MENOPAUSE

INTRODUCTION:-

Menopause is time in a woman’s life when her periods (menstruation) eventually stop
and the body goes through changes that no longer allow her to get pregnant.

It is a natural event that normally occurs in women age 45-55 yrs. Average age is 50
years. The menopause before the age of 40 years is called precocious menopause. A women
gradually changes from her reproductive life into senescence.(it means the change of life.)1% of
woman will undergo menopause before age 40 years.Women who smoke cigarettes and who are
malnourished will have earlier menopause.

DEFINITION:-

Menopause means permanent cessation of menstruation at the end of reproductive life due to loss
of ovarian follicular activity. It is the point of time when last and final menstruation.

-D.C Dutta.

Menopause is defined as the absence of menstrual periods of menstrual periods for at least 6
months in a woman over 40 years.

CS DAWN

Menopause refers to age of final cessation of menstruation while climacteric means the period at
which the woman gradually changes from the reproductive life into one of senescence.

www.wikipedia.com

TYPES OF MENOPAUSE:-

1.PRE MENOPAUSE

2.POST MENOPAUSE

3.PERI MENOPAUSE(CLIMACTERIC)

1.PRE MENOPAUSE:-

pre menopause is the part of the climacteric before menopause. when the menstrual cycle is
likely to be irregular.

2. POST MENOPAUSE:-
post menopause is the phase of life that comes after the menopause.

3. CLIMACTERIC:-

climacteric is the phase of aging process during which a woman passes from the reproductive to
the non-reproductive stage.

This phase covers 5 – 10 years on either side of menopause.

AGE OF MENOPAUSE:-

The age of menopause is not related to age of menarche or age at last pregnancy.

 It is also not related to number of pregnancy lactation. use of oral pill. socio-economic
condition race.height or weight.
 Thinner women have early menopause.however cigarette smoking and severe
malnutrition may cause early menopause.the age of menopause ranges between 45-55
years, average being 50 years.

ENDOCRINOLOGY OF CLIMACTERIC AND MENOPAUSE:-

HYPOTHALMO PITUITARY GONADAL AXIS:-

Few years prior to menopause along with depletion of the ovarian follicles.

 The follicles become resistant to pituitary gonadotrophins. As a result,effective

folliculogenesis is impaired with diminished oestradiol production.
 There is a siginificant fall in the level of serum estradiol from 50-300 pg/ml.before
menopause to 10-20 Pg/ml.after menopause.
 This decrease the negative feedback effect on hypothalmo pituitary axis resulting
increase in FSH.the increase in FSH is also due to diminished inhinbin.
 Inhinbin a peptide is secreted by the granulosa cells of the ovarian follicte.the increase of
LH occurs subsequently.
 Disturbed folliculogenes Is during this period may results in anovulation.oligo-
ovulation,premature corpus luteum or corpus luteal insufficiency.
 The sustained level of oestrogens may even cause endometrial hyperplasia and clinical
manifestation of menstrual abnormalities prior to menopause.
 The mean cycle length is significantly shorter this is due to shortening of the follicular
phase of the cycle.luteal phase length remaining constant.
 Ultimately,no more follicles are available and even some exist.they are resistant to
gonadotrophins.
 Oestradiol production drops down to the optimal level of 20pg/ml no endometrial
Growth
 Absence of menstruation.
OESTROGENS:-

following menopause the predominant oestrogen is oestrogen is oestrone and to a lesser extent
oestradiol.

 Serum level of oestrone(30-70pg/ml) is higher than that of oestradiol(10-20pg/ml).

 The major source of oestrone.is peripheral conversion(aromatization)of androgens from
adrenals(mainly)and ovaries.
 The aromatisation occurs at the level of muscle and adipose tissue.
 The trace amount of oestradiol is derived from peripheral conversion of oestrone and
androgens,compared to oestrdiol.oestrone is biologically less potent.
 With times,the sources fail to supply the precursors of oestrogen and about 5-10 years
after menopause.there is a sharp fall in oestrogen and also the tropic hormones.

ANDROGENS:-

After menopause the stromal cells of the ovary continue to produce androgens because of
increase in LH.

 The main androgens are androstonedione and testosterone.

 Though the secretion of androgens from post menopausal ovary are more.their peripheral
levels are reduced due to conversion of androgens to oestrone in adipose tissue.
 However the cumulative effect is a decrease in oestrogen,androgen ratio.
 This results in increased facial hair growth and change in voice.

PROGESTERONE:-

- A trace amount of progesterone detected is progesterone detected is probably adrenal in

origin.

GONADOTROPHINS:-

 The secretions of both FSH and LH are increased due to absent negative feedback effect
of oestrdiol and inhibin or due to enhanced responsiveness of pituitaray to GNRH.
 Rise in FSH is about 10-20 fold where is that of LH is about 3 fold.
 GnRH pulse section is increased both in frequency and amplitude.
 During menopause there is fall in the level of prolaction and inhibin.
 Ultimately,due to physiologic aging GnRH and both FSH,LH decline along with decline
of Oestrogens.

