (usually 1 to 3 years
early) are smoking cigarettes or being extremely thin.[34]

Premature ovarian failure

Premature ovarian failure (POF) is the cessation of the ovarian function

before the age of 40 years. It is diagnosed or confirmed by high blood levels
of follicle stimulating hormone (FSH) and luteinizing hormone (LH) on at least
three occasions at least four weeks apart.

Known causes of premature ovarian failure include autoimmune

disorders, thyroid disease, diabetes mellitus, chemotherapy, being a carrier of
the fragile X syndrome gene, and radiotherapy.[36] However, in about 50–80% of
spontaneous cases of premature ovarian failure, the cause is unknown, i.e., it is
generally idiopathic.

Women who have a functional disorder affecting the reproductive system

(e.g., endometriosis, polycystic ovary syndrome, cancer of the reproductive
organs) can go into menopause at a younger age than the normal timeframe. The
functional disorders often significantly speed up the menopausal process.

An early menopause can be related to cigarette smoking, higher body mass

index, racial and ethnic factors, illnesses, and the surgical removal of the ovaries,
with or without the removal of the uterus.

Rates of premature menopause have been found to be significantly higher

in fraternal and identical twins; approximately 5% of twins reach menopause
before the age of 40. The reasons for this are not completely understood.
Transplants of ovarian tissue between identical twins have been successful in
restoring fertility.
 Surgical menopause

Menopause can be surgically induced by bilateral oophorectomy (removal

of ovaries), which is often, but not always, done in conjunction with removal of
the Fallopian tubes (salpingo-oophorectomy) and uterus
(hysterectomy). Cessation of menses as a result of removal of the ovaries is called
"surgical menopause". The sudden and complete drop in hormone levels usually
produces extreme withdrawal symptoms such as hot flashes, etc.

Removal of the uterus without removal of the ovaries does not directly
cause menopause, although pelvic surgery of this type can often precipitate a
somewhat earlier menopause, perhaps because of a compromised blood supply
to the ovaries.

Mechanism

Bone loss due to menopause occurs due to changes in a woman's hormone

levels.

The menopausal transition, and postmenopause itself, is a natural change,

not usually a disease state or a disorder. The main cause of this transition is the
natural depletion and aging of the finite amount of oocytes (ovarian reserve). This
process is sometimes accelerated by other conditions and is known to occur
earlier after a wide range of gynecologic procedures such as hysterectomy (with
and without ovariectomy), endometrial ablation and uterine artery embolisation.
The depletion of the ovarian reserve causes an increase in circulating follicle-
stimulating hormone (FSH) and luteinizing hormone (LH) levels because there are
fewer oocytes and follicles responding to these hormones and producing
estrogen.

The transition has a variable degree of effects.

The stages of the menopause transition have been classified according to a

woman's reported bleeding pattern, supported by changes in the pituitary follicle-
stimulating hormone (FSH) levels.

In younger women, during a normal menstrual cycle the ovaries

produce estradiol, testosterone and progesterone in a cyclical pattern under the
control of FSH and luteinising hormone (LH) which are both produced by
the pituitary gland. During perimenopause (approaching
menopause), estradiol levels and patterns of production remain relatively
unchanged or may increase compared to young women, but the cycles become
frequently shorter or irregular. The often observed increase in estrogen is
presumed to be in response to elevated FSH levels that, in turn, is hypothesized to
be caused by decreased feedback by inhibin.[43] Similarly, decreased inhibin
feedback after hysterectomy is hypothesized to contribute to increased ovarian
stimulation and earlier menopause.

The menopausal transition is characterized by marked, and often dramatic,

variations in FSH and estradiol levels. Because of this, measurements of these
hormones are not considered to be reliable guides to a woman's exact
menopausal status.

Menopause occurs because of the sharp decrease of estradiol and

progesterone production by the ovaries. After menopause, estrogen continues to
be produced mostly by aromatase in fat tissues and is produced in small amounts
in many other tissues such as ovaries, bone, blood vessels, and the brain where it
acts locally. The substantial fall in circulating estradiol levels at menopause
impacts many tissues, from brain to skin.

In contrast to the sudden fall in estradiol during menopause, the levels of

total and free testosterone, as well as dehydroepiandrosterone sulfate (DHEAS)
and androstenedione appear to decline more or less steadily with age. An effect
of natural menopause on circulating androgen levels has not been observed. Thus
specific tissue effects of natural menopause cannot be attributed to loss of
androgenic hormone production.

