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• Natural Law : every human being will get old

• Women survival is increased year by year
In 2000  the number of elderly woman, who
reaches + 80 years, is increased
• Menopause is usually misinterpreted
– An initial point of descend woman’s function
– “Elderly periode” in woman life

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In the next 3 decades:

- The population with age > 60 years 

- developed countries: 59%
- developing countries : 159%

- In 2020  > 1 billion people

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ACCORDING TO WHO

A 50-YEAR WOMAN
- IN 1990  467 MILLION PEOPLE
- IN 2020  1,2 BILLION PEOPLE

SURVIVAL
- DEVELOPING COUNTRIES : 50-60 YEARS
- DEVELOPED COUNTRIES: 70-80 YEARS

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CENTRAL BEREAU OF STATISTIC

- IN 1997
INDONESIA 201,4 MILLION
WOMEN : 100,9 MILLION
50 YEARS : 14,3 MILLION

- IN 2000
A 50-YEAR WOMAN  15,5 MILLION

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SURVIVAL OF INDONESIA

-AT THE COMMENCEMENT OF

INDEPENDENCE : 45 YEARS
-AT THE COMMENCEMENT OF FIRST
SHORT-TERM DEVELOPMENT/PELITA I
: 48,5 YEARS
-IN 1980 : 50,9 YEARS
-IN 1985 : 61,7 YEARS
-IN 1995 : 66,7 YEARS
-IN 1998 : 69,9 YEARS
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THE AVERAGE OF MENOPAUSAL AGE OF
INDONESIAN WOMEN + 50 YEARS

MENOPAUSAL WOMEN WILL BE ALIVE

FOR 20 YEARS POST MENOPAUSE

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 Chronology of women’s life

The phase of women’s life:

a. Childhood : 00 - 08 years
b. Pre-puberty : 08 - 11 years
c. Puberty : 11 - (12-13) years
d. Reproductive : (12-13) - 40 years
e. Climacterium phase : 40 - 65 years
Pre-menopause : 40 - 49 years
Post-menopause : 49 - 52 years
Pre-senium : 52 - 65 years
f. Senium phase : 65 years above
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Women Aging Process

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 MENSTRUAL CYCLE
Menstruation
• Bleeding  periodic and cyclic from uterus
 discharge from endometrial
• Induced by: GnRH, FSH, LH
• There are 3 phases
– Menstrual phase ( 2 - 5 days )
– Proliferation phase (follicular phase)
– Secretion phase (luteal phase)

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Menstrual
cycle

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What happened during the
menopause :
• Menopause is derived from Greek
– Mensis = month
– Poresis = cessation
The cessation of menstruation due to
absence of ovarian function  out of follicle
/ovum

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 Age effect to the number of primordial follicle

Number The average of

Age primordial cell Limit
of women In both ovaries

5 06 - 09 486.600 28.500 - 750.000

5 12 - 16 382.000 85.000 - 591.000
7 18 - 24 150.000 39.000 - 290.000
11 25 - 31 59.000 81.000 - 228.000
8 32 - 38 74.000 15.000 - 208.000
7 40 - 44 8.300 350 - 23.000

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• Generally, menopause occurs between the
ages of 40 - 50 years, but it can be also:
– Precooks Menopause (premature)
• Chronic diseases (severe anemia, TBC)
• Radiation
• Bilateral Ooforectomy
• Ovarian blood flow disorder
– Late menopause  menstrual > 52 years,
caused by :
• Uterine myoma
• Ovarian Tumor
= Endometrial Ca (95,5 %  age of 45 - 59 years)

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 Pre-menopausal symptoms

Irregular menstruation
Excessive
bleeding/scanty blood
loss
Dizziness, headache
Excessive sweat

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 Disorders of menopause

The factors which induce the presence of complaint :

• The decreased of ovarian function
• Effects : Social-culture, Economy, Environment,
Health and Life standard
• Psychological factors  human relation :
husband, family, and society
• 40 - 80 % of women have complaints

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According to Lauritzen, there are 3 phases
of complaints :

1. Pre-menopausal phase
Menstrual disorders :
– Oligomenorrhoea
– Polymenorrhoea
– Hypo/hypermenorrhoea
– Metrorrhagia

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2. Perimenopausal phase
Menopausal syndromes :

– Hot  Fatigue

– Sweaty  Unstable emotion

– Fear  Muscle pain

– Tense/stress  Headache

– Insomnia  Palpitation

– Nervous  Crampy hands/feet

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3. Post-menopausal phase :
Effect of urogenital system:
– Vulva atrophy / vagina
– Susceptible to infection
– Dyspareunia
– Uterine muscle atrophy:
• Vesicocele
• Rectocele
• Prolapsus uterine

