MENOPAUSE MENOPAUSE. WHAT ? Menopause is a deviation of the ancient Greek words menos ( month) and...

MENOPAUSEMENOPAUSE

WHAT ?WHAT ?WHAT ?WHAT ?

Menopause is a deviation of the ancient

Greek words menos ( month) and pauses

(ending).

The menopause is sometimes known as the menopause is sometimes known as the

'change of life' and is marked by the ending of 'change of life' and is marked by the ending of

menstruation. menstruation.

WHAT?WHAT?WHAT?WHAT?

It be defined with certainty after It be defined with certainty after

twelve months' spontaneous twelve months' spontaneous

amenorrhoea. amenorrhoea.

End of reproductive life.End of reproductive life.

Age (years)

Pre-menopause Post-menopause

MENOPAUSE

1 YEAR

Peri-menopause “ Climacteric”

RELATED TERMINOLOGYRELATED TERMINOLOGYRELATED TERMINOLOGYRELATED TERMINOLOGY

WHEN?WHEN?WHEN?WHEN?

Menopausal age: 45-55 yearsMenopausal age: 45-55 years

(mean : 50.7 years)(mean : 50.7 years)

If the menopause occurs in a woman If the menopause occurs in a woman

who is under 45 years of age, it is who is under 45 years of age, it is

known as premature menopause. known as premature menopause.

Late menopause: >55 years oldLate menopause: >55 years old

WHEN?WHEN?WHEN?WHEN?

Other factors that can affect the age Other factors that can affect the age

at which women have their final at which women have their final

period include age at menarche, period include age at menarche,

parity, previous oral contraceptive parity, previous oral contraceptive

history ethnicity and family history.history ethnicity and family history.

WHY?WHY?WHY?WHY?

RELATIVE ACTIVITY OF ESTROGENRELATIVE ACTIVITY OF ESTROGEN

WHY?WHY?WHY?WHY?

The menopause is the end of egg The menopause is the end of egg

production (ovulation). This occurs production (ovulation). This occurs

as a result of falling levels of the as a result of falling levels of the

female sex hormone oestrogen, female sex hormone oestrogen,

which regulates a woman's periods.which regulates a woman's periods.

WHY?WHY?WHY?WHY?

The menopause results from a fall in The menopause results from a fall in

the level of the female hormone the level of the female hormone

oestrogen in the blood. oestrogen in the blood.

WHY?WHY?WHY?WHY?

At a hormonal level - as ovarian At a hormonal level - as ovarian

follicular activity begins to fail, follicular activity begins to fail,

oestrogen and progesterone levels fall oestrogen and progesterone levels fall

and the reduced negative feedback to and the reduced negative feedback to

the pituitary causes a rise in luteinising the pituitary causes a rise in luteinising

hormone (LH) and follicle stimulating hormone (LH) and follicle stimulating

hormone (FSH). hormone (FSH).

HOW?HOW?HOW?HOW?

Oestrogen reduction eventually Oestrogen reduction eventually

results in menstrual cycle disruption results in menstrual cycle disruption

and other menopausal symptoms.and other menopausal symptoms.

HOW?HOW?HOW?HOW?

Oestrogen reduction eventually results in Oestrogen reduction eventually results in

menstrual cycle disruption and other menstrual cycle disruption and other

menopausal symptoms.menopausal symptoms. * * FSH high (30 – 170 mU/ml)

* LH high (20 – 80 mU/ml)

* Estradiol low (< 110 pmol/L)

Vasomotor SymptomsVasomotor SymptomsSleep DisordersSleep DisordersMenstrual DisordersMenstrual DisordersMood ChangesMood Changes

Vaginal AtrophyVaginal AtrophyDyspareuniaDyspareuniaSkin AtrophySkin Atrophy

OsteoporosisOsteoporosisAtherosclerosisAtherosclerosisCoronary Heart DiseaseCoronary Heart DiseaseCerebrovascular DiseaseCerebrovascular Disease

40 yrs40 yrs 50 yrs50 yrs

MenopauseMenopause

60 yrs60 yrs

SYMPTOMS!SYMPTOMS!SYMPTOMS!SYMPTOMS!

ONSET OF SYMPTOMS IN RELATION TO AGE OF MENOPAUSE


Changes in your period—time between periods or flow may Changes in your period—time between periods or flow may be different.be different.

Hot flashes (“hot flushes”)—getting warm in the face, neck Hot flashes (“hot flushes”)—getting warm in the face, neck and chest.and chest.

Night sweats and sleeping problems that may lead to Night sweats and sleeping problems that may lead to feeling tired, stressed or tense.feeling tired, stressed or tense.