Hot flashes and other vasomotor symptoms accompany the menopausal

transition. While many sources continue to claim that hot flashes during the
menopausal transition are caused by low estrogen levels, this assertion was
shown incorrect in 1935 and, in most cases, hot flashes are observed despite
elevated estrogen levels. The exact cause of these symptoms is not yet
understood, possible factors considered are higher and erratic variation of
estradiol level during the cycle, elevated FSH levels which may indicate
hypothalamic dysregulation perhaps caused by missing feedback by inhibin. It has
been also observed that the vasomotor symptoms differ during early
perimenopause and late menopausal transition and it is possible that they are
caused by a different mechanism.

Long-term effects of menopause may include osteoporosis, vaginal

atrophy as well as changed metabolic profile resulting in cardiac risks.

Ovarian aging:

Decreased inhibin feedback after hysterectomy is hypothesized to

contribute to increased ovarian stimulation and earlier menopause. Hastened
ovarian aging has been observed after endometrial ablation. While it is difficult to
prove that these surgeries are causative, it has been hypothesized that
the endometrium may be producing endocrine factors contributing to the
endocrine feedback and regulation of the ovarian stimulation. Elimination of this
factors contributes to faster depletion of the ovarian reserve. Reduced blood
supply to the ovaries that may occur as a consequence of hysterectomy
and uterine artery embolisation has been hypothesized to contribute to this
effect.

TYPES OF MENOPAUSE
Perimenopause(menopausal transition,MT) :The time period from the first
instance of climacteric symptoms caused by fluctuating hormonal levels to
multiple years after menopause(The duration can vary greatly in different
women.However,the average length of perimenopause is 4 years)

• Premenopause
• The time period from the first occurrence of climacteric irregular
menstruation.

• Onset: usually 45 -55years of age.

 • Characterized by increasingly infrequent menstruation.
• Menopause
• Time at which menstruation ceases permanently.
• Confirmed after 12 months of amenorrhea.
• The average age at menopause is 49-52 years.
• Post menopause: The time period beginning 12 months after the last
menstrual period.

CLINICAL PRESENTATION
SYMPTOMS:
• Hot flashes
• Irregular periods
• Fatigue
• Memory lapses
• Night sweats
• Loss of libido
• Vaginal dryness
• Mood swings
• Panic disorders
• Urinary tract infections
• Bloating
• Hair loss or thinning
• Sleep disorders
• Dizziness
• Weight gain
• Incontinence
• Headaches
• Burning tongue
 • Digestive problems
• Muscle tension
• Allergies
• Brittle nails
• Body odor change
• Itchy skin
• Osteoporosis
• Tingling extremities
• Insomnia
• Difficulty concentrating
• Irregular heart beat
• Anxiety
• Depression
• Breast pain
• Joint pain
• Electric shock sensation
• Psychological symptoms
• Mood swings
• Fatigue
• Depression
• Anxiety
• Irritability
• Feelings of dread
• Cognitive symptoms
• Difficulty concentrating
• Memory lapses
• Vasomotor symptoms
• Changes in body odor
 • Hot flashes
• Night sweats
• Oral symptoms
• Burning tongue
• Gum problems
• Nervous system symptoms
• Electric shock sensation
• Tingling extremities
COMPLICATIONS
• Cardiovascular disease
• Musculoskeletal disease
• Cancer in middle aged and elderly women
• Cognitive impairment and dementia
• Chronic respiratory disease
• Diabetes
• Metabolic health
• Depressive disorders
• Vasomotor symptoms or hot flashes
• Insomnia
• Urinary incontinence
• Osteoporosis
• Weight gain
• Migraine
• Prolapse
DIAGNOSIS:
BONE MINERAL DENSITY TESTING DURING MENOPAUSE
It is important for menopausal women to get bone mineral density testing,also
known as bone densitometry.

• Bone mineral density testing is the gold standard for diagnosing

osteoporosis in certain bones

• There is direct relationship between the lack of estrogen after menopause

and the contribution to osteoporosis,because symptoms of osteoporosis
may not develop until bone loss is extensive,it is important for women at
risk for osteoporosis to undergo regular bone testing

• The procedure can be performed by many methods:

DUAL ENERGY X-RAY ABSORPTIOMETRY(DEXA):

DEXA is the most accurate method for measuring bone mineral density.

• Two x-ray beams are projected onto the bones,the amount of each x-ray
beam that is blocked by bone and soft tissue are compared to estimate the
bone density.

