Overview of menopause, the issues related to this subject and clinical implications for the student

1. An Overview of
Menopause
Associate Prof Dr Hanifullah Khan

2. objectives
! to understand this condition &
terminology
! physiology of menopause
! problems linked with menopause
! clinical scenarios

3. what is menopause?
! A physiological loss of ovarian hormonal activity
! Closely allied to loss of reproductive potential
! Permanent cessation of the primary ovarian
functions

4. Physiology

5. The Ovaries
! 2 functions - produce ova &
secrete hormones
! Start secreting estrogen &
progesterone from puberty to
menopause
! Most of the beneficial effects
derive from estrogen

6. actions of estrogen
! formation of the 20 sex characteristics
! Develop ovaries, tubes, uterus & vagina
! HPO axis interaction
! endometrial proliferation
! Increases fat deposition
! maintain the skin & vessels
! bone - incrrease formation & reduce
resorption

7. actions of
progesterone
! its actions are amplified in the presence
of estrogen
! Interacts with hypothalmus and pituitary
to regulate menstrual cycle
! converts endometrium to secretory stage
! makes cervical mucous & vaginal
epithelium impenetable to sperm
! inhibits lactation during pregnancy
! makes the uterus less contractile

8. When does
menopause occur?
! Tends to occur over a period of
years
! A consequence of biological ageing
! Genetic & environmental factors
! Malaysian women - 48 - 52 years*
*Jahanfar SH 2006, Ismael NN
1994

9. Types of
menopause
- Premature Menopause - menopause in a woman aged <40
years
- Early Menopause - menopause in a woman aged 50 - 59
years
- Late Menopause - menopause in a woman aged >60 years
- Surgical menopause - a result of surgical removal of both
ovaries
- Medical menopause -
- permanent damage to both ovaries - chemotherapy or
radiotherapy
- temporary - GnRHa tx in endometriosis

10. Perimenopause
- the time just before and soon after the
occurence of menopause
- symptoms of menopause have started
- not yet certain if menopause is established
yet

11. Diagnosis of
menopause
! The diagnosis of menopause is mainly clinical
• a. Clinical Criteria
1. age around menopause ( around 50 years )
2. no periods for 12 months
3. menopausal symptoms
• ( NB. All 3 clinical criteria need not be present for a diagnosis )
• Laboratory diagnosis is generally not necessary for the diagnosis of
menopause. However, where in doubt, laboratory testing of FSH may support
the diagnosis, viz
• b. Laboratory Criterion
• 1. FSH level > 35miu/ml

12. The consequences
of menopause

13. primary symptoms
- Menstrual changes
- Abnormal - Oligoamenorrhea – amenorrhea
- Vasomotor
- hot flashes, night sweats
- Urogenital
- Vaginal dryness, micrurition altered

14. secondary
symptoms
- Physical symptoms
- Muscle & joint pains
- Skin dryness, decreased stamina, backache
- Sexual
- Decreased libido
- Avoiding intimacy
- Psychophysiologic changes
- Decrease concentration
- Depressive symptoms

15. Monitoring symptoms

16. Long term effects
! Cardiovascular
! Bone
! Cancers
! Cerebrovascular

17. Clinical implications
of menopause

18. Minor conditions
- Urinary tract infections
- Vaginal dryness
- Vaginal infections
- Joint & muscle pains

19. Symptoms
mimicking disease
! Abnormal vaginal bleeding
! Perimenopausal
! Postmenopausal
! General pains e.g. Breast

20. Perimenopausal
abnormal bleeding
- At this age, there are many conditions that peak
- e.g. Adenomyosis, polyps, fibroids, hormonal
- Cancers are always a concern, esp Ca Cx
- Infections are the most common occurrence
- All these must be ruled out before a diagnosis of
perimenopausal bleeding is made

21. Postmenopausal
bleeding
- Consider it as always abnormal
- Always think of cancer
- Usually due to atrophy or infection

22. Cardiovascular
disease
! CV risk increases as
estrogen levels
decline
! 1 in 2 women will
die from
cardiovascular
disease
! Estrogen exerts
beneficial effects on
CV system through
! Direct effect on
the vasculature
! Indirect effect
of lipid
metabolism
Kramarow E et al. Health and Aging Chartbook. Health, United States, 1999. National
Center for Health Statistics; 1999.

23. Cholesterol
metabolism
! Only total cholesterol,
low-density lipoprotein
cholesterol, and
apolipoprotein B
demonstrated substantial
increases within the 1-year
interval before and after
the FMP, consistent with
menopause-induced
changes. This pattern was
similar across ethnic
groups.
Matthews K. J Am Coll Cardiol. 2009;54(25):2366-2373

24. Fracture risk
! decreased
bone density
! osteoporosis
! common
fractures
involve hip,
forearm &
spine

25. you wanna be like this?

26. Psychomotor &
Mental
! loss of libido
! suicidal tendencies
! marital discord

27. Urogenital problems

28. Menopausal
Hormone Therapy

29. potential risks &
concerns
- Breast cancer
- Cardio vascular disease
- Venous thrombosis
- Endometrial cancer
- Compliance/therapy
- The Women s health initiative study aimed
to confirm all these

30. Conclusion
• Estrogen plus progestin was associated with greater
breast
• cancer incidence, and the cancers are more commonly
node
• positive. Breast cancer mortality also appears to be
• increased with combined use of estrogen plus progestin.
• Writing Group for the Women s Health Initiative Investigators
JAMA. 2010;304(15):1684-1692

31. Current recommendations
- hormone therapy should be initiated for the
treatment of menopause-related symptoms
- the lowest dose should be used for the lowest
duration
- 5 years recommended for estrogen+prog therapy
- hormone therapy risks
- all forms of tx increse risk of VTE (deep vein thrombosis & pukmonary emboli)
- increased risk of breast Ca with est+prog combination
Stuenkel CA et al. Menopause. 2012;19(8):846-847

32. Summary

33. The important points
! menopause is a natural occurence
! it is associated with long- & short-term
issues
! some of the menopausal symptoms may
mimic medical disorders
! postmenopausal conditions such as bleeding
& masses must be seriously looked into
! hormone therapy should be used but it has its
problems

34. Q. A 40 year old woman presented
with no periods for 1 year. How
would you diagnose menopause?