MENOPAUSE

Menopause is the permanent physiologic cessation of menses associated with declining ovarian function. 

Cessation of menstrual periods in women aged 40 or younger is premature menopause. 

TYPES OF MENOPAUSE :- 

1. Physiologic menopause

2. Pathological menopause

Physiologic Menopause :- It is spontaneous progressive decline of ovarian function that starts at the age of 40 to 50 years. 

Pathological Menopause :- 

(i). Premature menopause :- It is premature ovarian failure before  age  of 40 years and affect 1% of all women under the age of 40 years. 

(ii). Artificial menopause :- It is the permanent cessation of ovarian function causes by surgical removal of the ovaries or by irradiation using either intra uterine radium or deep x-ray. 

(iii). Delayed menopause :- it is a cessation of menstruation above the age of 50 years. 

CLINICAL MANIFESTATION :- 

1. Irregular menses

2.Brest tenderness

3. Mood changes 

4. Hot Or warm flashes 

5.Night sweats 

6.Discomfort

7.Sleep disturbance

MENOPAUSAL CHANGES :- 

Menopausal changes includes decreasing circulating estrogen and progestrone and Increasing production of gonadotrophins (changes differ from women to another). 

1.Breast changes :- Increses subcutaneous fat, but later due to decrease in circulating estrogen, subcutaneous fat reabsorbed, atrophy of the gland tissue, the breast flattened and pendulous. 

2. Female genital organs :- 

(a).Ovaries :- Decrease size, Non- functional and unable to respond to circulatory gonadotrophins. 

(b).Uterus and fallopian tubes :- Become progressively atropic. 

(c).Vagina and vulva :- 

- Thinning of mucosa and easily irritated because of decreasing vaginal secretion.

- Gradual shrinkage of the labia 

- Dyspareunia

- Fatigue, Forgetfullness, weight gain, irritability, trouble sleeping (blue) and feeling panic. 

(d). Pelvic floor muscles :- Loss of their tones, loss of elasticity of connective tissue, development of prolapse and stress incontinence. 

3. Cardiovascular system :- Vasomotor disturbance Hot flashes with feeling of heat centered on the face which spreads to the neck and chest and may become generalized. 

4. Psychological changes :- Irritation, Depression, and Insomnia. 

5. Obesity due to increase appetite and alterations of carbohydrate metabolism as a result of hyperfunction of anterior lobe of Pituitary glands. 

6. Osteoporosis :- Affects more the vertebrae with one or more of the following 

- Bone pain

- Fractures

- Loss of height

- Deformities

DIAGNOSTIC EVALUATION :- 

1. History Taking 

2. Physical Examination 

3.Breast Examination

4. Pelvic examination 

5. Blood test - check level of FSH (Follicle Stimulating Hormone) 

6. Mammography

7. Hb, plasma glucose, lipid profile

MEDICAL MANAGEMENT :- 

HORMONE THERAPY :- Hormone therapy Or menopausal hormone therapy (previously referred to as hormone replacement therapy (HRT) has been found to increase some health disorders and to be less effective in preventing other than previously believed. 

INDICATION OF HRT :- 

1. Post menopausal women with symptoms like dryness, itching, burning and discomfort with intercourse. 

2. Women with certain health conditions like premature ovarian failure. 

TYPES OF HORMONAL REPLACEMENT THERAPY :- 

1.Estrogen only HRT(Hormone Replacement Therapy) :- It is usually recommends for women who have had their womb and ovaries removed by hysterectomy progesterone is no longer needed as there is no risk of endometrial cancer. 

2.Cyclical HRT :- Cyclical HRT is recommend for women who are experiencing menopausal symptoms but are still having periods. 

There are 2 types of HRT 

A. Monthly HRT

B. Three Monthly HRT

A. Monthly HRT :-  Daily dose of estrogen and progestrone at the end of menstrual cycles for 14 days Monthly HRT is normally recommended for women who are having regular periods. They will continue to have monthly periods until menopr cause them to stop. 

B. Three monthly HRT :- Daily dose of estrogen and progestrone for 14 days, every 13 weeks, 3 monthly HRT is normally recommended for women who are having irregular periods. 

3. Continuous HRT :- Continuous HRT is usually recommended for women who are post Menopausal it involves taking a continuous combination of estrogen and progestrone. 

FORMULATION OF ESTROGEN AND PROGESTRONE :- 

SYSTEMIC FORMULA

1. Oestrogen 

Oral

Conjugated equine oestrogen (CEE) -0. 625mg/day

Micronized Oestradiol - 1 mg / day 

2. Progestins 

Medroxy Progestrone Acetate (MPA) 

Transdermal patches and gel

a. Oestradiol patches 

b. Oestradiol gel

3.Implants :-

Oestradiol Implants - 25 -50 mg once in 3 month 

Local preparations :- 

Creams - 2mg/day 

Vaginal Rings - 1 ring once in 3 months 

BENEFITS AND RISK OF HRT :- 

1. Controlling symptoms of menopause 

2. Reduced risk of osteoporosis

3. HRT slightly raises the chance of developing certain conditions such as breast cancer, endometrial cancer, ovarian cancer. 

ALTERNATIVE THERAPIES FOR HOT FLASHES :- 

1.Probalematic hot flashes have been treated with low dose venlafaxine (Effexor) and other medications. Similarly,Vitamin B6 and Vitamin E may be effective. 

2. Some women have expressed interest in other alternative treatments (e.g. natural estrogens and progestins, black cohosh, ginseng, dongquai, soy products and several other herbal preparations). 

3. Maintaining bone health

4.Maintaining cardiovascular health

5. Behavioural Strategies