• DEXA scanning is fast and exposes the person to very low doses of
radiation,it is used to measure bone density in the hip and the spine

PERIPHERAL DUAL ENERGY X-RAY ABSORPTIOMETRY(P-DEXA)

P-DEXA is a modification of the DEXA test

• It measures bone density outlying or peripheral areas of the body,such as

the wrist.
 • P-DEXA exposes the person to very low doses of radiation,the results can
be obtained faster than DEXA.

• P-DEXA cannot be used to measure density of the bones in the hip and
spine and it has limited usefulness for monitoring the effects of medication
used to treat osteoporosis.

QUANTITATIVE COMPUTED TOMOGRAPHY(QCT):

This test can predict fracture risks and can monitor the effects of therapy

• However,it exposes people to higher radiation doses than DEXA.

• QCT scanning of the spine is the most sensitive method for diagnosing
osteoporosis,because it measures trabecular bone within vertebral body

• When compared to a DEXA scanning,QCT is more expensive

ULTRASOUND:

This method uses sound waves bounced off the bones to measure bone mineral
density,usually in the heel.

• Ultrasound is rapid ,painless and doesnot use potentially harmful radiation

• Ultrasound cannot be used to measure bone density of the bones in the hip
and spine and it has limited usefulness for monitoring the effects of
medication used to treat osteoporosis,this test helps predict the risks of
fracture

DUAL PHOTON ABSORPTIOMETRY(DPA):

DPA uses a radioactive substance to produce radiation.It can measure the density
of the bones of the hip and spine.DPA exposes the person to very low
radiation(rarely used)

URODYNAMICS:

Urodynamics(UDS)is the gold standard diagnostic tool for objectively diagnosing

lower urinary tract (LUT)dysfunction,including incontinence.

• Although a medical history ,physical examination,and other evaluations are

critical to determining the etiology of complex LUT symptoms ,they may
not adequately predict the condition's pathophysiology .UDS is used to:

• identify factors contributing to LUT dysfunction and assess their relevance .

• predict the consequences of LUT dysfunction on the upper urinary tracts.

• predict the consequences and outcomes of therapeutic intervention .

• confirm and understand the effects of interventional techniques

• investigate the reasons for treatment failure

Results of UDS investigation should always be compared with the patient's signs
and symptoms and interpreted in conjunction with her expressed symptoms and
voiding diary,along with their clinical findings

ASSESSMENT:

Digital evaluation of the vagina:

• This is an invasive technique of a sensitive area and requires great skill.

 • The patient is comfortably supported in half-lying with knees crooked and
apart.

• The physiotherapist wearing disposable gloves and using a lubricant

jelly,gently and slowly inserts the index and middle fingers into the vagina

• The therapist palpates the posterior vaginal wall with the distal two
phalanges,then judges the strength of the muscles by withdrawing the
fingers gently while the patient is asked to hold the fingers there.

• Strong muscles will squeeze the fingers firmly,thus a graded assessment

maybe :0nil,1 poor,2 fair,3 good ,4 very good condition.

PERIONOMETER:

A vaginal pressure guage or perionometer maybe used to assess the assess the
progress of muscle strength and it is often encouraging because it is visual.

• The guage needs some experience to be used properly since a gluteal or

abdominal contraction can give a misleading reading.

PAD TEST:

• This is an objective test of improved function,it is used in urodynamic

studies.

• First the patients voids,then wears a pre-weighed sanitary pad ,after

drinking 1000ml of fluid,she rests for 45 minutes,then exercises for 30
minutes (which includes walking,climbing stairs,coughing,jumping and
handwashing under running water)
 • The pad is re-weighed, the resulting measurement is given in grams of urine
lost.

INVESTIGATIONS :

• Blood sugar estimation

• Renal and liver function tests

• Lipid profile

• Pelvic ultrasonography

• endometrial sampling

• Bone densitometry

• Hysteroscopy with endometrial biopsy

• Pippelle smear

• FSH-Follicular stimulating hormone

• Estradiol

• TSH-Thyroid stimulating hormone

• Ovarian biopsy

• Prolactin levels

• Oestrogen levels

• HDL and LDL levels

• Breast examination
 MANAGEMENT

MEDICAL MANAGEMENT:

HORMONAL THERAPY:

Hormone therapy (HT) is one of the government-approved treatments for

relief of menopausal symptoms. These symptoms, caused by lower levels of
estrogen at menopause, include hot flashes, sleep disturbances, and vaginal
dryness. HT is also approved for the prevention of osteoporosis. Today, clinicians
prescribe much lower doses for much shorter terms (3-5 years) than before
2002.To begin this discussion about the benefits and risks of menopausal HT, here
is some background information.