Vaginal changes—the vagina may become dry and thin, Vaginal changes—the vagina may become dry and thin, and sex may be painful.and sex may be painful.

Thinning of your bones, which may lead to loss of height Thinning of your bones, which may lead to loss of height and bone breaks (osteoporosis).and bone breaks (osteoporosis).


It is estimated that 8 out of 10 women in It is estimated that 8 out of 10 women in

the UK experience symptoms leading up the UK experience symptoms leading up

to the menopause. to the menopause.

Of these, 45% find their symptoms difficult Of these, 45% find their symptoms difficult

to deal with.to deal with.


Without treatment, most menopausal Without treatment, most menopausal

symptoms gradually stop naturally. This usually symptoms gradually stop naturally. This usually

happens two to five years after the symptoms happens two to five years after the symptoms

start.start.

Although some women experience symptoms Although some women experience symptoms

for many more years.for many more years.


NORMAL TRABECULAR BONE

OSTEROPEROTIC BONE

TREATMENTTREATMENTTREATMENTTREATMENT

Only 1 in 10 women seek medical advice when they go Only 1 in 10 women seek medical advice when they go

through the menopause and many do not need any through the menopause and many do not need any

treatment. treatment.

If menopausal symptoms are severe enough to interfere If menopausal symptoms are severe enough to interfere

with daily life, there are treatments that can help.with daily life, there are treatments that can help.


The kind of treatment you can take depends on The kind of treatment you can take depends on

the severity of the symptoms, medical history the severity of the symptoms, medical history

and patient’s own preferences.and patient’s own preferences.


HRTHRT

NON- HRTNON- HRT

HOMONE REPLACEMENT HOMONE REPLACEMENT THERAPY (HRT)THERAPY (HRT)HOMONE REPLACEMENT HOMONE REPLACEMENT THERAPY (HRT)THERAPY (HRT)

As the name suggests, HRT works by replacing oestrogen.As the name suggests, HRT works by replacing oestrogen.

Hormone replacement therapy (HRT) can be an effective Hormone replacement therapy (HRT) can be an effective

treatment for the typical menopause-related symptoms.treatment for the typical menopause-related symptoms.


HRT may also have an influence on the long term health HRT may also have an influence on the long term health

problems(problems(osteoporosisosteoporosis, , cardiovascular diseasecardiovascular disease and and stroke)stroke) , ,

though it should be noted that it does not necessarily reduce their risk though it should be noted that it does not necessarily reduce their risk

for for allall women. women.


BENEFITSBENEFITS RISKSRISKS


For the treatment of menopausal symptoms For the treatment of menopausal symptoms

where the risk-benefit ratio* is favorable, in where the risk-benefit ratio* is favorable, in

fully informed women, in the lowest possible fully informed women, in the lowest possible

dose to control symptoms and for the shortest dose to control symptoms and for the shortest

duration possible.duration possible.


BENEFITSBENEFITS

Relieve menopausal symptomsRelieve menopausal symptoms

Maintenance of quality of lifeMaintenance of quality of life

Prevention of osteoporosisPrevention of osteoporosis Note: HRT should not be used as a first-line treatment in osteoparosis except in Note: HRT should not be used as a first-line treatment in osteoparosis except in

women who have women who have premature menopausepremature menopause


RISKS OF VTERISKS OF VTE

HRT (combined or oestrogen-alone) increases the risk of HRT (combined or oestrogen-alone) increases the risk of

a deep vein thrombosis or pulmonary embolism, a deep vein thrombosis or pulmonary embolism,

especially in the first year of treatment. The risk is more especially in the first year of treatment. The risk is more

pronounced in women with pre-existing risk factors.pronounced in women with pre-existing risk factors.

A recent meta-analysis suggests that transdermal A recent meta-analysis suggests that transdermal

oestrogens may be a safer option than oral oestrogens oestrogens may be a safer option than oral oestrogens

for HRTfor HRT..


RISKS OF BREAST CANCERRISKS OF BREAST CANCER The increased breast cancer risk is proportional to the duration of The increased breast cancer risk is proportional to the duration of

HRT. HRT. HRT increases this risk by about 1.6 times after 5 years of use HRT increases this risk by about 1.6 times after 5 years of use

and 2.3 times after 10 years of use. Risk decreases within a few and 2.3 times after 10 years of use. Risk decreases within a few

years of stopping HRT.years of stopping HRT.

Women considering HRT should be counselled that the absolute risk

for breast cancer for any individual remains relatively low* Her Her

actual risk increases actual risk increases 0.08% 0.08% (ACOG)(ACOG)


RISKS OF ENDOMETRIAL CANCERRISKS OF ENDOMETRIAL CANCEREndometrial cancer: increased risk only with Endometrial cancer: increased risk only with unopposed oestrogen. There is no increased risk unopposed oestrogen. There is no increased risk with combined (oestrogen and progestogen) HRT.with combined (oestrogen and progestogen) HRT.

