Menopause

Cabaddu | Elefante | Escudero | Garingalao | Macalalad | Manalac | Roque

 Objective
To present a case of a woman in menopause as a starting off
point for discussing pertinent physiology in the menopausal stage
in the female reproductive cycle.

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Identifying Information
LAM, 50
G3P3 (3003)
Married
Roman Catholic
Filipino
Cavite

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Identifying information
LAM, 50
G3P3 (3003)
Married Irregular Menses
Roman Catholic
Filipino
Cavite

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History of Present Illness
◉ Previously regularly menstruating every month lasting 5-7 days consuming 1-2
pads/day, moderately soaked since 14 years old until...

2 years prior
◉ Onset of irregularity of menses lasting 1-2 weeks occurring every month to 3
months consuming 2-3 pads/day moderately soaked
◉ (+) Bitemporal headache, dull in character, tolerable in severity
◎ Took Paracetamol occasionally with relief of headache
◉ (+) Flushing of the face and excessive sweating throughout the day
◉ No fever, no hypogastric pain, no nausea/vomiting
◉ No consult done
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History of Present Illness
13 months prior
◉ Noted frequency of vaginal bleeding occurring every 2 weeks to daily consuming
2-3 pads to 1 baby diaper fully soaked per day
◉ Still with associated headache, flushing of face and excessive sweating
◉ Now associated with mood changes described as being irritable and depressed
◉ No fever, no hypogastric pain, no nausea/vomiting
◉ No history of sexual contact, no trauma, no infection

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History of Present Illness
1 year prior
◉ Noted cessation of menses
◉ Still with associated headache, flushing of face and excessive sweating
◉ Still with occasional mood changes
◉ No fever, no hypogastric pain, no nausea/vomiting
◉ No history of sexual contact, no trauma, no infection

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Review of systems
General: no weight gain/loss, no change in appetite
HEENT: no blurring of vision, no tinnitus, no nasal congestion, no dysphagia
Cardio: no palpitations, no chest pain, no syncope
Respi: no cough/cold, no difficulty of breathing
GI: no bloatedness, no bowel changes
GU: no dysuria, no hematuria, no polyuria
Endo: no heat/cold intolerance, no tremors, no polydipsia, no polyphagia

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Past Medical History
No hypertension, diabetes, thyroid disease, kidney disease, tuberculosis, cancer
No allergies
Previous CS for breech presentation with bitubal ligation (1995)

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Immunization History
Completed childhood vaccination
Completed HepB, Tetanus vaccines during 3 pregnancies
No influenza, MMR/rubella, HPV vaccine

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Family history
(+) Hypertension, type II diabetes mellitus
No history of thyroid disease, kidney disease, cancer, tuberculosis

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Personal and Social History
College graduate
Housewife
Denies any vices
No recent travel history

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Obstetric History
Menarche: 14 years old
Interval: 30 days
Duration: 5-7 days
Amount: 1-2 pads/day moderately soaked
Dysmenorrhea: none

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Obstetric History
Year Term Sex Weight Manner of Complications
(lbs) Delivery

G1 1992 Term Female 4.5 NSD None

G2 1994 Term Male 6.6 NSD None

G3 1995 Tern Male 5.5 CS for breech None

presentation

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Gynecologic History
Number of partner/s: 1
Age of first coitus: 27
History of pelvic infection: none
Last pap smear: annually, unremarkable results
Family planning: s/p bitubal ligation (1995)

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Objective
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Physical Examination: Systemic
● General Survey: Awake, alert, coherent, not in cardiorespiratory distress
● Vital Signs: stable vital signs
● Anthropometrics: H 152 cm W 55 kg BMI 23.80 (Overweight)
● HEENT: Anicteric sclerae, pink palpebral conjunctivae, no nasal discharge, no CLADs
● Cardiovascular: Normal rate, no murmurs, distinct S1-2
● Chest and Lungs: Equal and symmetric chest expansion, clear breath sounds
● Abdomen: Soft nontender abdomen, no palpable masses
● Back and Spine: No masses, dimples, misalignment
● Extremities: Equal tone, no deformities, full and equal pulses
● Integumentary: No rashes, jaundice
● Neurologic: Oriented to three spheres, intact CNs, 5/5 5/5 MMT, 100% sensation all extremities
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Physical Examination: Pelvic
Not assessed

