M EN O PA U S E

BY: NAMITA ARYA

PDMSNC
INTRODUCTION
• MENOPAUSE – CESSATION OF MENSTRUATION.
• ITS DERIVED FROM A GREEK WORDS “MENOS AND PAUSE”
MEANING CESSATION OF MENSTRUATION.

• DEFINITION: PERMANENT STOPPAGE OF MENSTRUATION AS

A RESULT OF DECLINING OVARIAN FUNCTION LEADING TO
DEFICIENT OVARIAN HORMONAL SECRETIONS.
MENOPAUSE
• MENOPAUSE IS A HYPO-ESTROGENIC STATE.
• ESTROGEN SURGES HAVE CAUSED GROWTH OF THE
ENDOMETRIUM.

• NOW NO GROWTH = NO SHEDDING = NO PERIOD

• THE AGE OF MENOPAUSE RANGES BETWEEN 45-55YRS &

AVERAGE AGE 50YRS
Pathophysiology
CLIMACTERIC

NO OVULATION

NO PROGESTERONE

GRAFFIAN FOLLICLE FAILS TO DEVELOP

↓ESTROGEN ACTIVITY

ENDOMETRIAL ATROPHY

AMENORRHEA
ATTAINMENT OF MENOPAUSE

MENSTRUAL – 3 CLASSIC WAYS IN WHICH THE

MENSTRUATION CEASES ARE :

• SUDDEN CESSATION.

• GRADUAL DIMINUTION IN THE AMOUNT OF BLOOD LOSS

WITH EACH REGULAR PERIOD

• GRADUAL INCREASE IN SPACING OF PERIODS UNTIL THEY

CEASE FOR AT LEAST A PERIOD OF ONE YEAR.
PHASES OF MENOPAUSE
THE PHASES OF MENOPAUSE IS USUALLY BROKEN
DOWN INTO FOUR CATEGORIES:-
 PRE-MENOPAUSE: THE PERIOD PRIOR TO MENOPAUSE
 PERIMENOPAUSE: TO THE PERIOD AROUND MENOPAUSE
 MENOPAUSE : IT IS THE END OF MENSTRUATION THE
AGEOF MENOPAUSE RANGES BETWEEN 45 – 55 YEARS ,
AVERAGE BEING 50 YEARS.
 POST MENOPAUSE: TO THE PERIOD AFTER MENOPAUSE
CAUSES OF MENOPAUSE

• MENOPAUSE OCCURS WHEN THE OVARIES ARE TOTALLY

DEPLETED OF EGGS AND NO AMOUNT OF STIMULATION
FROM THE REGULATING HORMONES CAN FORCE THEM TO
WORK.
PHYSIOLOGICAL CHANGES
The lack of estrogen and progesterone causes many changes in
women’s physiology that affect their health and well-being . The
symptoms of menopause due to changes in the metabolism of
the body.
 Increased cholesterol level in the blood:
Hyperlipidemia or an increase in the level of cholesterol and
lipids in the blood is common. This lead to gradual rise in the
risk of heart disease and stroke after menopause.
 OSTEOPOROSIS : CALCIUM LOSS FROM THE BONE IS
INCREASED IN THE FIRST FIVE YEARS AFTER THE ONSET OF
MENOPAUSE, RESULTING IN A LOSS OF BONE DENSITY . THE
CALCIUM MOVES OUT OF THE BONES, LEAVING THEM WEAK
AND LIABLE TO FRACTURE AT THE SMALLEST STRESS.

 DIGESTIVE SYSTEM : MOTOR ACTIVITY OF THE ENTIRE

DIGESTIVE TRACT IS DIMINISHED AFTER MENOPAUSE. THE
INTESTINE TEND TO BE SLUGGISH RESULTING IN
CONSTIPATION.

 URINARY SYSTEM: AS THE ESTROGEN LEVEL DECREASES AFTER

MENOPAUSE, THE TISSUE LINING THE URETHRA AND THE
BLADDER BECOME DRIER, THINNER AND LESS ELASTIC . THIS
CAN LEAD TO INCREASED FREQUENCY OF PASSING URINE AS
WELL AS AN INCREASED TENDENCY TO DEVELOP UTI.
CHANGES IN THE GENITAL
ORGANS

OVARIES

• ovaries shrink in size, become wrinkled and white.