RISKS OF OVARIAN CANCERRISKS OF OVARIAN CANCER

long-term use of oestrogen-only HRT and combined long-term use of oestrogen-only HRT and combined HRT may slightly increase the risk. Risk decreases HRT may slightly increase the risk. Risk decreases after stopping HRT. after stopping HRT.


RISKS OF CARDIOVASCULAR DISEASERISKS OF CARDIOVASCULAR DISEASE

There is not the same evidence of cardioprotection There is not the same evidence of cardioprotection

from HRT as was originally thought.from HRT as was originally thought.

Assess all women's risk of CHD prior to starting HRT.Assess all women's risk of CHD prior to starting HRT.


sSequentially Sequentially combined combined HRTHRT E(continuously E(continuously D1-D21)D1-D21) P(sequentially P(sequentially D11-D21)D11-D21)

Continuous Continuous combined HRTcombined HRT E &PE &P(continuous: (continuous: D1-D28)D1-D28)


Women with an intact uterusWomen with an intact uterus

Vasomotor symptomsVasomotor symptoms Perimenopausal: systemic cyclical combined HRT .Perimenopausal: systemic cyclical combined HRT . Postmenopausal: systemic continuous combined Postmenopausal: systemic continuous combined

HRT or tibolone.HRT or tibolone.

Urogenital symptomsUrogenital symptoms Perimenopausal: low-dose vaginal oestrogen or Perimenopausal: low-dose vaginal oestrogen or

systemic cyclical combined HRT.systemic cyclical combined HRT. Postmenopausal: low-dose vaginal oestrogen or Postmenopausal: low-dose vaginal oestrogen or

systemic continuous combined HRT.systemic continuous combined HRT.


Women who have had a hysterectomyWomen who have had a hysterectomy

Vasomotor symptoms: systemic oestrogen-only Vasomotor symptoms: systemic oestrogen-only

HRT.HRT.

Urogenital symptoms: low-dose vaginal Urogenital symptoms: low-dose vaginal

oestrogen or systemic oestrogen-only HRT.oestrogen or systemic oestrogen-only HRT.

CONTRAINDICATIONS OF CONTRAINDICATIONS OF HRT!HRT!CONTRAINDICATIONS OF CONTRAINDICATIONS OF HRT!HRT!

Pregnancy and breast-feedingPregnancy and breast-feeding

Undiagnosed abnormal vaginal bleedingUndiagnosed abnormal vaginal bleeding

Venous thromboembolic diseaseVenous thromboembolic disease

Active or recent angina or myocardial infarctionActive or recent angina or myocardial infarction

Suspected, current or past breast cancerSuspected, current or past breast cancer

Endometrial cancer or other oestrogen-dependent cancerEndometrial cancer or other oestrogen-dependent cancer

Active liver disease with abnormal liver function testsActive liver disease with abnormal liver function tests

START-UP SYMPTOMS OF START-UP SYMPTOMS OF HRT!HRT!START-UP SYMPTOMS OF START-UP SYMPTOMS OF HRT!HRT!

Breast tendernessBreast tenderness

Nipple sensitivityNipple sensitivity

BloatingBloating

Nausea, headachesNausea, headaches

Appetite Appetite

Weight gainWeight gain

Leg crampsLeg cramps

INVESTIGATIONS BEFORE INVESTIGATIONS BEFORE HRT!HRT!INVESTIGATIONS BEFORE INVESTIGATIONS BEFORE HRT!HRT!

Investigations are not usually necessary before Investigations are not usually necessary before

starting HRT unless there is :starting HRT unless there is :

sudden change in menstrual pattern (IMB/PCB) sudden change in menstrual pattern (IMB/PCB)

High risk of breast cancerHigh risk of breast cancer

Personal /family history of VTEPersonal /family history of VTE

Woman has arterial risk factorsWoman has arterial risk factors

ALTERNATIVE TO HRT!ALTERNATIVE TO HRT!ALTERNATIVE TO HRT!ALTERNATIVE TO HRT!

“ “ Tibolone” is a synthetic hormone that acts in the Tibolone” is a synthetic hormone that acts in the

same way as HRT same way as HRT (SERM)(SERM)

Useful for post-menopausal women who want to end their Useful for post-menopausal women who want to end their

periods.periods.

Which has oestrogenic, progestogenic and androgenic Which has oestrogenic, progestogenic and androgenic

propertiesproperties. (. (estrogenic activity in estrogenic activity in bonebone, CNS vasomotor suppression , CNS vasomotor suppression

of of hot flushes hot flushes and and helpful in improving sexual function .helpful in improving sexual function .