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Assessment
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Salient Features: Subjective
◉ 50, G3P3 (3003), Filipino, CC: Irregular menses
◉ Changes in menstrual cycle
◎ 14/Regular/5-7 days/ 1-2 ppd, moderately soaked
◎ 2 years prior: irregular menses/every month-3 months/1-2 weeks/2-3ppd, moderately
soaked
◎ 13 month prior: frequency of vaginal bleeding every 2 weeks to daily consuming 2-3 pads
to 1 baby diaper fully soaked per day
◎ 1 year prior: Amenorrhea
◉ (+) Bitemporal headache dull -> Relieved by Paracetamol
◉ (+) Flushing of the face, excessive sweating
◉ (+) Mood changes: irritable and depressed
◉ No history of sexual contact, no trauma, no infection
◉ ROS: no palpitations, unintentional weight changes, heat/cold intolerance, tremors
◉ s/p Bitubal ligation (1995) 20
Salient Features: Objective
◉ Stable vital signs
◉ BMI 23.08 (overweight)
◉ Pelvic exam not assessed

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 Menopause

Primary Woking Impression

 Primary Working Impression:
Menopause
Age (40-50) Dysregulated Hot flashes, Sweating
thermoregulation
50 years old
Ethnicity (Filipina 47-48) Hormonal Headache Migraine

Parity G3P3 (3003) Estrogen-Progesterone Irregular Menses

Imbalance Amenorrhea

BMI 23.80 Mood changes

Genetics* Patient’s mother: 52

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 4.
Case Presentation
PLAN OF MANAGEMENT
Introduction
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Menopause
Permanent cessation of menses, dated by the last menstrual period followed by 12 months
of no flow
- Physiologic menopause: from loss of ovarian follicular activity
- Artificial menopause: surgery, ionizing radiation, chemotherapy
Average age: 51 years old (US); 47-48 years old (Filipinas)
Factors associated with menopause: smoking (earlier), higher parity (later)

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 Not Applicable to:
● Smoker
● Obese
● Abnormality with uterine or
ovarian anatomy
● Chronically irregular
menses
● Heavy aerobic exercise

Stages of Reproductive Aging

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Perimenopause
◉ Gametogenic Ovarian Failure: Decline in reproductive capacity
◎ Can occur as early as age 35
◎ May occur with normal menstrual function
◎ Decreased anti-Mullerian hormone, inhibin B levels and antral follicle count
→ rising FSH
◉ Major reduction in ovarian estrogen production occurs approximately a year
before menopause

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Perimenopause
◉ Although there is a general decline in oocyte number with age, accelerated atresia
occurs at ~37 or 38 years old
◎ High FSH → High Activin (with low Inhibin B) → accelerated growth and
differentiation of granulosa cells

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 Perimenopause
Age 40 Age 40-50 Age 60
- Hot flushes - Menstrual disorders - Osteoporosis
- Sweating - Atherosclerosis
- Sleep disorder - Cerebrovascular
- Mood changes Age 50 diseases
- Urogenital atrophy - Coronary Heart Disease
- Dyspareunia

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 Effects of Menopause
on various organ systems

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Central Nervous System
◉ Brain: active site for estrogen action and formation
◉ Estrogen receptor (ER) α and ER β

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Central Nervous System

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Central Nervous System

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Central Nervous System
◉ Hot Flashes
◎ Vasomotor episode
◎ Hypothalamic response to decrease estrogen levels
◎ Narrowed thermoneutral zone
◉ Sleep disruption
◎ Lower sleep efficiency
◎ Longer latency to REM sleep
◎ Leads to fatigue and irritability
◉ Depression
◉ Cognitive Changes 38
Collagen and other tissues
◉ 30% of skin collagen is lost within the first 5 years after menopause
◉ Collagen decreases approximately 2% per year for the first 10 years after
menopause
◉ Urinary incontinence and irritative bladder symptoms occur in 20% to 40% of
perimenopausal and postmenopausal women

