MEANING OF MENOPAUSE

The word menopause literally means end of monthly cycles From a GREEK word
Pausis means cessation Men means month

DEFINITION
Menopause is defined as the time of cessation of ovarian function resulting in permanent amenorrhoea.

DEMOGRAPHY
Sixty million women in India are above the age of 55 years. AGE OF MENOPAUSE The age of menopause ranges between 45-55 years, average being 50 years. If menopause occurs before 40 years of age, its called premature menopause.

PHASES

Premenopause is the period prior to menopause Post menopause is the period after menopause

Perimenopause is the period around menopause

Climacteric is the phase of aging process during which a woman passes from the reproductive to the nonreproductive stage. This phase covers 5-10 years on either side of menopause. Pre menopause is the part of climacteric before menopause, when the menstrual cycle is likely to be irregular. Post menopause is the phase of life that comes after the menopause.

PHYSIOLOGY

When women are in their forties, anovulation occurs more often. Menstrual cycles increase in length and ovarian follicles become less sensitive to hormonal stimulation from FSH and LH. Because of these changes, a follicle is stimulated to the point that an ovum grows to maturity and is released in some months

In other months no ovulation takes place. Without ovulation and release of an ovum, progesterone is not produced by the corpus luteum. The lining continues to grow until it lacks sufficient blood supply, at which point it will bleed.

During this time, a womans cycle will become more irregular. She may skip or miss periods; have shorter or lighter periods or longer, heavier periods; and experience clotting. FSH levels become elevated, reflecting an attempt to stimulate a follicule to produce estrogen.

ENDOCRINOLOGY OF CLIMACTERIC AND MENOPAUSE

HYPOTHALAMOPITUITARY GONADAL AXIS Depletion of ovarian follicles(prior to menopause) Follicles become resistant to pituitary gonadotropins

Impaired folliculogenesis

Significant fall in serum estradiol level

Decreases ve feedback back on hypothalamopituitary axis

Increases FSH
Increase LH

Anovulation

Oligo ovulation

Corpus luteal insufficiency

ESTROGENS

Following menopause, the predominant estrogen is oestrone and to a lesser extent oestradiol. The major source of oestrone is peripheral conversion(aromatization) of androgens from adrenals (mainly) and ovaries.

The trace amount of oestradiol is derived from peripheral conversion of oestrone and androgens. With times, the source fail to supply the precursors of estrogen and about 5-10 years after menopause. There is a sharp fall in estrogen and also the trophic hormones. The woman is said to be in a state of true menopause.

ANDROGENS

After menopause, the stroma cells of the ovary continue to produce androgens because of increase in LH. The main androgens are androstenedione and testosterone. Though the secretion from androgens from postmenopausal ovary are more,

Their peripheral levels are reduced due to conversion of androgens to oestrone in adipose tissue

However the cumulative effect is a decrease in estrogen:androgen ratio. This results in increased facial hair growth and change in voice.

PROGESTERONE

GONADOTROPHINS

The secretions of both FSH and LH are increased due to absent negative feedback effect of oestradiol and inhibin or due to enhanced responsiveness of pituitary to GnRH. Rise in FSH is 10-20 fold where as that of LH is about 3 fold.

GnRH pulse section is increased both in frequency and amplitude. During menopause there is fall in the level of prolactin and inhibin. Ultimately, due to physiologic aging GnRH and both FSH, LH decline along with decline of estrogens.

ORGAN CHANGES

Ovaries
shrink in size become wrinkled and white thinning of the cortex with increase in medullary components abundance of stromal cells which have got secretory activity.

Fallopian tubes
atrophy muscle coat becomes thinner cilia disappear plicae become less prominent

Uterus
smaller the ratio between the body and the cervix reverts to the 1:1 ratio endometrium may be proliferative or even hyperplastic The cervical secretion becomes scanty

Vagina
becomes narrower vaginal epithelium becomes thin rugae progressively flatten no glycogen Doderleins bacillus is absent The vaginal pH becomes alkaline

Vulva
features of atrophy labium becomes flattened pubic hair becomes scantier narrow introitus.

Breast fat
reabsorbed and the glands atrophy nipples decrease in size breast becomes flat and pendulous

Bladder and urethra

epithelium becomes thin more prone to damage and infection dysuria, frequency, urge or even stress incontinence

Loss of muscle tone

leads to pelvic relaxation, uterine descent and anatomic changes in the urethra and neck of the bladder pelvic cellular tissues become scanty ligaments supporting the uterus and vagina lose their tone As such preexisting weakness gets aggravated

OTHER EFFECTS OF MENOPAUSE

Bone metabolism
Following menopause there is loss of bone mass by about 3-5 per cent per year This is due to deficiency of estrogen Osteoporosis is a condition where there is reduction in bone mass but mineral to matrix ratio is normal Post menopausal women run a high risk for fracture of bones due to osteoporosis

Cardiovascular system
Risk of cardiovascular disease is high in post menopausal women due to deficiency estrogen. Estrogen prevents cardiovascular disease by several ways. It increases HDL and decreases LDL and total cholesterol. It inhibits platelet aggregation at the vascular intima.

It stimulates the release of nitric oxide to dilate the blood vessels. It prevents atherosclerosis by its antioxidant property.

MENSTRUATION PATTERN PRIOR TO MENOPAUSE

Any of the following patterns can be observed:

Abrupt cessation of menstruation(rare) Gradual decrease in amount and duration. It may be spotting or delayed and ultimately lead to cessation. Irregular with or without excessive bleeding.

MENOPAUSAL SYMPTOMS

The important symptoms and the health concerns of menopause are:

Vasomotor symptoms Urogenital atrophy Osteoporosis and fracture Cardiovascular disease Cerebrovascular disease Psychological changes Skin and hair Sexual dysfunction Dementia and cognitive decline

VASOMOTOR SYMPTOMS

The characteristic symptom of menopause is hot flush. Hot flush is characterized by sudden feeling of heat followed by profuse sweating. There may also be the symptoms of palpitation, fatigue and weakness.

GENITAL AND URINARY SYSTEM

Steriod receptors have been identified in the mucous membrane of urethra, bladder, vagina and the pelvic floor muscles. Estrogen plays an important role to maintain the epithelium of vagina, urinary bladder and the urethra. Estrogen deficiency produces atrophic epithelial changes in these organs. may cause dyspareunia.

VAGINA Minimal trauma may cause vaginal bleeding. Dyspareunia vaginal infections dryness pruritis and leucorrhoea are also common

The urinary symptoms are: urgency dysuria recurrent urinary tract infection and stress incontinence

SEXUAL DYSFUNCTION Estrogen is often associated with decreased sexual desire. This may be due psychological changes (depression anxiety) as well as atrophic changes of genito-urinary system.

SKIN AND HAIR There is thinning loss of elasticity and wrinkling of the skin

PSYCHOLOGICAL CHANGES Increased frequency of anxiety Headache Insomnia Irritability Dysphasia Depression Dementia Mood swings and Inability to concentrate