PHYSIOLOGY OF

MENOPAUSE
dr. Ide Pustaka Setiawan, M.Sc.(HPE), Sp.OG

FAKULTAS KEDOKTERAN, KESEHATAN MASYARAKAT DAN KEPERAWATAN

UNIVERSITAS GADJAH MADA
INTRODUCTION
 The term menopause refers to a point in time that follows 1
year after the cessation of menstruation
 The post-menopause describes those years following this
point
 The average age is 51.5 years
 perimenopause or climacteric generally refers to the time
period in the late reproductive years, usually late 40s to early
50s
 Characteristically, it begins with a menstrual cycle irregularly
and extends to 1 year after permanent cessation of menses.
 Menopausal transition (climacteric/perimenopause) typically
develops over a span of 4 to 7 years, and the average age at
its onset is 47 years
Stages of Reproductive Aging Workshop
(STRAW)
INFLUENTIAL FACTORS

 Environmental, genetic, and surgical

influences may speed ovarian aging
 Smoking advances the age of
menopause by approximately 2 years
 chemotherapy, pelvic radiation, ovarian
surgery, and hysterectomy may also
lead to an earlier age of menopause.
Symptoms Associated with Menopausal
Transition
PHYSIOLOGIC CHANGES

• An average woman may experience

approximately 400 ovulatory events
during her reproductive lifetime

• This represents a very small percentage

of the 6 to 7 million oocytes present at
the 20th week of gestation, or even the
400,000 oocytes present at birth
PHYSIOLOGIC CHANGES
6-7 million
oocytes

400.000 oocytes

Variation in oocyte number and hormone levels during prenatal and postnatal periods
Levels of AMH decrease markedly and progressively across the menopausal transition
PHYSIOLOGIC CHANGES:
Hypothalamus-Pituitary-Ovarian Axis Changes
 The transition from ovulatory
cycles to menopause typically
begins in the late 40s and in early
menopausal transition (stage -2)
 In menopause phase the levels of
FSH rise slightly
Perubahan Endokrinologik pada menopause

• Levels of FSH rise slightly and lead to

an increased ovarian follicular
response
• This, in turn, creates overall higher
estrogen levels
• Estradiol levels generally do not
decrease significantly until late in the
menopausal transition
• FSH and LH levels rise up to fourfold
higher than in the reproductive years
ENDOMETRIAL CHANGES

 Endometrium changes directly reflect the

level of systemic estrogen and progesterone
 During the later stage of menopausal
transition, anovulation is common, and the
endometrium will display estrogen’s effect
when unopposed by progesterone
 After menopause, the endometrium becomes
atrophic due to lack of estrogen stimulation
MENSTRUAL DISTURBANCES
 Abnormal uterine bleeding is common during
the menopausal transition
 Menses were irregular during the menopausal
transition
 Increased risk for developing endometrial
hyperplasia or carcinoma.
 Endometrial cancer is suspected in any woman
in menopausal transition with abnormal uterine
bleeding.
EVALUATION OF ABNORMAL
BLEEDING
SONOGRAPHY
 In postmenopausal women, an endometrial
thickness of 4 mm has a 99-percent negative
predictive value in excluding endometrial
carcinoma
 A thickness of 4 mm is a nonspecific finding.
 Endometrial biopsy is advised in any
postmenopausal women with abnormal bleeding
and endometrial thickness 4 mm
INFERTILITY
 For women entering menopausal transition, conception
may be difficult.
 For those desiring pregnancy, may require assisted
reproductive technologies
 Advanced maternal age during pregnancy is associated
with increased risks.
 miscarriage,
 chromosomal abnormalities,
 cesarean delivery,
 gestational diabetes,
 pregnancy-induced hypertension,
 and stillbirth (Montan, 2007; Schoen, 2009)
Central Thermoregulation Changes
 The most common complaints are symptoms related to
thermoregulation (hot flushes and night sweats )
 Longitudinal studies have shown that hot flashes are
associated with:
 high FSH and low estradiol levels,
 low exercise levels,
 smoking,
 increasing body mass,
 ethnicity,
 socioeconomic status,
 and a history of premenstrual dysphoric disorder (PMDD) or
 depression
 Some dysfunction of central thermoregulatory centres in the
hypothalamus is likely the cause of this common symptom.
Sleep Dysfunction and Fatigue
 Sleep disruption is a common
complaint of women with hot
flashes
 Disturbed sleep can lead to fatigue,
irritability, depressive symptoms,
cognitive dysfunction, and impaired
daily functioning.
Fatigue Prevention Instruction
 Bone Metabolism and Structural
Changes

