Menopause

By
Almaza ALI
Msc family medicine, MD family medicine, Professional diploma of infection control
Tel/ 01224498153
Email /almazasalim@yahoo.com
 Learning Objectives
• Definition of menopause and normal age of it.
• Clinical manifestation of menopause.
• How to diagnose a case of menopause.
• Treatment of menopausal symptoms.
• Screening to post menopausal woman
 Case Scenario
A 51-year-old woman has been experiencing
progressive symptoms of profuse night sweats and
frequent hot flushes occurring both day and night. She
finds her emotional state increasingly labile. She is also
experiencing sleep disturbances and anxiety. She denies
any other complaints. Her last period was
approximately 12 months ago. She has no history of
medical problems or affective disorders. Her pulse is 78
beats/ minute, and her blood pressure is 122/74
mmHg. Her pelvic examination reveals atrophic
external genitalia, The rest of her examination is
normal.
1. What is the most likely diagnosis in this patient?
a. pheochromocytoma
b. hyperthyroidism
c. menopause
d. generalized anxiety disorder.

2. What is the most effective treatment option for this patient?

a. thyroid replacement
b. estrogen with progestin (hormone therapy [HT])
c. antidepressants
d. estrogen alone (estrogen therapy [ET])
3.Alternative therapies, with demonstrated efficacy, for this
patient’s condition might include
a. black cohosh
b. soy isoflavones
c. red cloverd.
d. selective serotonin reuptake inhibitors (SSRIs)/selective serotonin and
norepinephrine reuptake inhibitor (SSNRIs)
 MCQ
•Which is the median age of natural menopause?
a. 41
b.46
c. 51
d.56
•Which of the following are the earliest manifestations of menopause?
a. Osteoporosis
b.Hot flushes
c. Vaginal dryness and dyspareunia
d.Psychological upset
e. B and C
•Which of the following drugs is the most effective in controlling hot flushes?
a. Estrogen
b.Testosterone
c. Isofavones
d.Gonadotropins
e. Vitamin E
• Which of the following would support the diagnosis of menopause in a
woman taking no medications?
A) Vaginal pH >4.5
B) FSH level <10 mIU/mL
C) Endometrial cells noted on Pap smear
D) TSH >5.6
E) Progesterone >10 ng/dL

• The addition of progesterone to estrogen replacement therapy (ERT)

prevents the development of
A) adenomyosis
B) fibroid tumors
C) cervical cancers
D) ovarian cancer
E) endometrial hyperplasia
• Which of the following statements regarding estrogen
replacement therapy (ERT) is true?
A) The addition of progesterone slightly raises the risk for endometrial carcinoma.
B) ERT lowers the risk for ovarian carcinoma.
C) All forms of estrogen delivery are equally effective in lowering cholesterol.
D) Patients with a prior history of thrombosis should avoid ERT.
E) Studies show that there is no increased risk for breast cancer with ERT.
• HRT offers protection against which of the following problems:
A)Breast CA
B)Osteoporosis
C)Alzheimer's
D)Colorectal Cancer
D)B,C,D

• which of the following as the preferred mammographic

screening protocol for breast cancer in women?
A-Screen all women older than 40 years every year.
B-Screen all women 40 years or older every 1 or 2 years
C-Screen all women 50 years or older every 1 or 2 years.
D-Screen all women older than 55 years every 1 or 2 years.
 Menopause
Definition:-cessation of menses for 12 months
without another pathologic cause. It occurs from
gradual depletion of functioning ovarian follicles.
After menopause, ovaries lose the ability to
produce estrogen. The average age of menopause
is 51 years. Most women experience vasomotor
symptoms for about 2 years after their LMP but
25% of women are asymptomatic.
 Types of menopause
• Physiologic menopause:-
The normal decline in ovarian function due to ageing
begins in most women between ages 45 and 55 on
average 51 and result in infrequent ovulation, decreased
menstrual function and eventually cessation of
menstruation.
• Pathologic menopause :-
The gradual or abrupt cessation of menstruation before
40 years occur idiopathic ally in about 5% of women in
USA.
Physiological Changes in patients with menopause
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.
Physiological Changes , cont

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.
 Physiological Changes , cont

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.
 Physiological Changes , cont

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 thinner and less elastic .
This lead to increased frequency of passing urine
as well as an increased tendency to develop UTI.
 Physiological Changes , cont

Uterus :-
• The uterus become small and fibrotic due to
atrophy of the muscles after menopause .
• The cervix become smaller and appears to flush
with vagina . In older women the cervix may be
impossible to identify separately from vagina .
• The vaginal and cervical discharge decreases in
amount and later disappear completely.
 Physiological Changes , cont