• there is thinning of the cortex with increase in medullary components.
there is abundance of stromal cells which have got secretary activity.
FALLOPIAN TUBES

• FALLOPIAN TUBES SHOW FEATURE OF ATROPHY. THE

MUSCLE COAT BECOMES THINNER, THE CILIA DISAPPEAR
AND PLICA BECOME LESS PROMINENT
UTERUS

• BECOMES SMALLER AND THE RATIO BETWEEN THE BODY

AND THE CERVIX REVERTS TO THE 1:1 RATIO.

• THE ENDOMETRIUM BECOMES THIN AND ATROPHIC.

• THE CERVICAL SECRETION BECOMES SCANTY.
VAGINA
• BECOMES NARROWER DUE TO GRADUAL LOSS OF
ELASTICITY.

• THE VAGINAL EPITHELIUM BECOMES THIN.

• THE RUGAE PROGRESSIVELY FLATTEN.
• DODERLEIN’S BACILLUS IS ABSENT.
• THE VAGINAL PH BECOMES ALKALINE.
VULVA AND BREAST FAT

• THE VULVA SHOWS FEATURES OF ATROPHY. THE LABIA

BECOMES FLATTENED AND THE PUBIC HAIR BECOMES
SCANTIER. THE END RESULT IS A NARROW INTROITUS.

• BREAST FAT IS REABSORBED AND THE GLANDS ATROPHY.

THE NIPPLES DECREASE IN SIZE. ULTIMATELY THE BREAST
BECOMES FLAT AND PENDULOUS.
BLADDER AND URETHRA

• UNDERGOES SIMILAR CHANGES TO THOSE OF THE VAGINA.

THE EPITHELIUM BECOMES THIN AND IS MORE PRONE TO
DAMAGE AND INFECTION.

• THERE MAY BE DYSURIA, FREQUENCY, URGE OR EVEN

STRESS INCONTINENCE.
LOSS OF MUSCLE TONE

• LOSS OF MUSCLE TONE LEADS TO PELVIC RELAXATION,

UTERINE DESCENT AND ANATOMIC CHANGE IN THE
URETHRA AND NECK OF THE BLADDER.

• THE PELVIC CELLULAR TISSUES BECOME SCANTY AND THE

LIGAMENTS SUPPORTING THE UTERUS AND VAGINA LOSE
THEIR TONE.
CHANGES IN THE GENERAL
APPEARANCE
 SKIN : THE SKIN LOSES ITS ELASTICITY AND BECOMES
THIN AND FINE. THIS IS DUE TO THE LOSS OF ELASTIN
AND COLLAGEN FROM THE SKIN.
 WEIGHT : WEIGHT INCREASE IS MORE LIKELY TO BE THE
RESULT OF IRREGULAR FOOD HABIT DUE TO MOOD SWING
. THERE IS MORE DEPOSITION OF FAT AROUND HIPS,
WAIST AND BUTTOCKS.
 HAIR : HAIR BECOME DRY AND COARSE AFTER
MENOPAUSE . THERE MAY HAIR LOSS DUE TO THE
DECREASING LEVEL OF ESTROGEN.
 VOICE : VOICE BECOME DEEPER DUE TO THICKENING OF
VOCAL CORDS.
CHANGES IN THE VASOMOTOR
SYSTEM
• HOT FLASHES : HOT FLASHES ARE INCIDENTS WHERE THE
WOMEN IN MENOPAUSE GETS A SUDDEN FEELING OF
WARMTH AND FLUSHING THAT STARTS IN THE FACE AND
QUICKLY SPREAD ALL OVER THE NECK AND UPPER BODY .
THIS `HOT FLASHES’ CAN OCCUR AT ANY TIME OF THE DAY
OR NIGHT . THEY VARY IN NUMBER FROM 1 IN EVERY ONE
HOUR TO AS ONE IN EVERY 15 MINTS . THE HOT FLASHES
ARE OFTEN ASSOCIATED WITH PROFUSE SWEATING.
 NIGHT SWEAT: NIGHT SWEAT ARE CLOSELY RELATED TO
HOT FLASHES
• . BOTH USUALLY OCCUR SIMULTANEOUSLY . SWEAT CAN
OCCUR ANY TIME OF THE DAY OR NIGHT, THEY ARE MORE
COMMON AT NIGHT . THE SWEAT CAN BE SEVERE ENOUGH
TO WAKE UP THE WOMEN FROM A SOUND SLEEP AND MAY
MAKE IT DIFFICULT FOR HER TO GO BACK TO SLEEP . THE
SUDDEN WAKING UP FROM SLEEP CAN CAUSE
PALPITATION AND SOMETIMES PANIC ATTACKS.
PSYCHOLOGICAL CHANGES
 FREQUENT HEADACHE
 IRRITABILITY,
 FATIGUE,
 DEPRESSION AND INSOMNIA .
 ALTHOUGH THESE ARE OFTEN SAID TO BE DUE TO
CHANGES IN THE HORMONAL LEVELS. THEY ARE MORE
LIKELY TO BE RELATED TO THE LOSS OF SLEEP DUE TO
NIGHT SWEAT.
 DIMINISHED INTEREST IN SEX MAY BE DUE TO EMOTIONAL
UPSET OR MAY BE SECONDARY TO PAINFUL INTERCOURSE
DUE TO A DRY VAGINA.
SOCIAL CHANGES DURING MENOPAUSE