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 Organic changes in
menopausal period
Reproductive Organ
• Thinning of tuba canalis
• Uterus becomes narrow and thinning of
endometrium
• Cervix shrinks  covers vagina (the canal
becomes shorten & narrow)
• Vagina
– Loses Elasticity
– Loses Folds
– The wall of uterus is thinner & vulnerable
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• Vulva : fat tissue is decreased  decrease of
vaginal orifice folds
• Uterine muscle atrophy  prolapse of uterus
• Corpus perineum / anus  atrophy 
incontinentia alvi
• Wall of bladder atrophy
• Tenderness and pendulous breast
• Chronic consequence --> lack of estrogen
– Osteoporosis
– Cardiovascular disease & stroke

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Osteoporosis (porous bones)
• Loss of bone density fracture
• Fracture occurs in women > men
• 85 % of women will have osteoporosis 10 years
after the menopause
• Fracture occurs most frequently at :
– Spine
– Femur
– Carpal
– Sternum
– Pelvis

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 The risk factor which induces osteoporosis
• Racial
• Increasing population of human being
• Obese women
• An early ovarian extraction surgery
• Life style : Smokers, drinkers and less exercises
• Deficiency of calcium absorption in intestine :
Deficiency of vitamin D and rarely get sun shine
• Deficiency of estrogen
• The history of bone disease

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 Osteoporosis can be established :
• Age
• Symptoms :
– Major joint pain
– Crampy bone  spine
– Pain for each movement  decrease of
walking agility
• X-ray  bone x-ray
• Blood calcium test
• Densitometer test

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 Psychological symptoms of
menopause :

1. The rate of complaints are affected by:

– Decrease of ovum activity
– Low socio-culture & environment
– Psychological acceptance

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2. Psychological complaints, such as:
– Fatigue / exhaustion
– Dizziness and headache
– Insomnia
– Apathetic and pessimistic
– Poor concentration
– Stress and depression
– Tense and anxious/ asthma
– Loss of interest in sex

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3.Psychologically  the changes in
menopausal period
– The cessation of the menstruation  free from
pregnancy
– A well-off family : husband has got a position
– The changes of vaginal epithelium

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4. Women’s responds on menopause
– Passive respond: submit to the fate: accept it
and unavoidable
– Neurosis respond: a strong denial, marked by:
Anxiety, unstable emotion and Depression
– Hyperactive respond: a strong denial and as if
ignore it by giving more attention to job and
hobby
– Adequate respond: tolerable respond which is
undergone by most of the women with a
healthy emotion

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 Menopausal Management

• General Management

• The treatment of non-hormonal symptoms

• Physical exercise, sufficient rest associated with
regular diet

• Hormonal treatment

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 HORMONE REPLACEMENT
THERAPY (HRT)
Variety of natural estrogen (HRT)

Estrogen Doses (mg)

• Estrogen equine conjugation0,3 – 0,625
• Esterified Estrogen 0,625
• Micronized Estradiol 0,5 – 1
• 17 -Estradiol 1–2

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 HORMONE REPLACEMENT
THERAPY (HRT)
Variety of natural progesterone (HRT)

Progestogen Doses (mg)

Sequential Continue
• Siproteron Asetat 1 1
• Klormadinon Asetat 1-2 1-2
• Medroksiprogesteron Asetat 10 1
• Didrogesteron 10 2,5

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 Basic Principle of HRT Treatment
• The women who still have uterus the estrogen
treatment must be combined with progesterone
• The women without uterus  sustainable estrogen
treatment only
• Perimenopausal women who still have menstruation
and still desire it  HRT is given sequence
• Perimenopausal women who still desire menstruation
 HRT is given sequence

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 Basic Principle of HRT Treatment
• Perimenopuasal women who do not desire
menstruation  HRT is given continuously
• Type of given estrogen  natural estrogen and
type of given progesteron  a type of progesteron
which is similar with natural progesteron
• HRT treatment is started from a low dose
• The women with libido disorder  estrogen can be
combined with androgen or treated with HRT which
one of its component is androgenic

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 Steps of HRT Treatment

1. Is there any complaint of HRT treatment

2. Menopause counselling
3. Basic examinations
- Anamnesis (history-taking)
- Physical and gynaecological examinations
- Blood chemistry test (for indication)

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 Contraindication of HRT Treatment
• Breast cancer or the history of breast cancer
• Cancer of the endometrium, except has been
hysterectomy
• Pervaginam bleeding which its cause remains
unknown
• Severe impairment of liver
• Tromboemboli, active tromboplebitis
• Hyperlipidemia

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 Method of HRT Treatment
1. Orally
– Most suggested
– Precipitate the HDL synthesis in liver
– Precipitate the formation of somatomedin  the
resorption of calcium in intestine
– Can burden the hepatic and gastrointestinal
disorder

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 Method of HRT Treatment
2. Transdermal method
- In form of bandage/salve bandage/gel
- Contains of 50 and 100 mg estradiol
- The bandage is patched  the skin in the buttock &
replaced every week
- Gel is smeared  stomach, upper tight, hand &
shoulder & used every day
- Used for women with liver function
disorder/digestive track

