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Tutorial session on
MENOPAUSE
Hirsutism

Yared D. Nov 01/2016

 menopause
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 is the point in time when permanent cessation of

menstruation occurs.
 occurs secondary to a genetically programmed loss of
ovarian follicles.
 Occurs at a mean age of 51.4 years in normal women .
 Climacteric /Greek word for ladder/
 Indicates time from the reproductive life to
postmenopausal
 The stages of reproductive aging
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 MENOPAUSAL TRANSITION
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 The menopausal transition

 begins with
variation in menstrual cycle length
 an elevated serum FSH concentration

 ends with
 the final menstrual period (not recognized until after 12 months of
amenorrhea).
 Stage -2 (early) : variable cycle length (>7 days different from
normal menstrual cycle length).
 Stage -1 (late) : ≥ 2 skipped cycles or an interval of amenorrhea
≥ 60 days
 women at this stage often have hot flashes .

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 Perimenopause 
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 Perimenopause means "around the menopause,"

 refers to the time before menopause when vasomotor
symptoms and irregular menses often commence.
 can start 5-10 years or more before menopause.
 begins in stage -2 of the menopausal transition and ends 12
months after the last menstrual period
 Climacteric is the general term for the time from the period
of this transition to the early postmenopausal phase

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 Menopause
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 Greek words: men (month) & pausis (cessation).

 point in time that follows 1yr after cessation of menstruation
after 45 yrs of age.
 is characterized by a continuation of vasomotor symptoms and
by urogenital symptoms such as vaginal dryness and
dyspareunia.
 It reflects
 complete, or near complete, ovarian follicular depletion

 absence of ovarian estrogen secretion.

 CONTD...
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 Although the average age at menopause is 51 years

 for 5 percent of women, it occurs after age 55 (late
menopause)
 for another 5 percent, between ages 40 to 45 years (early
menopause)
 Menopause occurring prior to age 40 years is
considered to be premature ovarian failure.
 Unlike the age of menarche, Is unaffected by race, general
health, socioeconomic status, age at menarche, or number of
prior ovulations .
 Postmenopause
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 Stage +1 (early)
 defined as the first five years after the final menstrual
period.
 It is characterized by further and complete dampening of
ovarian function and accelerated bone loss
 many women in this stage continue to have hot flashes.
 Stage +2 (late)
 begins five years after the final menstrual period and ends
with death

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 pathogenesis
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 Is not a central event, rather primary ovarian failure.

 At the level of the ovary, there is a depletion of ovarian
follicles, due to
 usually secondary to apoptosis.
 Radiation, chemotherapy, surgery - early menopause.
 Premature ovarian failure before 40 (1-5% of women)
 Hormonal changes
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 ↓es Inhibin
 Shrinking number of follicles, or a reduced functional capacity of older
follicles.
 Gonadotrophins
 both LH and FSH levels rise substantially, with FSH usually higher than
LH
 FSH level > 40 u/l is almost always indicative of menopause
 ↓es Estradiol
 Fluctuate within the wide range of normal or may rise until
follicular development ceases altogether.
 ↓es Progesterone
 In postmenopausal women, the levels of progesterone are only
30%
 Consequence of Estrogen Loss
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 Vasomotor Symptoms
 Urogenital atrophy
 Osteoporosis
 Dermatologic Changes
 Cardiovascular disease (unclear relationship)
 Central Nervous System symptoms
 Consequence of Estrogen Loss
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 Irregular ovarian function and considerable estrogen level

fluctuation—not a deficiency of estrogen—cause climacteric
symptoms during menopause;
 Thus, stopping hormone fluctuation with OCPs and HRT
alleviates climacteric symptoms.
 Cessation of menstruation in women of the appropriate age
continues to be the best confirmation of menopause.
 As the postmenopause years progress, with an accompanying
loss of ovarian response to gonadotropins, associated
symptoms of the climacteric also decline.
 CONTD...
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 With loss of estrogen, the vaginal epithelium atrophies, the

surface becomes pale because of a reduced number of
capillaries.
 A decrease in urine & vaginal pH leading to a change in
bacterial flora may result in pruritus and a malodorous
discharge.
 Ruggae also diminishes, and the vaginal wall becomes
smooth.
 Such changes often result in insertional dyspareunia and, for
many women, eventually lead to sexual abstinence if left
untreated.
 CONTD...
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 Inside the pelvis, the uterus becomes smaller.

 Fibroids, if present, become less symptomatic & shrinks.
 Endometriosis and adenomyosis if present, are also alleviated
with the onset of menopause, and many patients with pelvic
pain finally achieve permanent pain relief.
 The ovary diminishes in size and is no longer palpable
 a general loss of pelvic tone also occurs, and this may manifest
as prolapse of reproductive or urinary tract organs.
 Atrophic cystitis, when present, can mimic a UTI. Women
report symptoms of urinary frequency, urgency, and
incontinence.
 CONTD...
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 marked changes occur throughout the body also.

