Menopause

BY.KHUDA BUX MANGRIO

LECTURER (LNCON)

Menopause
Menopause :Perminent cessation of menstruation caused by
failure of ovarian follicular development in the
presence of adequate gonadotrophin stimulation.
Climacteric :The physiologic period in a women's life during
which there is regression of ovarian function.
Premature ovarian failure :Cessation of menstruation due to depletion of
ovarian follicles before the age of 40y.

Menopause
Menopause Age
Median - 51, range of 47-55 yrs
Median for perimenopause - 47 years, median length of 4
years
Premature menopause -caused by genetic abnormalities on
the long and short arm of X chromosome
Earlier menopause:
surgical causation (30%)
family history of early menopause
cigarette smoking
precocious puberty
left-handedness
Later age :
obesity
higher socioeconomic class

Types of Menopause
Physiologic menopause
Iatrogenic menopause :Surgical, radiation therapy
,chemotherapy, infection and tumer

Physiology of the Perimenpausae

Shorten of menstrual cycle length or anovulatory
cycle and prolong cycle
Shorten of the follicular phase ,no of follicles
FSH
inhibin hormone
Estradiol level fluctuate but remain within the
wide range
Progesterone level fluctuate depending on the
presence &adequacy of ovulation
Androgen level steadily during the transitional
period

Ovarian Dysfunction
Women are born with about 1.5 million ova
At menarche 400,000 ova
Most women menstruate about 400 times
between menarche & menopause
With menopause, the ovary is no longer
capable of responding to pituitary
gonadotropins production of estrogen
&progesterone

Physiology of Menopause
Ovarian dysfunction
Few remaining follicular units present
but those are no longer capable of
normal response despite stimulation
by marked of gonadotropins.

OVARIAN DYSFUNCTION
Degeneration of granulosa & thica cells

Failure to react to endogenous gonadotrophine

Estrogen

FSH & LH

Changes in hormones metabolism

associated with menopause
Androgens : androgen level due to stromal cell
stimulation by endogenous gonadotrophins
Androstenedion (adrenal)
Testosterone level
This lead to defeminization hirsutism
,virilism,

Con.
Estrogen :
In preimenpausal women ,the main
Estrogen is E2
In post menopause is E1(from the
peripheral conversion of
Androstenadione)

Clinical manifestation of
menopause

Target organ response to Esterogen

CVS
Urogenital system
Bone
Skin &teeth
Brain
Symptoms related to estrogen
Vasomotor instability
Altered menstrual function
Vaginal atrophy
Urinary tract symptom
Osteoporosis

Cardiovascular system
changes
Leading cause of death - twice as many women die
of cardiovascular disease than of cancer
Incidence rates of coronary heart disease in both
men and women were similar 6-10 years after the
menopause
Serum cholesterol increases significantly at 1-2
yrs or more after the menopause - marked by an
increase in triglycerides, an increase in LDL,
decrease in HDL - and are less cardio protective

Genitourinary system changes

Atrophy of vaginal epithelium -> atrophic vaginitis (itching,
burning, discomfort, dyspareunia and vaginal bleeding)
Urologic: 30% drop in urethral closure pressure at rest and
during stress in postmenopausal women because of atrophy of
the urethral mucosa, varying degrees of bladder and urethral
prolapsed and loss of UV angle
Atrophic urethritis -> urgency, frequency, dysuria, suprapubic
pain, UTI
Atrophic cystitis -> urge incontinence, frequency, dysuria, and
nocturia
Descent of uterus due to decreased collagen in uterosacral
ligaments and cardinal ligament

Menopause &Osteoporosis
25% of women have radiological evidence of
osteoporosis by 60; by 80Y 1 in 4 have fractured a
hip; after age 65 1 in 3 have a vertebral fracture
15% of women with hip fracture after age 80 will die
of complications within 6 months
Initial period of up to 4-5 years after the menopause
there is accelerated loss of bone at rate of 1-2% per
year; trabecular bone mainly
Bone loss is mainly in the trabecular type while cortical
type occur later .
Three most common fractures in postmenopausal
women - vertebrae, ultra distal radius and neck of
femur