There are three benchmark stages of natural menopause:

• Perimenopause (or the menopause transition) is the span of time between

the start of symptoms (such as erratic periods) and 1 year after the final
menstrual period.

• Menopause is confirmed 1 year (12 months) after the final menstrual

period.

• Postmenopause is all the years beyond menopause.

There are two basic types of HT:

• ET means estrogen-only therapy. Estrogen is the hormone that provides the

most menopausal symptom relief. ET is prescribed for women without a
uterus due to a hysterectomy.
 • EPT means combined estrogen plus progestogen therapy. Progestogen is
added to ET to protect women with a uterus against uterine (endometrial)
cancer from estrogen alone.

There are two general ways to take HT:

• Systemic products circulate throughout the bloodstream and to all parts of

the body. They are available as an oral tablet, patch, gel, emulsion, spray,
or injection and can be used for hot flashes and night sweats, vaginal
symptoms, and osteoporosis.

• Local (nonsystemic) products affect only a specific or localized area of the

body. They are available as a cream, ring, or tablet and can be used for
vaginal symptoms.

NUTRITION AND SUPPLEMENTS DURING MENOPAUSE:

• Soy beans-for hot flashes

• flaxseed-easing night sweats

• dong quai(angelica sinensis)-for hot flashes

• Black cohosh(cumicifuga racemosa)-for hot flashes

• Vitamin E

• B-Vitamins

• Evening primrose oil or black current oil

• Probiotics

• Calcium supplements-preventing bone loss

• Omega-3 fatty acids

• Multivitamin

• Vitamin D supplements-for absorption of calcium

• Vaginal estrogen:To relieve vaginal dryness,estrogen can be administered

directly to the vagina using a vaginal cream,tablet or ring.This treatment
releases just a small amount of estrogen ,which is absorbed by the vaginal
tissues.It can help relieve vaginal dryness,discomfort with intercourse and
some urinary symptoms

• Low-dose antidepressants:Certain antidepressants related to the class of

drugs called selective serotonin reuptake inhibitors(SSRIs) may decrease
menopausal hot flashes.A low dose anti depressant for management of hot
flashes maybe useful for women who can't take estrogen for health reasons
for women who need an antidepressant for mood disorder.

• Gabapentin(neurontin,Gralise,others):Gabapentin is approved to treat

seizures,but it has also been shown to help hot flashes.This drug is useful in
women who can't use estrogen therapy and in those who have nighttime
hot flashes

• Clonidine(catapres,kapvay,others):Clonidine,a pill or patch typically used to

treathigh blood pressure,might provide some relief from hot flashes

• Medications to prevent or treat osteoporosis:Depending on individuals

needs,doctors may recommend medication to prevent or treat
osteoporosis.Several medications are available that help reduce bone loss
and risk of fractures.Vitamin D supplements are recommended
 • Bioidentical hormones :These hormones come plant sources .The
term"Bioidentical" implies the hormines in the product are chemically
identical to those your body produces.However,though there are some
commercially available bioidentical hormones approved by the Food and
Drug Administration(FDA), many preparations are compounded-mixed in a
pharmacy according to a doctor's prescription -and aren't regulated by the
FDA,so quality and risks could vary.There's also no scientific evidence that
biomedical hormones work any better than traditional hormone therapy in
easing menopause symptoms

ALTERNATIVE MEDICINE:

• Plant estrogens:These estrogens occur naturally in certain foods.There are

main types of phytoestrogens-isoflavones and lignans.Isoflavones are found
in soybeans,lentils,chickpeas and other legumes.Lignans occur in flaxseed
,whole grains,and some fruits and vegetables.The herb sage is thought to
contain compounds with estrogen-like effects ,and there's good evidence
that it can effectively manage menopause symptoms.

ACUPUNCTURE:

• Acupuncture is a traditional Chinese medicine technique. The acupuncturist

inserts thin sterile needles through the skin at specific points on the body
where qi, or vital energy, runs. These points are called “acupuncture
points”, such as Guanyuan Ren-4, Quchi LI-11, and Sanyinjiao SP-6. The
needles are placed and kept on these points for about 20 minutes to
stimulate energy. Endorphins, the body’s natural painkillers may be
released as well.
 • Acupuncture can not only control pain, it can also increase blood flow and
bring the energy flow back into balance, which maybe useful for alleviating
symptoms of menopause.