 Skin loses elasticity,
 bone mineral density (BMD) declines, and
 dense breast tissue is replaced by adipose tissue,
making mammographic evaluation easier.
 The most common reason a woman presents at
menopause is because of symptomatic hot flashes.
 CLINICAL MANIFESTATIONS
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 Abnormal bleeding pattern ; Oligomenorrhea (irregular

cycles) for six or more months, or an episode of heavy
dysfunctional bleeding.
 Hot flashes
 Genito urinary symptoms
 CNS Sx - Depression
 Long term issues
 osteoporesis
 CVS disease
 dementia
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 Vasomotor Symptoms

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 Common complaint during menopausal transition.

 Begin an average of 2 years before the FMP
 Seen in 11 to 60 % of cases
 25 to 50 % will have for 5 yrs, and

 15 % may experience them for >15 years.

 The Pathophysiologic mechanisms are still not well understood.

 Affect quality of life for about 20 – 25% of women.
 Cont’d…
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 Manifestations
 Sudden wave of heat that spreads over the body, particularly on
the upper body and face with Sweating begining primarily on
the upper body.
 Increases in BP, HR & Metabolic rate.

 Palpitations, anxiety, irritability, & panic may accompany.

 An individual hot flush generally lasts 1 to 5 minutes.

 Are more frequent and severe at night or during times of stress.

 Overweight women report more hot flushing.
 Cool environment fewer, less intense, & shorter in duration .
 TREATMENT
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 Non- pharmacologic
 Psychological interventions
 Paced respiration (slow, deep breathing) - relaxation-based
procedures intended to counteract the elevated sympathetic
activation
Acupuncture
 Non-hormone therapy
 Reduce the frequency and severity of HF by 50 – 60% and are
superior to placebo.
 A good choice for women who have contraindications to HRT.
 Include - Antidepressants, Clonidine, Gabapentin
 TREATMENT
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 Pharmacological
 Hormone therapy
 Estrogens
 Currently the only treatment that gives effective control
 Up to 90% symptoms were abolished by 3 months
 Regimens with daily doses of 0.5 mg estradiol, 0.3 mg EE and 14 μ g
transdermal estradiol are effective.
 Vaginal estrogen cream
 Progestins alone
 HRT and ERT
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 HRT and ERT are not indicated for the prevention of

Coronary artery disease (CAD) primarily .
 Emerging analyses show that immediate use of HRT/ERT in
the peri- and postmenopausal time may reduce the risk of
CAD.
 women more than 5 years postmenopause should not be
started on HRT or ERT for CAD prevention.
 The benefit of estrogen is due to many factors, including
estrogen's effects on lipid metabolism (reducing low-density
lipoprotein (LDL) and increasing high-density lipoprotein
(HDL)).
 CONTD...
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 breast ca
 The general belief is that any increase in risk is small and
that each patient should be evaluated as a candidate for
ERT or HRT on an individual basis, with consideration of
the overall balance of risks and benefits
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Hirsutism & virilization

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 Hyperandrogenism

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 Hyperandrogenism most often present as hirsutism

 hirsutism usually arises as a result of androgen excess related
to abnormalities of function in the ovary or adrenal glands,
constitutive increase in expression of androgen effects at the
level of the pilosebaceous unit, or a combination of the two.
 By contrast, virilization is rare and indicates marked
elevations in androgen levels.
 Virilization usually is caused by an ovarian or adrenal
neoplasm, which may be benign or malignant.
 Hirsutism

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 Is the most frequent manifestation of androgen excess in

women.
 hirsutism is defined as excessive growth of terminal hair in a
male distribution.
 This condition refers particularly to midline hair, sideburns,
moustache, beard, chest or intermammary hair, and inner thigh
and midline lower back hair entering the intergluteal area.
 The response of the pilosebaceous unit to androgens in these
androgen–responsive areas transforms vellus hair (fine,
nonpigmented, short) that is normally present into terminal hair
(coarse, stiff, pigmented, and long).
 CONTD...
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 Androgen effects on hair vary in relation to specific regions of

the body surface.
 Hair that shows no androgen dependence includes lanugo,
eyebrows, and eyelashes.
 hair of the limbs & portions of the trunk exhibits minimal
sensitivity to androgens.
 Pilosebaceous units of the axilla and pubic region are
sensitive to low levels of androgens.
 Even the modest androgenic effects of adult levels of
androgens of adrenal origin are sufficient for substantial
expression of terminal hair in these areas.
 CONTD...
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 Follicles in the distribution associated with male patterns of

facial and body hair (midline, facial, inframammary) require
higher levels of androgens, such as those seen with normal
testicular function or abnormal ovarian or adrenal androgen
production.
 Scalp hair is inhibited by gonadal androgens in varying
degrees, as determined by age and genetic determination of
follicular responsiveness, resulting in the common frontal–
parietal balding seen in some men and in virilized women.
 CONTD...
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 Hirsutism results from both increased androgen production

and skin sensitivity to androgens.
 Skin sensitivity depends on the genetically determined local
activity of 5α–reductase, the enzyme that converts
testosterone to dihydrotestosterone (DHT), the bioactive
androgen in hair follicles.
 Hypertrichosis and Virilization