Ovaries :- The ovaries become smaller . The

ovaries which produce little androgen during
reproductive life begin to produce it in increasing
amounts.
Vagina :- The vaginal mucous membrane
becomes thin and loses its rugosity after the
menopause. Decreased secretion make vagina
dry . Sexual intercourse become painful and
difficult due to pain from the dry vagina.
 Clinical picture
 Vasomotor symptoms:-
1)Hot flashes:- occurs in up to 85% of post menopausal women, sudden
feeling of warmth and flushing that starts in the face and quickly spread
all over the neck and upper body, frequency between 1/hr to 1/15 min,
worsened by eating, exertion, emotional stress and alcohol .
2)- Night sweating.
 GU symptoms:-Vaginal atrophy leading to dryness, pruritus and
dyspareunia, urethral atrophy leading to stress incontinence,
frequency, urgency and recurrent dysuria.
Clinical picture,cont

• Mood changes:- Irritability, anxiety, depression

and sleep disturbance, decreased libido,
memory loss, and problems concentrating.
• Perimenopause:-Precedes actual menopause;
characterized by variable cycle length, often
accompanied by the symptoms of menopause.
 Diagnosis
• vaginal pH >4.5:- indicates menopause in women
who are without vaginitis and are not receiving
estrogen therapy. Studies have shown that vaginal pH
is similar to FSH levels in establishing the diagnosis of
low estrogen levels or menopause, and that a vaginal
pH of 4.5 or less can be used to .

• ↑ serum FSH (>40):-the most specific

 treatment
 Lifestyle modification:-
to ↓ vasomotor symptoms include lowering room
temperatures, consuming cold food and drinks,
avoiding caffeine , alcohol and spicy foods, weight
control, regular physical activity, tobacco avoidance,
and relaxation techniques.
 Pharmacological treatment :-
o non hormonal replacement therapy
o Hormonal replacement therapy
 Non hormonal replacement therapy

SSRIs and the SSNRI ( venlafaxine):-

have been shown to reduce hot flashes in 19% to
60% and well tolerated.
gabapentin (gapten):- have also demonstrated
significant reductions in vasomotor symptoms.
Soy isoflavones:- reduced hot flashes in some
trials, but most trials showed no difference
compared to placebo.
Non hormonal replacement therapy ,cont
Black cohosh and red clover :-have also had
inconsistent results, with some trials showing
benefit and some no difference compared with
placebo.
evening primrose oil(femarose cap), ginseng,
mirtazapine, trazodone, vitamin E :-few data
regarding their effectiveness have been
published
 Hormone replacement therapy (HRT)‫ممم‬
 Associated with a significant ↓ in severity and frequency of hot
flash, improves GU symptoms and can prevent osteoporosis.
 it is most appropriately used as a small dose and short-term
treatment aimed at symptom relief.
Indications:-
1-treatment of moderate to severe vasomotor symptoms
(2) treatment of moderate to severe symptoms of vulvar and
vaginal atrophy (dryness and irritation) associated with menopause,
(3) prevention of postmenopausal osteoporosis.
 Hormone replacement therapy (HRT),cont
Whom HRT should be prescribed:-
• Premature ovarian failure
• Gonadal dysgenesis
• Surgical or radiation menopause
Route of administration :-oral, transdermal
patches, intra-vaginal (cream/ tablet/ring).
Duration of therapy:- short period of 3-5 years
have been devised. Reduction of dosage should be
done as soon as possible.
 Hormone replacement therapy (HRT),con
women with a uterus must be treated with a
combination of estrogen and progestin to prevent
endometrial hyperplasia and consequently carcinoma.
cyclical pattern is 0.625 mg/day estrogen with 5 or 10
mg/day progesterone given on days 19 through 25.
Transdermal estrogen is also available, but is less
beneficial with regard to lipid metabolism.
 Complication of HRT
Endometrial cancer: when estrogen is given alone to a women with
intact uterus
Breast cancer: combined HRT increases the risk of breast cancer
slightly(9%).
Venous thromboembolic disease (VTE): It has been found to be
increased with the use of combined oral estrogen and progestin.
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
Precautions during prescribing HRT
As the HRT increases woman’s risk of coronary disease, stroke (24%),
DVT, breast cancer and endometrial cancer so Woman who choose to
take estrogens or combined estrogen and progestin therapies after
good counseling with their doctor should have :-
• yearly breast examinations ,perform monthly breast self-
examinations, and receive periodic mammography (scheduled based
on their age and risk factors).
• Women should also talk to their health care provider about other
ways to reduce their risk factors for heart disease and osteoporosis
 Screening post menopausal women)‫ممم‬
(1) height/weight (periodically).
(2) blood pressure (periodically).
(3) vision (periodically).
(4) mammogram (after 50 years; annually).
(5) Pap test (every 1 to 3 years until age 65 years.
(6) colorectal (after 50 years; frequency depends on method—fecal occult
blood test, flexible sigmoidoscopy, or colonoscopy).
(7)bone mineral density (BMD) .
(8) fasting lipid profile (after 45 years; every 5 years ).
Wrap-up
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