•THE FEELING THAT A WOMEN HOLDS ABOUT HER SELF AND

HER SOCIAL RELATIONSHIP AS WELL AS THE SYMPTOMS SHE
EXPERIENCES CAN BE DEFINED BY THE CULTURE IN WHICH
SHE LIVE. WOMEN VARY IN THERE SUBJECTIVE EXPERIENCES
OF SYMPTOMS . NOT ALL OF THE WOMEN’S PERCEIVE
CHANGES IN THE BODY ARE REFLECTED IN THE MIRROR;
SOME ARE DERIVED FROM WOMEN’S PERCEPTION OF
HERSELF BASED ON THE ACCOUNT OF OTHER EXPECTATION
VARY AND ARE ADJUSTED TO ACTUAL EXPERIENCE.
MENOPAUSAL SYMPTOMS
• VASOMOTOR SYMPTOMS
• UROGENITAL ATROPHY
• OSTEOPOROSIS AND FRACTURE
• CARDIOVASCULAR DISEASE
• CEREBROVASCULAR DISEASE
• PSYCHOLOGICAL CHANGES
• SKIN AND HAIR
• SEXUAL DYSFUNCTION
• DEMENTIA AND COGNITIVE DECLINE
• VASOMOTOR SYMPTOMS : HOT FLUSES AND NIGHT
SWEATS

• GENITAL AND URINARY SYMPTOMS: DYSPAREUNIA AND

DYSURIA.

• VAGINA: DYSPAREUNIA, VAGINAL INFECTIONS, DRYNESS,

PRURITIS AND LEUCORRHEA.

• SEXUAL DYSFUNCTION: DECREASE SEXUAL DESIRE DUE

TO OESTROGEN DEFICIENCY
.
• SKIN AND HAIR: THINNING, LOSS OF ELASTICITY AND
WRINKLING OF THE SKIN.

• PSYCHOLOGICAL SYMPTOMS: ANXIETY, HEADACHE,

INSOMNIA, IRRITABILITY, DYSPHASIA AND DEPRESSION. THEY
CA ALSO SUFFER FROM DEMENTIA, MOOD SWING AND
INABILITY TO CONCENTRATE

• OSTEOPOROSIS
• FRACTURE
• CARDIO VASCULAR AND CEREBROVASCULAR:VASCULAR
ATHEROSCLEROTIC CHANGES, VASOCONSTRICTION AND
THROMBUS FORMATION. INCREASED RISK OF ISCHAEMIC
HEART DISEASE, CORONARY ARTERY DISEASE AND STROKES
DIAGNOSIS

• CESSATION OF MENSTRUATION FOR CONSECUTIVE 12

MONTHS DURING CLIMATERIC.