STARTING HRT!STARTING HRT!STARTING HRT!STARTING HRT!

“ “A full physical examination is mandatory”A full physical examination is mandatory” Full blood countFull blood count Renal ProfileRenal Profile - Baseline- Baseline Liver Function TestLiver Function Test Lipid profileLipid profile

FOLLOW UP OF TAKING FOLLOW UP OF TAKING HRT!HRT!FOLLOW UP OF TAKING FOLLOW UP OF TAKING HRT!HRT!

Review the woman 3 months after starting HRT and Review the woman 3 months after starting HRT and once each year thereafter.once each year thereafter.

At 3-months:At 3-months:– Enquire about bleeding patterns, check blood Enquire about bleeding patterns, check blood

pressure, and body weight.pressure, and body weight.– Assess the effectiveness of treatment and adjust Assess the effectiveness of treatment and adjust

to achieve symptom control.to achieve symptom control.– Enquire about adverse effects and manage Enquire about adverse effects and manage

appropriately.appropriately.


Once each year:Once each year:

– Check blood pressure, effectiveness of treatment Check blood pressure, effectiveness of treatment

and adjust to achieve symptom control.and adjust to achieve symptom control.

– Enquire about adverse effects and manage Enquire about adverse effects and manage

appropriately.appropriately.

– Consider switching from cyclical HRT to Consider switching from cyclical HRT to

continuous combined HRT, if appropriate.continuous combined HRT, if appropriate.


– Discuss the risks and benefits of HRT. Discuss the risks and benefits of HRT.

– Perform a breast examination if indicated by personal or Perform a breast examination if indicated by personal or

family history.family history.

– Encourage breast awareness and participation in the Encourage breast awareness and participation in the

national breast screening programme as appropriate for national breast screening programme as appropriate for

their age.their age.

– Pelvic examination is required only if clinically indicatedPelvic examination is required only if clinically indicated

NON- HRTNON- HRT

Lifestyle modification

Stop smoking

Healthy diet

Weight control

Regular moderate-intensity exercise

Control blood pressure and cholesterol

NON- HRTNON- HRT

For vasomotor symptoms For vasomotor symptoms

– A trial (2 weeks) of paroxetine,fluoxetine A trial (2 weeks) of paroxetine,fluoxetine

citalopram or venlafaxine (SSRI)citalopram or venlafaxine (SSRI)

– A trial (2–4 weeks) of clonidine A trial (2–4 weeks) of clonidine

– A progestogen such as norethisterone or A progestogen such as norethisterone or

megestrolmegestrol

NON- HRTNON- HRT

For vaginal drynessFor vaginal dryness

Vaginal lubricant or moisturizer, such as Vaginal lubricant or moisturizer, such as ReplensReplens®®..

NON- HRTNON- HRT

For osteoporosisFor osteoporosis

– Alendronate (Alendronate (FosamaxFosamax ) )

– RocaltriolRocaltriol

– Alpha-calcidolAlpha-calcidol

– Raloxifene (Raloxifene (EvistaEvista))

NON- HRTNON- HRT

For psychological symptomsFor psychological symptoms

- - Self-help groupsSelf-help groups

- Psychotherapy- Psychotherapy

- Other forms of counselling- Other forms of counselling

- Antidepressants.- Antidepressants.

NON- HRTNON- HRT

Complementary therapiesComplementary therapies Remifemin (Cimicifuga rhizome extract)Remifemin (Cimicifuga rhizome extract) Red clover plantRed clover plant Soy productsSoy products Evening primroseEvening primrose Black cohoshBlack cohosh PhytoestrogensPhytoestrogens GinsengGinseng

NON- HRTNON- HRT

Complementary interventionsComplementary interventions AcupunctureAcupuncture ReflexologyReflexology

Diet and supplementsDiet and supplements Vitamins and mineralsVitamins and minerals Vitamin EVitamin E

HomeopathyHomeopathy

Premature Premature menopause?menopause? Menopausal symptoms in women who are Menopausal symptoms in women who are

younger than 40 years (1%)younger than 40 years (1%)

Offer lifestyle advice.Offer lifestyle advice.

Offer systemic hormone replacement therapy Offer systemic hormone replacement therapy

(HRT) or the combined oral contraceptive pill (HRT) or the combined oral contraceptive pill

(COC)(COC)

Decreased libido: testosterone implants and Decreased libido: testosterone implants and

patches may be consideredpatches may be considered

THANK YOUTHANK YOU

MENOPAUSE MENOPAUSE. WHAT ? Menopause is a deviation of the ancient Greek words menos ( month) and...

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