1. 1. Mrs. A walked into the menopausal clinic looking distraught. She was a 50 year old housewife, mother of two children who had spent her entire lifetime looking after the family. Her menstruation had stopped 1 year ago and she was miserable, depressed and irritable, had several hot flushes throughout the day and night and could hardly sleep for 3-4 hours. Her husband was a busy executive and travelled a lot; her children had grown up and left home. She was lonely and left unwanted
2. 2. Sanchari Dutta Priyadharshini. M PRIYADHARSHINI.M
3. 3. Menopause Greek: menos:month, pausis:cessation Permanent cessation of menstruation resulting from loss of ovarian follicular activity(WHO) It also refers to states of ovarian failure & ovarian destruction/removal with accompanying estrogen deficiency. (Amenorrhea for 1 year) Marks the end of reproductive life RETROSPECTIVE DIAGNOSIS(1 year from FMP)
4. 4. FSH Ovary Hypothalmus Inhibin B + GnRH Normal Ovary Reproductive Aging Hormonal Changes
5. 5. FSH Ovary Hypothalmus Estradiol / Inhibin B + GnRH Menopausal Ovary Reproductive Aging Hormonal Changes
6. 6. Stages of Reproductive Aging Workshop (STRAW)- WHO STRAW
7. 7. Perimenopause/Climacteric (greek : klimax-ladder) Follows period of declining fertility Precedes menopause Characterized by cycle irregularity (shortening then lengthening) increasing symptoms Duration 2 to 8 years (average 5 years)
8. 8. Diagnosing Perimenopause Clinical diagnosis based on menstrual cycle pattern. Early follicular phase FSH and symptoms may help solidify diagnosis. Rule out hypothyroidism, depression etc.
9. 9. Perimenopause -- Symptoms Vasomotor instability (85%) Sleep disturbances Mood disturbances. Somatic symptoms: Fatigue, palpitations, headache, increased migraine, breast pain and enlargement. Oligo- Anovulation heavier or irregular cycles. Highly Variable
10. 10. Managing Perimenopause Goals: Patient education Prevention of endometrial cancer Individualized symptomatic relief Menstrual control Minimizing hot flashes Mood disturbances
11. 11. Menopause Facts Average age -51 years (1% - 40, 5%- > 55) Factors impacting age at menopause Maternal age at menopause Tobacco, SES/ Education, Alcohol, BMI Factors that probably dont impact on age at menopause- OCP use, Parity, Race, Height 70% - symptoms may occur before menopause is biochemically or clinically evident spontaneously improve over 2-5 years
12. 12. Premature Menopause- aged below 40 years. Early Menopause -aged 50 - 59 years. Late Menopause aged 60 years or over Surgical menopause- surgical removal of both ovaries in a woman. Medical menopause- permanent damage to both ovaries in a woman following either chemotherapy or radiotherapy.
13. 13. What is Menopausal transition? Progressive endocrinologic continuum that takes reproductive aged women from regular, cyclic, predictable mestruation that are characteristics of ovulatory cycles, to a final menstrual period(FMP) associated with ovarian senescence and menopause
14. 14. Signs and Symptoms During the Menopausal Transition Adapted from Bungay G et al. Br Med J 1980;281:1813; Van Keep PA et al. Maturitas 1990;12:16370. Vasomotor Symptoms Sleep Disorders Mood Changes Urogenital Atrophy Dyspareunia Osteoporosis Atherosclerosis Coronary Heart Disease Cerebrovascular Disease 40 yrs 50 yrs Menopause 60 yrs Menstrual Disorders
15. 15. DIAGNOSIS OF MENOPAUSE a. Clinical Criteria 1. age around menopause ( around 50 years ) 2. no periods for 12 months 3. menopausal symptoms However, where in doubt, laboratory testing of FSH may support the diagnosis b. Laboratory Criterion 1. FSH level > 35miu/ml 2. Estrogen 5 years) VASOMOTOR CASCADE Hot Flashes Sleep Disruption Daytime Fatigue & Irritability
16. 18. Managing Hot Flushes/Flashes Set realistic goals! Lower the ambient temperature Estrogen (80-95% reduction) Alternative therapies High dose progestin Tibolone SSRIs (Paroxetine, Fluoxetine(+/-)) SNRI (Venlafaxine (+/-)) Gabapentin Clonidine (+/-)
17. 19. Effect of ERT and HRT on Number of Hot Flushes Over 12 Weeks Efficacy-evaluable population included women who recorded taking study medication and had at least 7 moderate-to-severe flushes/day or at least 50 flushes per week at baseline. *Adjusted for baseline. Mean hot flushes at baseline = 12.3 (range, 11.313.8). Adapted from Utian WH, et al. Fertil Steril. 2001;75:1065-79. 0 2 4 6 8 10 12 1 2 3 4 5 6 7 8 9 10 11 12 Week AdjustedDailyMean Number* 0.625 CEE Placebo 0.625 CEE/2.5 MPA
18. 20. Sleep and Mood Disturbances Sleep disturbances history of depression-at risk of reoccurrence Cognition: Lack of agreement- menopausal impact on cognition Vascular infarcts associated with estrogen may worsen dementia in women over 65
19. 21. Metabolic Changes with Menopause Mechanisms of Menopause-Related Increases in Adiposity Hormonal changes of the menopause transition Preferential abdominal fat accumulation Increased fat accumulation Increased abdominal and intra-abdominal adiposity Altered energy metabolism
20. 22. The Menopausal Metabolic Syndrome Lipid Triad Hypertriglyceridemia LDL Cholesterol Abnormalities in Insulin Insulin resistance insulin elimination Other Factors Endothelial dysfunction visceral fat uric acid HDL Cholesterol insulin secretion Hyperinsulinemia SHBG blood pressure PAI-1
21. 23. Annual Incidence of Myocardial Infarction in Women and Men in the U.S. 0 100 200 300 400 500 29-44 45-64 >65 Age, years Men Women No. X 103 Cardiovascular Disease
22. 24. Decreased bone mass microarchitectural deterioration of bone tissue enhanced bone fragility fractures 0.8 0.9 1.0 1.1 50 55 60 65 70 BMD(g/cm2) Perimenopausal Menopausal for 4 Years Menopausal for 5-14 Years Menopausal for 15 Years Mean Age (years) n = 1426. Pouills JM, et al. J Bone Miner Res. 1994;9:311-5. Spinal BMD by Age and Menopausal Status Osteoporosis
23. 25. When to Measure BMD in Postmenopausal Women Age > 65 Caucasian race Family history History of fracture History of falls Bad eyesight Dementia Early menopause (