• APPEARANCE OF MENOPAUSAL SYMPTOMS ‘HOT FLUSH’

AND NIGHT SWEATS.

• FEATURES OF LOW OESTROGEN

• SERUM OESTRADIOL: < 20 PG/ML
• SERUM FSH AND LH: > 40MIU/ML
TREATMENT
NATURAL - Live a Healthy Lifestyle – Enhance and
accept what nature has given you.

MEDICAL TREATMENT - treat specific symptoms or

problems with medications as they arise.

HORMONAL – replace the original substance that is

missing - prevention.
NATURAL/ NON- HORMONAL TREATMENT

• LIFE STYLE MODIFICATION INCLUDES: PHYSICAL

ACTIVITY, REDUCING HIGH COFFEE INTAKE, SMOKING AND
EXCESSIVE ALCOHOL.

• THERE SHOULD BE ADEQUATE CALCIUM INTAKE (300ML OF

MILK)

• REDUCING MEDICATIONS THAT CAUSE BONE LOSS

• NUTRITIOUS DIET- BALANCED WITH CALCIUM AND PROTEIN IS
HELPFUL.

• SUPPLEMENTARY CALCIUM- DAILY INTAKE OF 1-1.5 GM CAN

REDUCE OSTEOPOROSIS AND FRACTURE.

• EXERCISE – WEIGHT BEARING EXERCISES WHICH MEANS

EXERCISE ONE PERFORMS WHILE ON THEIR FEET THAT WORKS
THE BONES AND MUSCLES AGAINST GRAVITY LIKE WALKING,
JOGGING.

• VITAMIN D- SUPPLEMENTATION OF VIT-D3 ALONG WITH

CALCIUM CAN REDUCE OSTEOPOSROSIS AND FRACTURES.
EXPOSURE TO SUNLIGHT ENHANCES SYNTHESIS OF
CHOLECALCIFEROL (VIT-D3) IN THE SKIN.

• CESSATION OF SMOKING AND ALCOHOL.

• MENOPAUSE DECREASES VAGINAL ELASTICITY, LEADING TO
VAGINAL DRYNESS . VITAMIN E CAN HELP AS CAN KEGAL
EXERCISES WHICH HELP RESTORE ELASTICITY .

• USING WATER BASED LUBRICANTS DURING SEXUAL

INTERCOURSE ALSO MINIMIZES DISCOMFORT RELATED TO
VAGINAL DRYNESS.

• MENOPAUSE OFTEN LEAD TO DRY, ITCHY SKIN, AND WEAK

THIN HAIR THAT BREAKS AND THAT HAS LOTS OF SPLIT
ENDS . FLAX SEED OIL(FOUND IN POULTRY , DAIRY, RED
MEAT AND WHOLE GRAINS) CAN HELP RESTORE HAIR AND
SKIN’S HEALTHY APPEARANCE , AS CAN VITAMIN E.
MEDICAL TREATMENT
• BIPHOSPHONATE: PREVENTS OSTEOCLASTIC BONE
RESORPTION.
-IT IMPROVES BONE DENSITY AND PREVENTS FRACTURE.

• FLUORIDE: PREVENTS OSTEOPOROSIS AND INCREASES

BONE MATRIX.
-DOSE- 1MG/KG FOR SHORT TERM ONLY
• CALCITONIN: INHIBITS BONE RESORPTION. SIMULTANEOUS
THERAPY WITH CALCIUM AND VIT-D SHOULD BE GIVEN.
-IT IS GIVEN EITHER BY NASAL SPRAY (200 IU DAILY) OR BY
INJECTION(SC) (50-100 IU DAILY).

• CLONIDINE : USED TO REDUCE THE SEVERITY AND

DURATION OF HOT FLUSHES.

• THIAZIDES: :REDUCE URINARY CALCIUM EXCERTION.

