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MENOPAUSE

THE

-------------------------------------------------------------------------------------------------------------------DEFINITION
Menopause: permanent cessation of menstruation due to an intrinsic ovarian failure
resulting in follicular inactivity.
Climacteric: The few years that precede menopause. It represents the transition, from
reproductive to non-reproductive state.
TYPES
Natural Menopause: A retrospective diagnosis is established when menstruation stops for 12
months in the absence of an organic or a pathological cause. This usually occurs at the age of
45-50 years. If it occurs before the age of 40 years, it is referred to as Premature Menopause.
Induced Menopause: May be
a. Surgical after bilateral oophorectomy
b. Radiological after irradiation of the ovaries
c. Chemotherapeutic after exposure to chemotherapy during treatment of malignant diseases
PATHO-PHYSIOLOGY:
a) Endocrine Changes:
The sequalae of endocrine changes is as follows:
Decrease in inhibin production by the ovary
Decrease in oestradiol blood level
Increase in follicle stimulating hormone (FSH) production by the pituitary gland (> 30 lU/ml)
Increase in lutenizing hormone (LH) production

The menstruation may stop abruptly but more commonly after a period of oligo and/or
hypomeorrhoea. During this climacteric period, bleeding from a proliferative endometrium
(because of anovulation) may be irregular and acyclic. In such cases, endometrial carcinoma
should be excluded before attributing it to hormonal changes.
B) Morphological Changes:
Morphological changes are characterized by atrophy because of Oestrogen Lack
The ovaries look small and fibrous
The uterus become smaller and the cervix flush with the vaginal vault
The vagina looks pale with loss of rugae and acidity
The vaginal smear becomes atrophic
The labia majora become smaller and the vulval orifice gaps

 The ligaments become weak with a tendency to prolapse and stress incontinence
The breasts become small and flabby

-2-

SYMPTOMS
Collectively known as the menopausal syndrome and are related to oestrogen deficiency
About 50% of women do not develop these symptoms

Duration and severity vary in different women

May occur before, during, or after cessation of menstruation
Vasomotor: Hot Flushes or a wave of heat over the chest, neck, and face followed by cold

sweating is the most characteristic symptom occurring for few seconds or minutes. Frequency
vary and may occur at night disturbing sleep. Palpitation, headache, and dizziness may also
occur.
Nervous and psychological: Anxiety, irritability, mood changes, lack of concentration.
Gastro-intestinal: constipation, abdominal distension
Urinary: frequency, dysuria, stress incontinence with predisposition for urinary tract infections
Vaginal: atrophy and dryness leads to dyspareunia. Decrease in vaginal acidity predisposes to
senile vaginitis
Hirsutism, uterine prolapse.
Special investigations:
If any doubt exists about the diagnosis of menopause measurement of serum FSH level is
done. Elevation of FSH level to 20 mIU/ml indicates early ovarian failure
REMOTE HEALTH HAZARDS
Osteoporosis or decreased bone mass density due to oestrogen lack with increased risk of
fractures. It affects vertebrae, femoral neck, distal radius, and calcaneum. Risk factors are
smoking, caffeine consumption, sedentary life, genetic (white race), familial, and low body
weight. The decrease in body mass may lead to curvature of the spine, fractures of the vertebrae
or hip and loss of height. Diagnosis by X-ray densitometry. It is prevented by avoiding risk
factors, calcium, and vitamin D supplementation.
Cardiovascular disease as myocardial infarction, atherosclerosis, hypertension, and stroke
because of losing the protective effect of oestrogen leading to hypercholesterolaemia, increase
in Low Density Lipoproteins (LDL) and decrease in High Density Lipoproteins (HDL).
MANAGEMENT
Examination: general, breast, and pelvic to exclude a disease that may contraindicate the use of
Hormone Replacement Therapy HRT.
Assurance about the physiological nature of the symptoms may be the only treatment needed.
Regulation of diet and exercise.
Sedatives, tranquilizers, or antidepressants if needed.
Hormone Replacement Therapy (see below).