• hot flushes

• night sweats

• insomnia

• anxiety

• depression

• fatigue

• mood swings

• headaches and migraine

• palpitations

• pain (low back pain, neck pain, osteoarthritis/knee pain).

• It affect the nerves and muscles involved in bladder control

HYPNOTHERAPY:

Hypnotherapy is a type of complementary and alternative medicine in which the

mind is used in an attempt to help with a variety of problems, such as breaking
bad habits or coping with stress.

It is used for a wide variety of applications, and studies into its efficacy are often
of poor quality which makes it difficult to determine efficacy. Several recent
meta-analyses and systematic reviews of the literature on various conditions have
concluded that the efficacy of hypnotherapy is "not verified", that there is no
evidence or insufficient evidence for efficacy.

• A form of psychotherapy ,hypnotherapy is used to create subconscious

changes in the form of new responses,thoughts,attitudes and
behaviors.This access to the subconscious mind is thought to re-establish
the connection between the bladder and the brain.

Hypnotherapy can help women manage their menopausal symptoms, and

the life transitions that accompany the menopause, at several levels.

What many women find most frustrating during this time is symptoms, which can
range from mild to debilitating and include hot flushes, insomnia, anxiety and
cognitive impairment. Hypnotherapy can help by increasing an awareness of the
connection between the mind and body, helping women to understand and
control hot flushes and develop means of dealing with insomnia and anxiety
through relaxation techniques and by helping them to shift perspective.

Hypnotherapy also helps women at a much deeper level than symptom

alleviation. The menopause is a time of transition which may bring old memories
and concerns to the surface. Any transitional times in life require consideration of
how our future will be. In order to allow change to happen and move forward,
hypnotherapy can help women deal with past experiences which they may have
denied or ignored for some time. There is often a link between unresolved hurt
and anger and physical symptoms such as flushes and insomnia, which are
successfully acknowledged and dealt with through hypnotherapy.
Although many women see the menopause initially in a negative light, it is a time
of change which can lead to many new opportunities. These include career and
creative opportunities. Hypnotherapy can help women navigate their way
through this transition in a positive and empowered manner.

SURGICAL MANAGEMENT:

Surgical menopause occurs when a premenopausal woman has her ovaries

surgically removed in a procedure called a bilateral oophorectomy. This causes an
abrupt menopause, with women often experiencing more severe menopausal
symptoms than they would if they were to experience menopause naturally.

In most cases, bilateral oophorectomy is performed because of cancer,

including cervical, endometrial (cancer of the uterus), and ovarian cancer.
However, it may occasionally be done to treat noncancerous conditions such as
uterine fibroids, endometriosis, or infections.

Hysterectomy,(the surgical removal of the uterus) can sometimes, though

not always, include bilateral oophorectomy. Hysterectomy that does not involve
removal of the ovaries usually does not result in menopause. Even though menses
will stop once the uterus is removed, the ovaries will probably continue to
function.

Other surgeries that may involve the removal of both ovaries include:

Abdominal resection. This is a surgical procedure done to treat colon and rectal
cancer. While this surgery usually involves the removal of the lower colon and
rectum, it can also include partial or total removal of the uterus and ovaries, as
well as the rear wall of the vagina.
Total pelvic exenteration. This procedure is usually only performed in cases of
cervical cancer that recurs despite treatment with surgery and radiation. It
involves the removal of most pelvic organs, including the uterus, cervix, ovaries,
and fallopian tubes, vagina, bladder, urethra, and part of the rectum.

Medical treatments such as chemotherapy and pelvic radiation therapy can

cause menopause by damaging the ovaries. However, not all premenopausal
women undergoing these procedures will experience induced menopause.
Additionally, even if the ovaries are damaged, the damage is not always
permanent.