Menopause &osteoporosis
Risk factors:
white or Asian
reduced weight for height
early spontaneous menopause or surgical menopause
family history of osteoporosis
low dietary calcium intake
low vitamin D intake
high caffeine intake
high alcohol intake
cigarette smoking
endocrine disorders - diabetes mellitus,
hyperthyroidism, Cushing disease

Hot Flushes
Cause of hot flushes: the mechanism is
not known, but data indicate that symptom
result from a defect in central
thermoregulatory function
A pulse of LH is released with the onset
of each hot flush, therefore a central
hypothalamic mechanism
Development of hot flushes more than1
year prior to the menopause is probably
not due to estrogen deficiency but to
other factors such as stress

Hot flushes &menopause

Onset : 10% prior to menopause
50% after cessation of menses
it has abrupt onset, last for 30 sec - 5min
Flush preceded by increase in digital
perfusion, followed by increases in skin
temp, circulating norephinephrine levels
and LH levels, heart rate

Skin and Teeth

Significant decrease in epidermal thickness
and collagen content postmenopausally,
healing of skin is generally slower
Postmenopausal estrogen maintains
premenopausal levels of synthesis of
collagen and prevents thinning of skin and
retards wrinkling process
Women ingesting estrogen
postmenopausally are less likely to loose
teeth

Other systemic symptom

Anxiety ,depression ,irritability ,fatigue
headaches, tiredness, lethargy,
nervousness, depression, sleep difficulties,
inability to concentrate, hot flushes
Sleep latency interval is increased and
amount of REM is decreased
The mechanism is not clear ??
Postmenopausal women have lower level of
plasma -endorphin

MEDICAL MANAGEMENT

Management of menopause
Advise on a healthy life style
Psychological support
Hormone replacement therapy

Indications for HRT

Relief of menopausal symptoms
Long term prevention of osteoporosis

Absolute contraindications
Existing breast cancer
Existing endometrial cancer
Venous thrombo-embolism
Acute liver disease

Routes of administration of
oestrogen
Oral
Transdermal
Implants
Local vaginal preparation

Oral therapy
Natural occurring oestrogens: includes
premarin and various oestradiol preparations. These
oestrogens are metabolised in the liver to the weaker
metabolite oestrone and then converted to oestradiol
in the peripheral circulation and in the target tissue.

Tibolone: a steroid hormone that has oestrogenic,

progestogenic and androgenic properties

Transdermal therapy
Patches (oestrogen only or combined
preparation) or oestrogen gels
Womens preference
Skin irritation may be a problem but new matrix
patches and the gels are usually well tolerated
Route of choice for women with risk factors for
venous thrombo-embolism, liver disease or
gastro-intestinal problems

Oestrogen implants
Now less widely used
Implants should be given no more than
every 6 month

Local vaginal therapy

Useful for local vaginal dryness and
symptoms of urgency
Contraindication to systemic HRT but
require oestrogen for local symptoms

HRT regimens
Women who have had a hysterectomy only
need to take oestrogen
Women with an intact uterus must take
progestogen for endometrial protection to
prevent endometrial cancer or hyperplasia
Regular surveillance of endometrium is
required for women (extreme intolerance of
progestogen) on unopposed oestrogen

HRT regimens
Sequential preparation: progestogen added for
12-14 days each month. Some women will not bleed on
sequential preparations and this is not a cause for
concern provided that the progestogen is taken correctly.

Continuous combined HRT: give oestrogen

and progestogen daily. These preparation induces
endometrial atrophy. Intermittent bleeding and spotting
are common in the first few month of use. More suitable
for women who are at least one year since their last
spontaneous period.

Side effects of HRT

Nausea
breast pain
heavy or painful withdrawal period
premenstrual syndrome type of side
effects
weight gain

Nursing Management
Nurse can encourage women to view
menopause as a natural change
resulting in freedom from symptoms
related to menses .
No relationship existing between
menopause and mental health
problems .

 The nurse explain to the patient that

cessation of menses is a normal
occurrence that is rarely
accompanied by nervous system
illness.
Patient teaching and counseling
regarding healthy life styles,health
promotion are of paramount
importance .

 Women are encouraged to decrease

their fat and caloric intake and
increase use of whole grains,
fibers ,fruits and vegetables and
increase intake of food high in
calcium (non fat yogurt ,green leafy
vegetables ,sea foods).

THANK YOU