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 Method of HRT Treatment
3. Nose spray treatment
- dose 300 ug (2 times spray) / day
- if the complaint does not disappear, the dose
is added to be 450ug (3 times spray) or
600 ug (4 times spray)

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 Method of HRT Treatment
4. Implant treatment
- uninteresting  needs skin incision
- if side effect occurs  extracted immediately
- if there is a uterus  can cause excessive
bleeding

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 Method of HRT Treatment
5. Pervaginam treatment
- cream which contains of estradiol/estriol
- fast resorption  vaginal mucosa
- estriol cream  no systemic effect
- for atrophy urogenital therapy/vaginal
dryness

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The control during HRT Treatment
A month after HRT treatment
– Monitoring the blood pressure / body weight
– Monitoring side effect : breast pain, the increase
of body weight, whity discharge, headache,
bleeding
– If there is no complaint  re-control in the next 3
months
3 months after HRT treatment
– ask whether there is complaint or not
– check the blood pressure / body weight
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The control during HRT Treatment
6 months after HRT treatment
- pap test
- check the blood pressure & evaluate the
result of treatment
12 months after HRT treatment
- examine by using mammography

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 The advantages of Long-term HRT
Treatment

1. Prevent Osteoporosis
2. Prevent coronary heart disease
3. Prevent Alzheimer’s disease

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 FITOESTROGEN

• Its chemical substance & function are similar

to estradiol
• Used as HRT
• There are 4 types: Isoflavin, Lignan,
Komestan, Resorcylic acid lactones

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 The role of isoflavin to
a menopausal woman

• Decrease hot flushes

• Prevent coronary heart disease
• Prevent osteoporosis
• Prevent breast cancer

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 Side effects of Fitoestrogen
• Remains unknown
• The extension of menstrual cycle about 1-5
days
• Might result in hormonal equilibrium,
competitive with steroid metabolic enzyme,
drugs & effects of the gonad function

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 Perimenopause/Menopause

YES NO

Px need to used Hormonal th/? Patient need used Hormonal th/ to prevent?
Have Complaint? • Coronary hearth disease
• Hot flashes • Osteoporosis
Absolute contraindications?
• Breast cancer/history
• Sweating • Demensia
• Endometrial cancer • urogenital atrophy • Colon cancer
• severe disturbance of liver function • impair of perimenopause mens • other camplaint
• Unknowed vaginal bleeding • other complaint
• History of thromboembolism
• Angina, Infark miocard, uncontrole HT YES NO
• Meningioma
• Keep Healthy living
YES NO • BMD every year

Spesial condition / relative contraindications? Have been Hormonal th/

• Not give Hormone th/ • MIgraine
NO Hysterectomy? NO After menopause NO Hormonal th/ cycle

• Alternative • Epilepsy
• Risk factor of breast cancer YES YES Explain propose
Risk of • Mastoplasia Hormonal th/
• Cholelithiasis • Time periode
Osteoporosis? Estrogen Continue
• Endometriosis uterine myoma hormonal th/
therapy Hormonal th/ • Risk of breast ca
YES NO • Body weight effect
• Blood Pressure effect
YES

• Bisfosfonid • Healthy live

+ Calsium style • Migraine : transdermal th/ , low dose 1. Basic examination
• Calcitonin • Calsium • Epilepsy  therapy ?? Evaluation for 3 month : - Blood Pressure
• BMD every + Vit D3 • History breast cancer : carefull therapy !!
• Blood Pressure
- Body weight
year • BMD every • Mastoplasia : low dose therapy - Breast palpation
• Cholelithiasis : transdermal therapy,
• Bleeding pattern - Pelvic
year
,low dose Evaluation for 6-12 month - Mammography
• Endometriosis uterine myoma : • Side effect hormonal th/ 2. Laboratorium
- Lipid profile
low dose contraception therapy • Fluor albus - SGOT, SGPT
( if tumor become large, stop the therapy) • Mammography (1 year) - Urine analized
3. BMD
- If have risk of osteoporosis
 CONCLUSION

Menopause is a psychological aging process which will

be realized eventually in a woman’s life
The menopause is being a problem because of the
improvement of public health level, where women
survival is also increased
The presence of changes in menopausal period mainly
caused by the deficiency of estrogen hormone

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 CONCLUSION
There are lots of efforts have been done to overcome the
complaints which occur during the menopausal period
The goal of HRT treatment is one of the method which is
used to maintain & or improve the life quality of woman
The types of either estrogen or progesterone which is
used as HRT is a natural hormone
HRT treatment has to be used in long-term to achieve
maximum efficiency, prevent & cure menopausal
symptoms & give protection of osteoporosis, coronary
hearth disease & Alzheimer’s disease

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 CONCLUSION
The benefits of HRT has been published a lot,
but has not been widely released. The side
effects and expensive price induce rare usage
& it remains unsatisfactory of society in
developing countries
Each 40-years-age woman or above should
have regular check-up to the doctor at least
every 6 months

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THANK YOU

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