PHYSIOTHERAPY MANAGEMENT :

• Women today are more competent and independent as

compared to those of the previous era

• They have redefined gender roles,claimed more authority

and freedom for themselves and proved their potential to the

fullest

• However,in the process of fighting for equality and carving a niche

for themselves ,its usually their health thats neglected

• Here are a few benefits of physiotherapy for some of the top issues
faced by women

• Women by nature are caregivers and there are numerous pccasions

when they tend to neglect their health inorder to help a loved one
 • This neglect can cause a number of health complications as they
grow older

• Preventive health care is much better than taking medications after

being diagnosed with a health condition

• Physiotherapy is one such branch of medicine that help you prevent

a number of health issues when followed diligently

ELECTROTHERAPY FOR MENOPAUSE:

CRANIAL ELECTROTHERAPY STIMULATION(CES) is a form of neurostimulation that

delivers a small,pulsed,alternating current via electrodes on the head

• CES is used with intention of treating a variety of conditions such as

sleep,anxiety,depression and insomnia

• It has been suggested as a possible treatment for

headaches,smoking cessation and opiate withdrawal

ELECTRICAL STIMULATION :It uses a mild electric current to treat Urine

incontinence

• Electrical stimulation helps in better control over the muscles of the

bladder

• MICROCURRENT ELECTROTHERAPY (MET):This therapy is used to promote

the healing of wounds and tansplanted tissues as well as to treat pain
 • MET applies minute micro-amp electrical stimulation to specific places on
the body in order to promote the natural current flow in the tissue and
allow cells in the traumatized region to regain their capacitance and healing

• MET can be effective as the only treatment used for headaches,menstrual

problems

AUDIO-VISUAL ENTERTAINMENT(AVE) :The therapy combines the use of mild

pulsating LED lights in the eye frames and psychoacoustic sounds in headphones
for quick deep realaxation by guiding the brain into various states of brainwave
activity

• Hence,AVE is known as a mind machine that can help in the treatment of

psychological and physiological disorders

• In AVE process ,the adjustable sound makes it easier for the person to focus
and relax in peace,the eyes are specially designed for the allowance of left
and right visual fiels of each of eyes to be stimulated individually rather
than the entire eye ar once

• Regular sessions of this therapy will make the effects for a longer duration
of time

• This therapy leads to less stress,better focus and mood,improved quality of

sleep,high energy and enhanced creativity.

EXERCISE THERAPY:

It is defined as "Activity that is performed or practiced to develop or improve a

specific function or skill to develop and maintain physical fitness
 • Other words used for exercise therapy are Activity based Therapy,Activity
based recovery Therapy,Neuro-based therapy,Restorative therapy

• Exercise therapy is based on the principles of exercise science and when

adapted to the neurologically impaired client,its focus is on recovery of
function above and below the site of injury.

AIMS of Exercise Therapy:

• To improve Circulation

• To improve strength and Power

• To stimulate and increase sensory awareness of movement

• To maintain and increase mobility of the joints

• Enable ambulation

• Improving respiratory capacity

• Release Contracted Soft tissues

• Decrease Stiffness

RELAXATION TECHNIQUES:

"Relaxation" is defined as a state in which the muscles of the body are

comparatively free from tension,this is because functioning muscles can never be
completely free from tension as they retain a certain degree of freedom known as
muscle tone

These methods may be of two types :

 • Methods for general relaxation-which relax the total body

• Methods for local relaxation-which relax a specific part of a body

GENERAL RELAXATION TECHNIQUES

JACOBSON'S PROGRESSIVE RELAXATION:

This method encourages the patients to tense,and then relax sequentially,groups

of muscles while concentrating on the components of tension and relaxation that
are being experienced

• The raionale is that by teaching the patient to contract a muscle and

recognize the symptom or feeling of tension,reduction of tension in daily
life would be possible

• The method appears to be of clinical value ,particularly in

hypertension,epilepsy and respiratory distress

• The muscles targeted in this method are shoulder depressors,elbow

extensors,shoulder abductors,finger and thumb extensors in the upperlimb
and hip lateral rotators ankle dorsiflexors,trunk flexors,neck extensors

MITCHELL'S SIMPLE PHYSIOLOGICAL RELAXATION:

This is based mainly on the physiological principle that in an action involving

group muscles,there is reciprocal innervation of opposing groups,whereby
contraction in agonist muscles is accompanied by reflex relaxation of antagonists

• This eliminates tension while preserving ones awareness about relaxed

posture
RHYTHMICAL PASSIVE MOVEMENT :

Passive movements of the limbs and head may assist in general relaxation in
some cases .Group movements of joints are preferable

LOCAL RELAXATION TECHNIQUES:

If the joint is the source of pain-passive movements should be given in the pain
free range .Deep rhythmical massage also helps in relaxing the area where it is
given.