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Vulvovaginal atrophy

◉ Associated with estrogen deficiency

◉ Dryness and atrophic changes occur in 47% and 55% of women, respectively
◉ Increase in sexual complaints also occurs, 41% incidence of dyspareunia
◉ Estrogen deficiency results in:
◎ thin, paler vaginal mucosa
◎ moisture content is low,
◎ pH increases (usually greater than 5)
◎ mucosa may exhibit inflammation and small petechiae

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Bone Health

◉ Here you have a list of items

◉ And some text
◉ But remember not to overload your slides with content

Your audience will listen to you or read the content, but won’t do both.

42
Degenerative Arthritis

◉ Here you have a list of items

◉ And some text
◉ But remember not to overload your slides with content

Your audience will listen to you or read the content, but won’t do both.

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Cardiovascular Effects
◉ Cardiovascular disease risk INCREASES with
menopause.
◉ Framingham study shows risk is 3x lower in women before
menopause
◎ And risk becomes equal in women and men by the age
75-79

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Cardiovascular Effects
◉ Increases risk for myocardial infarction
◎ 2-3 fold increase in risk with premature ovarian
failure/insufficiency
◎ 7 fold increase in risk with oophorectomy before 35
(surgical menopause)

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Cardiovascular Effects
◉ Why the increase in CVD? When examined for possible
reasons,
◎ Accelerated rise in total cholesterol is the most
prevalent finding.
◉ The rise in total cholesterol is mostly attributable to the
increases in levels of low-density lipoprotein cholesterol

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Cardiovascular Effects
◉ Apart from its effects on cholesterol (increase HDL and
decrease LDL), the other cardiovascular effects of estrogen
are:
◎ Blood vessel dilation, increasing blood flow
◎ Counteraction of free radicals that cause damage to
arteries

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Cardiovascular Effects
◉ In animal models estrogen was found to slow down
atherogenesis
◎ Monocyte adhesion and migration
◉ While estrogen imparts protection for cardiovascular
events, estrogen therapy cannot be initiated for this
purpose alone.
◎ Estrogen has been shown to aggravate existing
coronary disease.
◎ The best time to initiate hormone replacement is
within the first 10 years48after menopause
 Hormone Regimens
&
Alternative Treatment

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Hormonal Therapies
◉ Primary indication: relief of symptoms of menopause
◉ Estrogen with or without progestin
◎ Most effective therapy for vasomotor symptoms
○ Administered orally or transdermally in the form of patches, gels, or sprays
◉ Individualize care and treat women with the lowest effective dose for the shortest
duration that is needed
◉ In younger postmenopausal women on HRT: benefits outweigh risks with standard
doses, lower doses may reduce risk

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Risk and Benefits
◉ The risks of systemic combined HT include thromboembolic
disease and breast cancer
◉ Adverse effects, such as breast tenderness, vaginal bleeding,
bloating, and headaches.
◉ Low-dose and ultra-low systemic doses of estrogen may have
better adverse effect profile and reduce vasomotor symptoms

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Risk and Benefits
● Benefits:
◎ Metabolic effects
◎ Maintenance of bone Mineral Density
◎ Relief of menopause symptoms
◎ Reduction in total cholesterol

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Alternative Therapies
◉ Nonhormonal alternatives for menopausal symptoms
◉ MPA and NET → for hot flushes but not for long-term therapy
◉ SSRIs/SNRIs
◎ Paroxetine → moderate effect but interfere with tamoxifen therapy
◎ SE: nausea, dry mouth, sexual dysfunction
◉ Gabapentin
◉ Antihypertensives → Clonidine, Methyldopa

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Alternative Therapies
◉ Phytoestrogens
◉ Cognitive Behavior Therapy → talk therapy
◉ Acupuncture
◉ Stellate Ganglion Blockade

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