• IT INCREASES BONE DENSITY SPECIALLY WHEN COMBINED
WITH OESTROGEN.
• PARAXETINE :IS EFFECTIVE TO REDUCE HOT FLUSHES
• GABAPENTINE: ALSO EFFECTIVE TO REDUCE HOT FLUSHES
• SOY PROTEIN: IS ALSO FOUND EFFECTIVE TO REDUCE
VASOMOTOR SYMPTOMS.
 HORMONAL
REPLACEMENT THERAPY
(HRT)
HORMONAL REPLACEMENT
THERAPY (HRT)

• HORMONAL REPLACEMENT THERAPY (HRT) IS ALSO KNOWN

AS MENOPAUSAL HORMONE THERAPY(MHT) OR
POSTMENOPAUSAL HORMONE THERAPY(PHT).

• HORMONAL THERAPY(HT) INVOLVES THE ADMINISTRATION

OF SYNTHETIC ESTROGEN AND PROGESTERONE TO
REPLACE A WOMEN’S DEPLETING HORMONE LEVELS AND
THUS ALLEVIATE MENOPAUSAL SYMPTOMS.
• HRT CAN BE ADMINISTERED ORALLY( IN PILL
FORM),VAGINALLY( AS A CREAM),OR TRANSDERMALLY ( IN
PATCH FORM) BECAUSE IT REPLACES FEMALE HORMONES
PRODUCED BY THE OVARIES,

• HORMONE REPLACEMENT THERAPY MINIMIZE MENOPAUSE

SYMPTOMS.

• IT CAN BE USED BEFORE, DURING AND AFTER MENOPAUSE.

 TYPES OF HRT
 Estrogen and progesterone :The most common type of HRT
involves both estrogen and progesterone . More than 8 million
women are currently taking combination HRT and it is designed
specifically for women who have a uterus .
 During this therapy, estrogen is given regularly while
progesterone is added in on a supplementary basis
 These two hormones are given in combination in order to
prevent the overgrowth of uterine lining . Estrogen alone may
irritate this lining which could lead to endometrial cancer.
 Estrogen only : Estrogen therapy alone is usually given to
women who have lost their uterus due to surgical menopause .
Because no uterus is present , the need for progesterone is not as
great.
 Progestin only: Progestin-only therapy is not prescribed very
often. Progestin does seem to provide excellent relief for women
plagued with hot flashes.
INDICATIONS OF HRT
• THE HRT IS INDICATED IN MENOPAUSAL WOMEN TO
OVERCOME THE SHORT-TERM AND LONG-TERM
CONSEQUENCES OF OESTROGEN DEFICIENCY.
Indications Special group of women to whom HRT
should be prescribed:

Relief of menopausal symptoms Premature ovarian failure

Prevention of osteoporosis Gonadal dysgenesis

To maintain the quality of life in Surgical or radiation menopause

menopausal years
RISK FACTORS FOR OSTEOPOROSIS IN A WOMEN

Family history

Age – elderly

Race- asian,white race

Lack of oestrogen

Body weight- Low BMI

Early menopause- Surgical, radiation

Dietary – calcium, and vit-D, caffeine , smoking

Sedentary habit

Drugs – heparin, corticosteroids, GnRH analogues

Diseases – Thyroid disorders, hyperparathyroidism malabsorption, multiple myeloma.

BENEFITS OF HRT
• IMPROVEMENT OF VASOMOTOR SYMPTOMS
• IMPROVEMENT UROGENITAL ATROPHY
• INCREASE IN BONE MINERAL DENSITY
• DECREASE RISK IN VERTEBRAL AND HIP FRACTURES
• REDUCTION IN COLORECTAL CANCER
• POSSIBLY CARDIO PROTECTION
RISKS OF HRT

1. ENDOMETRIAL CANCER: WHEN ESTROGEN IS GIVEN

ALONE TO A WOMEN WITH INTACT UTERUS , CAUSES
ENDOMETRIAL PROLIFERATION , HYPERPLASIA AND
CARCINOMA.
2. BREAST CANCER: COMBINED ESTROGEN AND
PROGESTIN REPLACEMENT THERAPY , INCREASES THE
RISK OF BREAST CANCER SLIGHTLY .
3. VENOUS THROMBOEMBOLIC DISEASE (VTE): IT
HAS BEEN FOUND TO BE INCREASED WITH THE USE OF
COMBINED ORAL ESTROGEN AND PROGESTIN.
• CORONARY HEART DISEASE: COMBINED HRT THERAPY
SHOWS A RELATIVE HAZARDS OF CHD .