• Hold relax and contract relax techniques are given to muscles under tension
in the area of pain or their antagonists

• First they are put into isometric contraction by applying maximal resistance
,then the patient is instructed to voluntarily relax those muscles

PROGRESSIVE RELAXATION TRAINING(PRT):

The trainee is asked to focus attention on a particular group of muscles.This group

of muscles is held tense for 5-7 seconds during which trainee concentrates on the
sensation of muscle contraction.On a predetermined word 'release','let go',the
muscle group is relaxed

PASSIVE NEUROMUSCULAR RELAXATION:

The client imagines that he or she is relaxed and is asked to state the phase,"I am
relaxed", and repeats it everytime he breathes out.

• The technique consists of one continuous wave of relaxation which begins

at the crown of head and progress down
 • Relaxation techniques are useful in controlling cardiovascular
disease,depression,insomnia,

KEGEL'S EXERCISES :

Repetitive contractions of the pelvic muscles that control the flow in urination
inorder to strengthen these muscles especially to control or prevent incontinence

• These exercises are said to be effective for conditions such as urinary

incontinence,prolapse of uterus

• Pelvic floor contractions maybe performed in all

positions(sitting,standing,lying).For example,the legs should be slightly
apart ,the therapist guarding against the patient breathholding or
contracting the abdominal or gluteal muscles whilst learning the exercise

• Some proprioception of muscle contraction of muscle contraction can be

achieved by the patient leaning forward in stride sitting,the perineum will
be in contact with the chair seat

• The contractions should be repeated a few times only because of fatigue

• Patients are instructed to perform exercise frequently and are encouraged

to do so during daily activities

• Laycock(1987) described the different demands of fast and slow twitch

fibres,some contractions should last 4-10 seconds and some should last 1
second
 • Stress exercises that raise intra-abdominal pressure (jumping,bending)
should include active pelvic floor contraction before attempting the
activity.

VALSALVA MANEUVER:

This technique is performed by moderately forceful attempted exhalation against

a closed airway,usually done by closing one's mouth and pinching one's nose shut
,temporarily holding their breath during exercise ,the glottis of larynx is closed
keeping air from escaping the lungs while the muscles of the abdomen and ribs
contract

• This technique is useful for conditions like urinary incontinence

BREATHING EXERCISES :The exercises that enhances the respiratory system by

improving ventilation,strengthening respiratory muscles and increasing
endurance.

TYPES OF BREATHING:

• DIAPHRAGMATIC BREATHING

• SEGMENTAL BREATHING:Lateral costal expansion,Posterior basal

expansion,Right middle or lingula expansion,Apical expansion

• PURSED LIP BREATHING

• GLOSSOPHARYNGEAL BREATHING

Breathing exercises are very useful for respiratory conditions

AEROBICS:These are high intensity cardio exercises

 • These are energetic,physical, vigorous exercises to increase cardiovascular
efficiency and increase the amount of oxygen in the blood

• Aerobic exercises ease menopause symptoms like night

sweats,moodswings,Irritability

• Walking,bicycling,dancing,swimming are few of Aerobic exercises

• Exercises like squats,lunges,crunches,waterexercises(pool walking,leg

swings,cross country skiing,arm circles)

STRETCHING AND STRENGTHENING EXERCISES :

Strength training is crucial and can provide an essential type of fitness maintaining
and gaining mucle mass as well as bone density

• These exercises help to combat muscle loss during menopause

• DUMBBELLS:Adding dumbbells to the regimen provides flexibility and

convenience

• WEIGHT MACHINE:They safely work on strengthening muscles,as they

allow a very specific set of movements

• EXERCISE BAND:These are strong, resistant rubber bands with handles at

each end which can be grabbed and stretched

STRETCHING :It is highly beneficial for mental health ,as stretching releases
dopamine,which is a happy hormone
 • Stretching helps in loosening up the muscles and tendons,relieving muscle
fatigue,which makes an individual flexible as well as help with injury
prevention

ENDURANCE EXERCISES:

These exercises are any activity that challenges the cardiorespiratory function and
increases heart rate and breathing for an extended period of time

HYDROTHERAPY:

The uniqueness of water lies in its buoyancy ,which relieves strees on weight
bearing joints and permits movement to take place with reduced gravitational
forces.The benefits of using an exercise pool are:

• The relief of pain and muscle spasm,

• The maintenance or increase in range of motion of joints,

• The strengthening of weak muscles and an increase in their tolerance to

exercise

• The improvement of circulation

• The encouragement of functional activities

• The maintenance and improvement of balance,co-ordination and posture

OCCUPATIONAL THERAPY:"The art and science of directing mans participation in

selected activities to restore ,reinforce and enhance function or performance or
decreased disability and thus ,to promote health".It focuses on improving the well
being of women in menopause
 • Women in menopause experience physical,mental and emotional
conditions that completely change their lives

