MENOPAUSE

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Overview of Presentation

• Definition

• Etiology/Endocrinology

• Epidemiology

• Clinical Manifestations

• Diagnosis

• Therapies

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 Definition
• Stages of Reproductive Aging Workshop ( STRAW)
Staging System 2001
1) Menopausal transition: a) Variation in menstrual cycle
( > 7d different from normal) and ≥2 skipped cycles and
≥60 d amenorrhea; b)  FSH
2) Perimenopause: Starts at the time of the menopausal
transition and ends 12 months after last menstrual period

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 Definition
3)Menopause:12 months of amenorrhea after final
menses

4)Postmenopause:It is bleeding from the genital tract

occurring 6months or more after cessation of
menstruation in a woman above the age of 40

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 Etiology/Endocrinology
• Occurs due to programmed loss of ovarian follicles
• During perimenopause inhibin B falls due to decline in
follicular number and FSH rises, estradiol preserved,
low progesterone
• In late menopausal transition, FSH and estradiol
fluctuate
• After menopause, ovary no longer secretes estradiol,
however produces androgens under the stimulation of
LH

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 Epidemiology

• Average age of menopause is app. 51.4 years

• Menopause prior to age 40 is premature ovarian failure

• Age of menopause reduced in smokers

• Important to assess family history of early menopause

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 Clinical Manifestations
• Irregular bleeding patterns- if heavy bleeding should
perform endometrial surveillance given period of
unopposed estrogen exposure
• Hot flashes-Etiology unknown, Thermoregulatory
dysfunction, Self limited to 1-5yrs,Variable among
cultures – 75% US women complain of hot flashes,
20% seek therapy
• Sleep disturbance–Hot flashes can arouse from sleep
and primary sleep disorders more common

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Clinical Manifestations-2
• Vaginal dryness–Estrogen deficiency leads to thinning
of epithelium ≥vaginal atrophy(loss of rugae, pale, pH
increase to > 6.0)
• Sexual dysfunction–decrease in blood flow to
vagina/vulva ≤decreased lubrication; dyspareunia
• Urinary sx–low estrogen results in atrophy of urethral
epithelium and predispose to stress/urge urinary
incontinence

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Clinical Manifestations -3

• Depression–Overall studies support an association

between menopause and mood changes such as
irritability/nervousness; controversial if related to true
depression
• Bone loss – secondary to estrogen deficiency
• Breast pain – Common in early menopausal transition
• Skin changes–estrogen def -> reduced collagen content
of the skin/bones

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Therapies
Tx moderate/severe vasomotor sx only
• Estrogen– most effective; po or transdermal; if women
has uterus give in conjunction with progesterone; short
term therapy; taper to end
• Behavioral changes– keeping temp cool, regular
exercise, relaxation therapy

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Therapies -2

• Progestins–Megestrol acetate, norethindrone acetate,

high dose DMPA shown to be effective
• Clonidine–effective in some trials; try transdermal;
may be good in women with HTN

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 Postmenopausal Bleeding

• It is bleeding from the genital tract occurring 6 months

or more after cessation of menstruation in a woman
above the age of 40
• It is a serious symptom because in about 25% of cases,
it is due to a malignant lesion in the genital tract

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Prevalence

• About 7 per 1000 postmenopausal women

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Etiology
A) General Causes

1)Oestrogen therapy (25%)

Oestrogen given for menopausal symptoms may lead to

withdrawal bleeding

2) hypertension

3) blood diseases as leukemia

4)anticoagulant therapy

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(B)Local Causes
• Vulva-Malignant tumour, fissured leucoplakia,
urethral caruncle, and direct trauma
• Vagina-Malignant tumour, senile vaginitis, trophic
ulcer in prolapse, and retained foreign body or
pessary in the vagina
• Cervix-Malignant tumour, erosion and ulcers
• Uterus-Malignant tumour, senile endometritis, fibroid
tuberculosis endometritis

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Local cause

• F. tube carcinoma-This leads to a watery vaginal

discharge which finally becomes blood stained
• Ovary-Carcinoma with metastases in the
endometrium and oestrogenic ovarian tumours

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Cause

• (C) In about 15% of cases no cause is found after

physical examination and uterine curettage which
shows atrophic endometrium

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Diagnosis
A.History
• Personal history
(a) Age: The commonest age incidence for carcinoma
of uterus is 55-70 years while that for carcinoma of
the vulva is 60-70 years
(b) parity: some tumours are more common among
nulliparae e.g. endometrial and ovarian carcinoma

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Diagnosis

Present history
• Ask about the amount, character and duration of
bleeding, duration of menopause, and the presence of
other symptoms as pain and foul discharge, urinary
and gastrointestinal symptoms (malignant invasion of
bladder or bowel)

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Diagnosis
• Past history
(a)Estrogen therapy
(b) Diseases as diabetes mellitus, hypertension and
blood diseases as leukemia
Endometrial carcinoma is more common in diabetic
hypertensive patients
• Family history
Carcinoma of the body of the uterus and ovary have a
familial tendency

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B. General Examination
(I) Signs of anaemia
(2) signs of bleeding disorders
(3) presence of cachexia
(4) examination of heart and chest for secondaries
(5) estimation of blood pressure

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C. Abdominal Examination

For a pelvic-abdominal mass and ascites which is

common with ovarian malignancy
D. Pelvic Examination
To detect a local cause for bleeding
The urethra and anal canal are excluded as being the
source of bleeding

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E. Special Investigations
Transvaginal sonography-It excludes the presence of an
ovarian tumour or a lesion in the uterus as
endometrial carcinoma

Cervical smear-Taken in absence of bleeding to detect

the presence of malignant cells which may come
from the cervix, endometrium, tubes, or ovaries

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Endometrial biopsy
 It must be done in every case of postmenopausal bleeding, as
it is the only sure method to exclude endometrial carcinoma

Endometrial biopsy is taken by one of three methods;

o Fractional uterine curettage
o Endometrial aspiration, or
o Hysteroscopy

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Investigation
Biopsy is taken from any suspected lesion in the vulva,
vagina, or cervix
Laboratory tests-These are done according to the
clinical findings and include:
a. Complete blood count
b. Platelet count, bleeding time, coagulation time,
estimation of clotting factors if a bleeding
disorder is suspected

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 Treatment
• Treatment of the cause is important
• If no cause can be detected the patient should be
followed up
• If bleeding recurs it is better to do hysterectomy and
bilateral salpingo-oophorectomy which may reveal a
missed early carcinoma of uterus or tube

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