An Overview of Menopause

Associate Prof Dr Hanifullah Khan

objectives

!   to understand this condition & terminology

!   physiology of menopause

!   problems linked with menopause

!   clinical scenarios

what is menopause?

!  A physiological loss of ovarian hormonal activity !  Closely allied to loss of reproductive potential !  Permanent cessation of the primary ovarian

functions

Physiology

The Ovaries

!   2 functions - produce ova & secrete hormones

!   Start secreting estrogen & progesterone from puberty to menopause

!   Most of the beneficial effects derive from estrogen

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

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

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

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

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

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

The consequences of menopause

primary symptoms

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

secondary symptoms

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

Monitoring symptoms

Long term effects

!   Cardiovascular

!   Bone

!   Cancers

!   Cerebrovascular

Clinical implications of menopause

Minor conditions

- Urinary tract infections - Vaginal dryness

- Vaginal infections - Joint & muscle pains

Symptoms mimicking disease !   Abnormal vaginal bleeding

!  Perimenopausal

!  Postmenopausal

!   General pains e.g. Breast

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

Postmenopausal bleeding

- Consider it as always abnormal

- Always think of cancer

- Usually due to atrophy or infection

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.

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

Fracture risk !   decreased

bone density

!   osteoporosis

!   common fractures involve hip, forearm & spine

you wanna be like this?

Psychomotor & Mental

!   loss of libido

!   suicidal tendencies

!   marital discord

Urogenital problems

Menopausal Hormone Therapy

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

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

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

Summary

!   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

The important points

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