• Because of its strength based,occupation based focus,the women pursue

healthy living through reflecting on what can bring them
physical,mental,emotional and relational well-being as they progress
through this stage of life

COGNITIVE BEHAVIOURAL THERAPY:

AIMS:

• helps to recognize distorted ,self critical thoughts and question their truth

• helps to replace false assumptions with accurate ones

• encourages to schedule enjoyable social activities

Cognitive behavioural therapy have also been proved to relieve menopausal

symptoms.This therapy increase sleep intervals by changing the sleep practices

This therapy is useful in treating depression,anxiety and insomnia which are the
complications usually seen in menopausal women

ALTERNATIVE THERAPY:

RECREATIONAL THERAPY:It uses recreational activities to improve social and

emotional behaviour ,fine motor skills,gross motor skills and range of motion

• COGNITIVE:improve a client's decision making skills

• EMOTIONAL:journalising as a way to decrease stress and depression and as

a way to express one's emotions
 • SOCIAL:increases co-operation and team building skills

• At the end it's not all about fun and games .It's about having
goals+measurable objectives

MUSIC THERAPY :It is the skillful use of music and musical elements to promote
,maintain and restore mental,physical ,emotional and spiritual health

• It can be used for different issues from stress relief to mental,emotional

and behavioural problems

• It has been show to treat depression,anxiety,insomnia,memory

loss,migraine

• It improves self-expression and communication

• Helps reduce symptoms of psychological disorders

DANCE THERAPY:It is psychotherapeutic use of movement to promote

emotional,social,cognitive and physical integration

• It is a healing approach that involves the use of dance and body movement
to improve physical ,emotional and mental well-being

• In addition,dance therapy is said too reduce stress,improve self -confidence

and enhance mobility and muscle co-ordination

• It is a form of expressive therapy which looks at the correlation between

movement and emotion
AROMA THERAPY:It uses plant materials and aromatic plant oils,including
essential oils and other aroma compounds for improving psychological or physical
wellbeing

• The benefits of aroma therapy include its ability to relieve anxiety and
depression,boost energy levels,speedup healing process,cure
headaches,boost cognition,induce sleep,strengthen immune system,reduce
pain

YOGA:

The word "yoga" itself means to 'unite'-uniting the individual energy with cosmic
energy ;or the various aspects of life to achieve a harmonious whole

Benefits of yoga:

• It is safe(if taught by a competent guru of the system) and conserves

energy,except in conditions like hypertension it would be better to avoid

• There is no strain and it helps to become relaxed and more focused

• It rejuvenates the muscles in a shorter period of time

Yoga asanas or postures are body positions associated with the poostures of
yoga.They maintain well-being and improve the body flexibility and vitality

PRANAYAMA: The meaning of "Prana" is life force ,while "Ayama" signifies control
.Pranayama thus indicates an activity that develops and controls the life
force.Pranayama includes breathing techniques which are as follows:

• ANULOMA-VILOMA-ALTERNATE NOSTRIL BREATHING:This form of

breathing through the nostrils alternately,orients the energy flow in a
 balanced manner and simultaneously makes the person energetic and
relaxed

• BHASTRIKA BREATHING:"Bhastrika" in sanskrit means " bellows" similar to

that used by a blacksmith.This is a forceful breathing exercise both in
inspiration and expiration where the air drawn in and out of the lungs
through the nose equally,deeply and slowly initially and later more rapidly
like the pumping action of the bellows

• BHRAMARI BREATHING:Bhramar means "bee",In this breathing practice a

soft "humming-bee" sound is produced during exhalation,by closing the
ears with the fingers

• KAPALA BHATI:The sanskrit word "kapala" means "skull" (and by

implication ,the brain) and bhati means"shining".Inhalation is slow and
exhalation is prolonged and vigorous with a gap after each expiration

All these techniques play varying roles in purifying the nasal passages and the
lungs ,helping the lungs throw out carbon di oxide and other impurities.They
activate the spleen,pancreas and other abdominal organs

REFERENCES:

• TIDYS PHYSIOTHERAPY TEXTBOOK

• TEXTBOOK OF REHABILITATION BY SUNDER

• PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY BY MARGARET

POLDEN AND JILL MANTLE

• PUBMED
 • GOOGLE SCHOLARS

BIBILIOGRAPHY: