M E N O P A U S M E N O P A U S EE

King Khalid University HospitalKing Khalid University HospitalDepartment of Obstetrics & Department of Obstetrics &

GynecologyGynecologyCourse 481Course 481

Menopause is the permanent cessation of Menopause is the permanent cessation of menstruation resulting from loss of ovarian menstruation resulting from loss of ovarian

follicular activity. Natural menopause is follicular activity. Natural menopause is recognized to have occurred after 12 recognized to have occurred after 12 consecutive months of amenorrhoea.consecutive months of amenorrhoea.

Perimenopause includes the period beginning Perimenopause includes the period beginning with the first clinical, biological and with the first clinical, biological and

endocrinological features of the approaching endocrinological features of the approaching menopause (e.g. vasomotor symptoms, menopause (e.g. vasomotor symptoms,

menstrual irregularity) and ending 12 months menstrual irregularity) and ending 12 months after the last menstrual period.after the last menstrual period.

Climacteric is the phase in the ageing of women Climacteric is the phase in the ageing of women marking the transition from the reproductive to the marking the transition from the reproductive to the

non-reproductive state.non-reproductive state.

Post menopause dates from the final menstrual Post menopause dates from the final menstrual period and it’s determined after a period of 12 period and it’s determined after a period of 12

months of spontaneous menstruation.months of spontaneous menstruation.

Premature menopause is defined as menopause that Premature menopause is defined as menopause that occurs before the arbitrary cut off age of 40 years.occurs before the arbitrary cut off age of 40 years.

Induced menopause is the cessation of menstruation Induced menopause is the cessation of menstruation which follows either surgical removal of both ovaries which follows either surgical removal of both ovaries

or iatrogenic ablation of ovarian function (e.g. or iatrogenic ablation of ovarian function (e.g. chemotherapy or radiotherapy)chemotherapy or radiotherapy)..

The menopause is caused by ovarian failure. The menopause is caused by ovarian failure. It occurs earlier in smokers than in non-It occurs earlier in smokers than in non-

smokers. It also occurs early in women with smokers. It also occurs early in women with Down’s Syndrome. From mid gestation Down’s Syndrome. From mid gestation

onwards, there is a gradual reduction in germ onwards, there is a gradual reduction in germ cells until the oocyte store becomes cells until the oocyte store becomes

exhausted, on average at the age of 51 years.exhausted, on average at the age of 51 years.

Effects of the Effects of the MenopauseMenopause

1.1. Vasomotor SymptomsVasomotor Symptoms::

Hot flushes and night sweats are episodes of Hot flushes and night sweats are episodes of inappropriate heat loss. They can occur at inappropriate heat loss. They can occur at

anytime and at night disturb sleep. Chronically anytime and at night disturb sleep. Chronically disturbed sleep can in turn lead to insomnia, disturbed sleep can in turn lead to insomnia,

irritability and difficulties with short term irritability and difficulties with short term memory and concentration.memory and concentration.

2.2. Mood disorders:Mood disorders:

The mood disorders that have been associated The mood disorders that have been associated with the menopause include depression, anxiety, with the menopause include depression, anxiety,

irritability, mood swings, lethargy and lack of irritability, mood swings, lethargy and lack of energy.energy.

Con’t.Con’t. Effects of the Effects of the MenopauseMenopause

3.3. Urogenital Atrophy:Urogenital Atrophy:

Embryologically, the female genital tract and Embryologically, the female genital tract and urinary systems develop in close proximity, both urinary systems develop in close proximity, both

arising from the primitive urogenital sinus. arising from the primitive urogenital sinus.

Urogenital complaints such as vaginal discomfort, Urogenital complaints such as vaginal discomfort, dysuria, dyspareunia, recurrent lower urinary tract dysuria, dyspareunia, recurrent lower urinary tract

infections and urinary incontinence are more infections and urinary incontinence are more common in women after the menopause and more common in women after the menopause and more than 50% of post menopausal women suffer from than 50% of post menopausal women suffer from

at least one of these symptoms.at least one of these symptoms.

The vaginal mucosa often becomes quite thin. The vaginal mucosa often becomes quite thin. Premenopausally, the vaginal mucosa is colonized Premenopausally, the vaginal mucosa is colonized

by lactobacilli which provides protection against by lactobacilli which provides protection against gram-negative bacteria. After the menopause the gram-negative bacteria. After the menopause the

vagina is colonized by fecal flora.vagina is colonized by fecal flora.

Con’t.Con’t. Effects of the Effects of the MenopauseMenopause

4.4. Sexual dysfunction:Sexual dysfunction:

Interest in sexual activities declines in both men Interest in sexual activities declines in both men and women with increasing age and this change and women with increasing age and this change

appears to be more pronounced in women.appears to be more pronounced in women.

5.5. Osteoporosis:Osteoporosis:

This is a disease characterized by low bone mass This is a disease characterized by low bone mass and micro architectural deterioration of bone and micro architectural deterioration of bone

tissue, leading to enhanced bone fragility and a tissue, leading to enhanced bone fragility and a consequent increase in fracture risk. One in consequent increase in fracture risk. One in

three post-menopausal women has osteoporosis.three post-menopausal women has osteoporosis.

Con’t. Con’t. Effects of the Effects of the MenopauseMenopause

Osteoporosis affects both sexes, but in general Osteoporosis affects both sexes, but in general men have fewer fractures than women. Following men have fewer fractures than women. Following

the menopause there is an accelerated period of the menopause there is an accelerated period of bone loss, which lasts for 6-10 years. The main bone loss, which lasts for 6-10 years. The main

clinical manifestation of osteoporosis are fractures clinical manifestation of osteoporosis are fractures of the wrist, hip and vertebrae. In clinical practice, of the wrist, hip and vertebrae. In clinical practice,

the most important risk factors are early ovarian the most important risk factors are early ovarian deficiency and corticosteroid use.deficiency and corticosteroid use.

6.6. Cardiovascular disease :Cardiovascular disease :

The primary end points of cardiovascular disease The primary end points of cardiovascular disease are myocardial infarction and stroke. After the are myocardial infarction and stroke. After the

sixth decade, it is the most common cause of death sixth decade, it is the most common cause of death in women. The incidence of coronary heart disease in women. The incidence of coronary heart disease

(CHD) increases after the menopause.(CHD) increases after the menopause.

Treatment OptionsTreatment OptionsThe three main options available are oestrogen The three main options available are oestrogen

based hormone replacement therapy or HRT, based hormone replacement therapy or HRT, Biphosphonates or selective oestrogen Biphosphonates or selective oestrogen

receptor modulators. In the HRT, oestrogen is receptor modulators. In the HRT, oestrogen is combined with a progestogen to reduce the combined with a progestogen to reduce the

risk of endometrial neoplasia in women whose risk of endometrial neoplasia in women whose uterus is intact. HRT can be delivered by a uterus is intact. HRT can be delivered by a

variety of routes: Oral, transdermal, variety of routes: Oral, transdermal, subcutaneous, vaginal and intranasal.subcutaneous, vaginal and intranasal.

The benefits of HRT include relief of vasomotor The benefits of HRT include relief of vasomotor symptoms, prevention of osteoporosis, symptoms, prevention of osteoporosis,

reducing the risks of cardiovascular disease reducing the risks of cardiovascular disease and coronary heart disease.and coronary heart disease.

ContCont…Treatment …Treatment OptionsOptions

The risks of HRT include an increased risk of The risks of HRT include an increased risk of breast cancer especially in those who take breast cancer especially in those who take

oestrogen progestin preparations compared to oestrogen progestin preparations compared to those who take oestrogen alone, increased risk those who take oestrogen alone, increased risk of endometrial cancer in those who still have a of endometrial cancer in those who still have a

uterus and do not take progestin and an uterus and do not take progestin and an increased risk of venous thrombo embolic increased risk of venous thrombo embolic

disease.disease.

Post Menopausal Post Menopausal BleedingBleeding

Can be caused by simple or pathological conditions Can be caused by simple or pathological conditions including cervical polyps, cystic hyperplasia, including cervical polyps, cystic hyperplasia,

endometrial hyperplasia, cervical dysplasia, cervical endometrial hyperplasia, cervical dysplasia, cervical endometrial and ovarian carcinomas or even tubal endometrial and ovarian carcinomas or even tubal

carcinoma.carcinoma.

The older the patient and the more frequent the The older the patient and the more frequent the episodes of bleeding, the more likely there is to be episodes of bleeding, the more likely there is to be

an underlying endometrial malignancy.an underlying endometrial malignancy.

Clinical Examination:Clinical Examination:

a.a. Enlarged lymph nodes in the groin or supra Enlarged lymph nodes in the groin or supra clavicular fossa.clavicular fossa.

b.b. Metastatic focus in the vaginaMetastatic focus in the vagina

c.c. Enlarged UterusEnlarged Uterus

d.d. Breasts – for possible secondaries from uterus or Breasts – for possible secondaries from uterus or ovariesovaries

InvestigationsInvestigations1.1. Transvaginal ultrasound – endometrial Transvaginal ultrasound – endometrial malignancy is unlikely if the endometrial malignancy is unlikely if the endometrial

thickness is less than 5 mmthickness is less than 5 mm

2.2. Cervical smearCervical smear

3.3. Colposcopy and cervical biopsyColposcopy and cervical biopsy

4.4. Pipelle sampling for endometrial biospyPipelle sampling for endometrial biospy

5.5. HysteroscopyHysteroscopy

6.6. MRIMRI

TreatmentTreatment

1.1. Atrophic vaginitis, cervicitis, endometritis Atrophic vaginitis, cervicitis, endometritis may need local oestrogen preparationsmay need local oestrogen preparations

2.2. Malignant cervical, uterine or ovarian Malignant cervical, uterine or ovarian pathology will require specific treatment.pathology will require specific treatment.