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 Hypertrichosis is the term reserved for the presence of

androgen–independent terminal hair in nonsexual areas, such
as the trunk and extremities.
 This condition may result from an autosomal–dominant
congenital disorder, a metabolic disorder (such as anorexia
nervosa, hyperthyroidism, porphyria cutanea tarda), or
medication use (e.g., acetazolamide, corticosteroids,
cyclosporine, diazoxide, interferon, minoxidil, phenytoin,
streptomycin).
 CONTD...
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 Virilization is a marked and global masculine transformation

that includes coarsening of the voice, increase in muscle mass,
clitoromegaly and features of defeminization (loss of breast
volume and body fat contributing to feminine body contour) .
 Although hirsutism accompanies virilization, the presence of
virilization indicates a high likelihood of a more serious
condition than those that occur with hirsutism alone.
 Assessment of Hyperandrogenemia

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 The history should focus on the age at onset and rate of

progression of hirsutism or virilization.
 A rapid rate of progression of androgen effects or the presence
of virilization, regardless whether it occurs before, during, or
after puberty, is associated with a more severe degree of
hyperandrogenism and should raise suspicion of ovarian and
adrenal neoplasms or Cushing syndrome.
 Anovulation, manifesting as amenorrhea or oligomenorrhea,
increases the probability of underlying hyperandrogenism.
 CONTD...
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 Hirsutism occurring with regular cycles is more often

associated with normal androgen levels; it is attributed to
increased genetic sensitivity of the pilosebaceous unit and is
termed idiopathic hirsutism.
 Anovulation virtually always occurs in the presence of
virilization.
 A family history should be obtained to disclose evidence of
idiopathic hirsutism, PCOS, congenital or adult onset adrenal
hyperplasia (CAH or AOAH), diabetes mellitus, and
cardiovascular disease.
 CONTD...
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 A history of drug use should also be obtained. In addition to

drugs that commonly cause hypertrichosis, anabolic steroids
and testosterone derivatives may cause hirsutism and even
virilization.
 During the physical examination, attention should be directed
to obesity, hypertension, galactorrhea, male–pattern baldness,
acne (face and back), and hyperpigmentation.
 Hirsutism often is the presenting symptom of Cushing
syndrome, which may mimic AOAH and PCOS.
 CONTD...
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 Physical signs of the syndrome include “moon face,” plethora,

purple striae, dorsocervical and supraclavicular fat pads, and
proximal muscle weakness.
 Laboratory Evaluation

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 When laboratory testing for the assessment of hirsutism is

indicated, a bioavailable testosterone level (total testosterone,
SHBG, and albumin level) or a calculated free testosterone
level provides the most accurate assessment of the androgen
effect derived from testosterone.
 When hirsutism is accompanied by absent or abnormal
menstrual periods, assessment of LH, follicle–stimulating
hormone (FSH), prolactin, and thyroid–stimulating hormone
(TSH) values are required to diagnose an ovulatory disorder.
 Elevated LH:FSH ratios are noted in some women with
PCOS, but cannot be used to confirm the diagnosis.
 CONTD...
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 In cases of suspected Cushing syndrome, patients should

undergo screening with a 24–hour urinary cortisol (most
sensitive and specific) assessment or an overnight
dexamethasone suppression test.
 Elevated 17–OHP levels identify patients with AOAH
 Normal morning baseline follicular phase 17–OHP levels are
less than 200 ng/dL
 When levels are greater than 200 ng/dL but less than 800
ng/dL (24 nmol/L), ACTH testing should be performed to
distinguish PCOS from AOAH.
 CONTD...
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 Levels greater than 800 ng/dL (24 nmol/ L) also warrant

ACTH testing but are virtually diagnostic of AOAH because
of 21– hydroxylase deficiency.
 Total testosterone levels greater than 200 ng/dL should prompt
a workup for ovarian or adrenal tumors, and DHEAS levels
greater than twice the upper limit of normal should prompt
evaluation for adrenal neoplasm.
 Both total testosterone and DHEAS should be measured in the
presence of virilization.
 CONTD...
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 the upper limit of a DHEAS level is 350 μg/dL (9.5 nmol/L).

 A normal level essentially rules out adrenal disease, and
moderate elevations are a common finding in the presence of
PCOS.
 A DHEAS level of more than twice the upper limit of normal,
700 μg/dL (20nmol/L), usually indicates the need to rule out
an adrenal tumor or Cushing syndrome.
 Reading From William gynecology

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 Hysterosalpingography
 Culdocenteisis
 Punch biobsy
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Thank you