• LIPID METABOLISM: AN INCREASED INCIDENCE OF

GALLBLADDER DISEASE HAS BEEN OBSERVED FOLLOWING
ERT DUE TO RISE IN CHOLESTEROL (IN BILE).

• DEMENTIA, ALZHEIMER DISEASE ARE INCREASED.

AVAILABLE PREPARATIONS FOR HRT

 The principle hormone used in HRT is estrogen . This is

ideal for a women who had her uterus removed already. But, a
women with intact uterus , only estrogen therapy leads to
endometrial hyperplasia and even endometrial carcinoma.
Addition of progestin for last 12-14 days each month can
prevent this problem.
 Commonly used estrogen are conjugated estrogen (0.625-
1.25 mg/day). Progestin used are medroxyprogesterone (100-
300 mg/day).Considering the risks, hormonal therapy should be
used with the lowest effective dose and for a short period of
time. Low dose of oral conjugated estrogen 0.3 mg daily is
effective and has got minimal side effects.
 Oral estrogen regime
estrogen –conjugated equine estrogen 0.3 mg or 0.625 mg
is given daily for woman who had hysterectomy.
 Estrogen and cyclic progestin
For a women with uterus estrogen is given continuously
for 25 days and progestin is added for last 12 -14 days.
 Continuous estrogen and progestin therapy
Continued combined therapy can prevent
endometrial hyperplasia.
 Sub dermal implants
Implants are inserted subcutaneously over the anterior
abdominal wall using local anaesthesia.17β oestradiol
implants 25 mg , 50 mg or 100 mg are available and can
be kept for 6 month.
 Percutaneous estrogen gel
1 gm applicator of gel delivering 1 mg of oestradiol daily
is to be applied onto the skin over the anterior abdominal
wall or thigh..Effective blood level of oestradiol (90-120
pg/ml) can be maintained.
 Transdermal patch
It contains 3.2 mg of 17β oestradiol releasing about 50µg
of oestradiol in 24 hrs.It should be applied below the waist
line and changed twice a week.
 Vaginal cream
Conjugated equine vaginal estrogen cream 1.25 mg daily
is very effective specially when associated with atrophic
vaginitis . Women with symptoms of urogenital atrophy
and urinary symptoms and do not like to have systemic
HRT, are suitable for such treatment.
 Progestin
Patient with history of breast carcinoma or endometrial
carcinoma , progestin may be used It may be effective in
suppressing hot flushes and it prevent osteoporosis.
Medroxy progesterone acetate 2.5 -5 mg/day can be used.
 Tibolone
Tibolone is a steroid having weakly oestrogenic,
progestogenic and androgenic properties. It prevents
osteoporosis , atrophic changes of vagina and hot flashes.
It increases libido. A dose of 2.5 mg per day is given.
 DURATION OF HRT
 Generally, use of HRT for a short period of 3-5 years
have been devised. Reduction of dosage should be done
as soon as possible.
CONTRAINDICATION OF HRT
MONITORING PRIOR TO &
DURING HRT
ABNORMAL MENOPAUSE
MANAGEMENT
GENERAL PRINCIPLES & HOLISTIC APPROACH TO
MENOPAUSE

• LIFESTYLE CHANGES AND PERSONAL HABITS

• EXERCISES: BRISK WALKING FOR 40 – 60 MIN., AT LEAST 5
TIMES / WEEK

• PHYSICAL WORKOUT: WT. BEARING EXERCISES FOR LIMBS

AND BACK STRENGTHENING.
• YOGA AND MEDITATION: BREATHING EXERCISES,
DECREASE STRESS

• SIMPLE DIET: PLENTY OF VEGETABLES, FRUITS , DECREASE

FAT, DECREASE SUGAR

• FLUID INTAKE: PLENTY OF FLUIDS TO MAINTAIN

HYDRATION.

• CONTROL OR ABSTAIN: SMOKING, ALCOHOL INTAKE, MORE

TEA AND COFFEE.