-3-

HORMONE REPLACEMENT THERAPY (HRT)

HORMONES IN USE
Estrogens:
The natural compounds are preferred
a. Estradiol valerate
1-2 mgm/day
b. Conjugated equine
0.625 mgm/day

The oral route is easy, cheap, and convenient. However, hepatic first pass reduce the
biological activity (converted to estrone) and can activate certain liver enzymes.
The transdermal route (by skin patches) or administration by subdermal implants, avoid the
above-mentioned side effects.
Must be combined with a progestin when given to women with an intact uterus to avoid
endometrial hyperplasia or carcinoma. However oestrogen alone is prescribed for
hysterectomized patients.
Progestagens:
Synthetic compounds with progestational activity. Either:
a. Testosterone derivatives:
Norgestrel 0.05 mgm/day
Norethisterone acetate 1 mgm/day
Gestodine 50 mcg/day
b Progesterone derivatives
Micronized progesterone 200 mgm/day
Medroxyprogesterone acetate 2.5 mgm/day
REGIMEN OF HRT
Sequential regimen: Oestrogen alone for 2 weeks followed by a combination of estrogen and
progestagen for another 2 weeks. Withdrawal bleeding occurs in 80% of cases
Combined regimen: Daily continuous combination of oestrogen and progestagen allows using a
lower dose of progestagen resulting in less bloating, weight gain, and mastalgia. Withdrawal
bleeding occurs in 20% of cases in the first year.
Oestrogen alone: Used only in hysterectomized women
INDICATIONS OF HRT
Although all menopausal women suffer from oestrogen lack, not all of them need HRT.
Worldwide, only about 20% of menopausal women use HRT for 1-2 years
Symptomatic menopausal women to relieve menopausal symptoms

 Premature or induced menopause

To prevent osteoporosis for a minority of women with one or more risk factors. Beneficial

effect occur only during treatment and stop with cessation of treatment.
-4CONTRAINDICATIONS
Absolute: Breast and endometrial cancer, active liver diseases, uncontrolled hypertension, and

thromboembolic diseases
Relative: Uterine fibroid, endometriosis, and migraine

BENEFITS OF HRT
Relieves menopausal symptoms
Prevents urogenital atrophy and osteoporosis
Decreases risk of colonic cancer and Alzheimer disease.
LONG-TERM RISKS
Slight increased risk for breast cancer if used for more than 5 years (relative risk 1.3)
Slight increased risk of thromboembolic disease during the first year of use
Increased risk of endometrial cancer with oestrogen-only regimen
For those reasons, use of HRT should not exceed 5 years
FOLLOW-UP FOR HRT CASES
Periodic mammography every 1-2 year.
Pap smear yearly
Bone densitometry
Ultrasonography for cases with bleeding
Endometrial biopsy for abnormal bleeding pattern to avoid delay in the diagnosis of endometrial
carcinoma.
N.B.: The decision to use HRT should be made jointly by the patient and her health care
provider with full consideration of all known and possible benefits and risks.
THERAPY FOR PREVENTION AND TREATMENT OF OSTEOPOROSIS
1. Calcium supplementation 1200 mg/day, vit D and exercise are important.
2. HRT: can be used for no more than 5 years, however when HRT is stopped the rate of bone loss
increases.
3. Bisphosphonates: e.g. alendronate 5-10 mg, risedronate (5mg). It inhibits bone resorption.
4. Raloxifene (SERM): 60 mg/day it has a combined oestrogen-like effect (on bone) and
antioestrogenic-effect (on breast and uterus). It can be used for osteoporosis if HRT is
contraindicated or refused.
5. Calcitonin: It nasal spray 200 mg/day it inhibits bone resorption by decreasing osteoclasts
activity

6. Phytoestrogens: plant substances found in food similar in its action to oestrogen e.g. soya.

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Gynaecology
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The Menopause
Gynaecology

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