Bone remodeling.
A. Osteoclasts resorb matrix, whereas osteoblasts deposit new lamellar bone. Osteoblasts that are trapped in the matrix become osteocytes. Osteoblasts
produce the proteins RANKL and OPG. When RANKL binds to RANK, which is a receptor on the surface of osteoclast progenitor cells, this promotes
those cells’ development, activity, and survival as osteoclasts. This leads to bone resorption. OPG serves as a counterbalance. OPG binds to RANKL,
and thereby, RANKL is incapable of binding with RANK to promote osteoclast development. Through this mechanism, bone resorption is limited.
B. With hypoestrogenism, RANKL production is increased. Excessive levels of RANKL outnumber those of OPG, and osteoclast development and bone
resorption is favored. OPG osteoprotegerin; RANK receptor activator of nuclear factor kappa-β; RANKL RANK ligand.
 BONE LOSS

GERIPAUSE

Active Slow Rapid Continuing

growth loss loss loss
 MENOPAUSE GERIPAUSE AWAL GERIPAUSE LANJUT

Prevalensi kepadatan mineral tulang paha (BMD) pada laki-laki dan wanita.
CARDIOVASCULAR CHANGES
 Before menopause, women have a
much lower risk for cardiovascular
events compared with men their age.
 Younger women have high-density
lipoprotein (HDL) levels which is an
effect of estrogen.
 The risk of CVD increases
exponentially for women as they enter
the postmenopause and estrogen levels
decline
Dermatologic Changes

 Skin changes that may develop during

menopausal transition include
hyperpigmentation (age spots), wrinkles, and
itching.
 These are caused in part from skin aging
 Hormonal aging of the skin is thought to be
responsible for many dermal changes
 Dental changes

 Dental problems may also develop as estrogen

levels wane in late menopausal transition
 The buccal epithelium undergoes atrophy due to
estrogen deprivation, resulting in decreased saliva
and sensation
 A bad taste in the mouth, increased incidence of
cavities, and tooth loss also may occur
 Oral alveolar bone loss is strongly correlated with
osteoporosis and can lead to tooth loss
Breast changes
 The breast undergoes change
during menopause mainly because
of hormonal withdrawal
 In premenopausal women, estrogen
and progesterone exert
proliferative effects on ductal and
glandular structures, respectively
 At menopause, withdrawal of
estrogen and progesterone leads to
a relative reduction in breast
proliferation.
Central Nervous System Changes

 Sleep Dysfunction
 Sleep fragmentation is commonly associated
with hot flashes and results in daytime
fatigue, mood lability, irritability, and
problems with short-term memory

 Cognitive dysfunction
 Memory decreases with advancing age
 Although no direct effect of lowered
estrogen levels on memory and cognition
has been determined, many investigators
suspect a relationship cognitive decline during
menopause
Psychological changes

 Psychological and cognitive

symptoms may develop during
menopausal transition and include
depression, mood changes, poor
concentration, and impaired
memory
LIBIDO CHANGES
 Menopausal status was observed to be
significantly related to decreased sexual
interest.
 However, after adjustment for physical and
mental health, smoking, and marital
satisfaction, menopause status no longer
had a significant relationship to libido
 Menopause was significantly associated
with dyspareunia and indirectly with
sexual response
Lower Reproductive Tract Changes

Estrogen receptors have been identified in the vulva, vagina, bladder, urethra, pelvic floor musculature, and
endopelvic fascia
Lower Reproductive Tract Changes
 Symptoms of urogenital atrophy, including
vaginal dryness and dyspareunia
 Without estrogen, the vagina loses collagen,
adipose tissue, and ability to retain water
 Vaginal pH becomes more alkaline, and a pH
greater than 4.5 is typically observed with
estrogen deficiency
 An alkaline pH creates a vaginal environment
less hospitable to lactobacilli and more
susceptible to infection by urogenital and faecal
pathogens
Terima kasih
Ide Pustaka Setiawan
dr.idepustaka.spog