MENOPAUSE

Introduction
Definitions
– Permanent cessation of menstrual periods due to declining
estrogen and progesterone production by the ovaries, i.e.
cessation of ovarian function.
– Lab. Defn = presence of signs of hypoestrogenemia and serum
FSH level of >40 IU/L (N=5-10IU/L).
– Refers to the final menstrual period (cycle)

• must be free of periods for one year to be called menopause

 Cont’d…

•At the level of the ovary, there is a depletion of ovarian

follicles, most likely secondary to apoptosis.
•Radiation, chemotherapy, surgery can results in early
menopause.
•It reflects complete, or near complete, ovarian follicular
depletion and absence of ovarian estrogen secretion.
 Introd. Contd.
• Menopause is a natural event in all women’s life

• Many women will experience menopausal changes prior

to their last period or “perimenopause"

• 1% of women undergo premature menopause before age

40
 Introd. Contd.
• Key public health issues for postmenopausal women
– Heart disease
– Osteoporosis
– Cancer
– Postmenopausal Symptoms – commonly vaginal dryness, hot
flashes
– Urinary Issues – incontinence, frequency
• Advantages of menopause
– No risk of unwanted pregnancy
– Resolution of many gynecologic problems
• Hemorrhagic / dysmenorrhea
• Uterine fibroids
• Endometriosis
 prediction of the age of
Menopause
There is no prediction of the age of menopause

Best predictor is the age of menopause of female

relatives; likely genetically determined
Menopause seems to occur later in well
nourished western populations.
Early menopause has been associated with
smoking, living in high altitude.
Age of menopause is not affected by age of first
period, pregnancy, use of birth control, use of
fertility medication or perimenopausal Changes
 Stages of Menopause
 Menopausal transition — 
– The period immediately prior to menopause when the endocrinologic,
biologic & clinical features of approaching menopause start; and ends
with the final menstrual period.
– Mostly begins with variation in menstrual cycle length and an elevated
serum FSH concentration
 Perimenopause —  "around the menopause,"
– Begins with the menopausal transition and ends 12 months after the
last menstrual period
 Menopause –
–  Menopause is defined by 12 months of amenorrhea after the final
menstrual period.
 Post menopause- women who has not experienced any
menstrual flow for a minimum of 12 months. 
 Classification
•  The average age at menopause is approximately
51 years,
– Early menopause
• When between ages 40 to 45 years
• In 5 percent women
– Late menopause
• When it occurs after age 55
• In 5 percent of women,
– Premature menopause (ovarian failure).
• Menopause occurring prior to age 40 years
• Occur in 1% of women.
 Causes of menopausal states
A. Natural (physiologic ) menopause
• Occurs between age 40—55
• Median age =51yrs
• It reflects complete, or near complete, ovarian
follicular depletion and absence of ovarian
estrogen secretion
 Causes contd.
B. Premature ovarian failure
Can occur as early as few years after menarche.
Higher risk of osteoporosis and cardiovascular disease.
Causes:-
Genetic abnormalities.
Auto immune disturbances.
Tumors
 Abnormal gonadotrophin structure & function.
Physical insult: -radiation
-chemotherapy
-surgery - oophorectomy
- vascular supply
Severe infections - viral , TB
Idiopathic.
 Hormonal changes of menopause
• Menstrual cycle and hormone patterns begin to change
many years prior to menopause.
• In the late reproductive years, menstrual cycles are
ovulatory, but follicular phase length begin to shorten.

 FSH:-
• Serum FSH levels begin to rise.
• The early evidence of change in ovarian function
• Elevated 10-20X,
• Level >40 IU is consistent with complete cessation of ovarian
function
 Hormonal changes contd.
• LH:-
– Rise only by 2-3 fold.
• Estrogens:-
– Origin = 90% ovary, 10% adrenal & peripheral
• Secretion markedly decreases in post menopause
• Main source becomes peripheral conversion of androgens.
– Mainly is estrone
 Hormonal changes contd.
• Progesterone:-
– 90 % in theca lutein cells of corpus luteum & 10 % in adrenal
cortex.
– Post menopause is only adrenal source
• Androgens:-
– In reproductive age ovary produces 50% androstenendione
and 25% testosterone
– Although the total level of androgens drops after menopause,
there is relative increase in androgenesity.
 Menopause-related Symptoms
Vasomotor Genitourniary Other Systemic
Headache Vaginal dryness Fatigue
Palpitations Dyspareunia Reduced sexual
desire/arousal
Night sweats Vaginal
Insomnia/sleep itching/burning Anxiety, irritability
disturbance Urinary and depression
frequency, Cognitive
dysuria, urgency difficulties
Backache/
stiffness
 Hot Flashes
• Definition:
• Sudden onset of reddening of the skin of head, neck, chest,
intense body heat, rapid heart rate, followed by perspiration
and chilling .
• Cause:
• vasomotor instability triggered by hormonal changes
• Significance:
• Affect 30 to 85% women, incapacitating in 10%
• Has no inherent health hazard.
• Significant effect on sleep, mood, and cognitive function
• Typically begin to decrease within 2 years after last period,
 Pathophysiology

 The mechanisms are still not well understood.

 Disturbance of the temperature-regulating mechanism in the
hypothalamus, initiated at the level of the hypothalamus by
estrogen withdrawal
 Manifestations
– Sudden wave of heat that spreads over the body,
particularly on the upper body and face.
– An individual hot flush generally lasts 1 to 5 minutes.
– Sweating begins primarily on the upper body.
– Increases in BP
– HR increases 7 to 15 BPM
– Metabolic rate rises.
– Palpitations, anxiety, irritability
– 5 - 9 min after, core temperature decreases 0.1 - 0.9°C.
 Cont’d…

• more frequent and severe at night or during times of

stress.
• Cool environment - fewer, less intense, & shorter in
duration .
• Overweight women report more hot flushing
• the effect of body fat causing a higher core body temp.
• Treatment: estrogen quickly stops hot flashes
• Home remedies: dress in light layers; small
fan to cool the face; light bedclothes and
cotton blanket; avoid alcohol and caffeine, etc.
 Vaginal Dryness
• Definition:
– Reduced vaginal secretions and thinning of the mucous
membranes lining the vagina  dryness, itching, painful
intercourse ,vaginal discharge or spotting, and vaginal
infections.
• Significant symptoms affect 50% of women.
• Cause:
– Declining estrogen levels
• Treatment:
– Estrogen lubricant
• Home remedies:
– Regular sexual activity or vegetable oils
 Bladder and Pelvic Changes
• There is a loss of muscle and supportive tissues and this
leads to natural weakness of the vagina.
• Increased risk of urinary tract infection and urinary
leakage with cough/exercise .
• Treatment:
– estrogen therapy may improve bladder control
• Other remedies:
– exercises; avoid caffeine and alcohol
 Loss of Bone/Osteoporosis
• The most prevalent bone
problem for
postmenopausal women.
• Bone in the spine and hip is
most estrogen sensitive;
loss is about 5%/yr early in
menopause with 50% loss
in 20 yr
• Risk for fractures increases
in those with low calcium
diet, smoking, limited
exercise, and very low
body weight.
 CONTD.
• Cardiovascular System
– Loss of estrogen causes an increase in bad cholesterol (LDL)
and a decrease in good cholesterol (HDL)
– During reproductive years women are protected from CHD,
and it is lost after menopause.
• Mood Changes/Depression
– It has been suggested that women with severe hot flushes are
more likely to have mood changes.
– Estrogen may improve depression in menopausal women, but
the reason for this effect is not clear.
 CONTD.
• Cognitive Function
– The effect of menopause and estrogen loss on cognitive
function is unclear
– Loss of estrogen is associated with decrease in short term
memory
– Hormone therapy may decrease Alzheimer's disease,

• Sexual Dysfunction
– Most women with changes in sexual function after
menopause report lower sexual satisfaction with their
partner after menopause.
– estrogen therapy increases libido in 50% of women with
sexual dysfunction
 Indications & benefits of HRT
A. Treatment of perimenapausal symptoms.
i. Hot flush (vasomotor instability):-
 The most common symptom and indication for HRT
 80-100% reduction with ERT.
ii. Atrophic changes:-
 Vaginal mucosal atrophies  vaginitis, dyspareunia & stenosis.
 Genitourinery atrophies  uretritis, recurrent UTI
 Atrophic skin changes. -ERT  better skin quality
iii. Affective symptoms.
 Depression ,insomnia, irritability, & loss of concentration.
 Direct or indirect effects.
iv. Loss of libido:-
 A direct or indirect effect.
 HRT 
 HRT contd.
B. Protection of cardiovascular diseases
• Decreases risk of MI & stroke by ~50%.
• A favorable impact on lipids & lipoproteins.
C. Effect against osteoporosis
• Especially indicated in smokers, family history, low body wt , x-ray
evidence & premature menopause.
• Decreases bone loss & gain bone density
 Risks & S/E of HRT

• Breast Ca.
• Endometrial hyperplasia & ca. :-
 1yr unopposed 20-50% hyperplasia
 A common reason for avoiding HRT by women.
• Weight gain & water retention.
• Stroke, thromboembolism
• Progestational side effects :-
Breast tenderness , bloating, depression, anxiety, irritability.
• Venous thrombosis:-
The actual risk is very low & limited to first year oral HRT.
• Ovarian ca.
 CONTRAINDICATIONS
A. Absolute B. Relative
1.Conditions related to estrogen  High serum triglycerides.
exposure:  Seizure disorders
 Active thromboembolic
event.  Current gallbladder disease.
 Endometrial Ca.  Migraine headache.
 Breast Ca.  Poorly controlled
 Undiagnosed AUB. hypertension
2.Related to estrogen metabolism:-
 Active hepatic disease.
 Chronically impaired liver
function.
.
 Alternative managements
 Methods:-
 Life style modification:- Physical activity, Avoid smoking,
Avoid excessive alcohol, Avoid high coffee
 Calcium supplementation(1000mg/day), 1 cup milk = 300mg
 vitamin D
THANK YOU!
 Assignment

 Malformations of the female genital tract

 Tumors of the female genital tract