ORGAN CHANGES

Ovaries:-
 shrink in size become wrinkled and white there is thinning of the cortex with increase in
medullary components. There is abundance of stromal cells which have got secretory
activity.

Fallopian tubes:-

show feature of atrophy,the muscle coat becomes thinner,the cilia disappear and the plicae
become less prominent.

Uterus:-

Becomes smaller and the ratio between the body and the cervix reverts to the 1:1 ratio.

Endometrium

Becomes thin and atrophic.

 In some women however with high endogenous oestrogens,the endometrium may be

proliferative or even hyperplastic
 The cervical secretion becomes scanty

vagina:-

Becomes narrower due to gradual loss of elasticity.

 The vaginal epithelium becomes thin

The rugae progressively flatten.there is no glycogen

 The vaginal PH becomes alkaline.

 Maturation index is 10/85/5.

vulva:-

shows features of atrophy.

The labia becomes flattened and the public hair becomes flattened and the public hair becomes
scantier,the end result is a narrow introitus.

Breast

fat:-is reabsorbed and the glands atrophy.

The nipples

Decrease in size,ultimately the breasts become flat and pendulous.

Bladder and urethra:-

undergo similar changes to those of vagina.

The epithelium becomes thin and is more prone to damage and infection.

There may be dysuria.frequency urge,or even stress incontinence.

Loss of muscle tone:-

leads to pelvic relaxation uterine descent and anatomic changes in the urethra and neck of the
bladder.

 The ligaments supporting the uterus and vagina lose their tone.
 As such pre existing weakness gets aggravated.

Bone metabolism:-

Normally bone formation and bone resorption are in balance depending on many factors.(age
endocrine ,nutrition, and genetic)

 Following menopause there is loss of bone mass by about 3-5 percent per year.
 This is due to defiency of oestrogen
Osteoporosis is a condition where there is reduction in bone mass but bone mineral to
matrix ratio is normal.
 Post menopausal woman runs a high risk for fracture of bones due to osteoporosis.
 Ostetrogen prevents osteoporosis by several mechanism’s.
 It inhibits osteoclastic activity and inhibits release of II – I by monocytes.

Oestrogen increases absorption of calcium from the gut. stimulates calcitonin secretion.from
the‘C’ cells of the thyroid and increases 1.25 dihydroxy vitamin D.

All these lead to increased bone mineralization.

Cardiovascular system:-

Risk of cardiovascular disease is high in post-menopausal women due to deficiency of oestrogen.

Oestrogen prevents cardiovascular disease by several ways.

MENOPAUSAL SYMPTOMS:-

 Vasomotor symptoms.
  Urogenital atrophy.
 Oesteoporosis and fracture.
 Cardiovascular disease.
 Cerebrovascular disease.
 Psychological changes.
 Skin and hair.
 Sexual dysfunction.
 Dementia and cognitive decline.

First symptoms are offen menstrual irregularitres.

 Menstrual cycles shorten or lengthen.

Vasomotor symptoms:-

The characteristic symptom of menopause is “hot flush”

Hot flush is characterised by sudden feeling of heat followed by profuse sweating.

 There may also be the symptoms of palpitation fatigue and weakness.

 The physiologic changes with hot flushes are perspiration and cutaneous vasodilatation.
 Both these 2 functions are under central thermo regulatory control.
 Low oestrogen level is a prerequisite for hot flush.
 Hot flush coincides with GnRH pulse secreation.
 It may last for 1-10 mts.
 Sleep may be disturbed due to night sweats.

Urogenital atrophy:-

Steroid receptors have been identified in the mucous membrane of urethra.bladder vagina and
the pelvic floor muscles.

Oestrogen plays an important role to maintain the epithelium of vagina.urinary bladder & the
urethra.

oestrogen deficiency produces atrophic epithelial changes in these organs.this may cause
dyspareunia.

Vagina:-minimal trauma may cause vaginal bleeding dypareunia.vaginal infections.dryness

prurritas and leucorrhoea are also common.

Urinary:-symptoms are –uregency,dysuria & recurrent urinary tract infection & stress
incontinence.

OSTEOPOROSIS AND FRACTURE:-

Osteoporosis may be primary (type 1)due to oestrogen loss.age deficient nutrition(calcium
vitamin D)or hereditary.

 It may be secondary (type2) to endocrine abnormalities(para thyroid,diabetes) or

medication.
 Osteoporosis may lead to back pain. Loss of height & kyphosis.
 Fracture of bones is a major health problem.
 Fracture may involve the vertebral body femoral neck.or distal forearm.
 Morbidity & mortality in elderly women following fracture is high.

Cardiovascular disease and cerebro vascular disease:-

 Oxidation of LDL and foam cell formation cause vascular endothelial injury.cell death
&smooth muscle proliferation.
All these lead to vascular atherosclerotic changes vasoconstriction and thrombus
formation.
 Risks of ischemic heart disease.coronary artery disease and strokes are increased.

Psychological changes:-

There is increased frequency of anxiety headache,insomnia,irritability dysphasia and depression.

 They also suffer from dementia ,mood swing and inability to concentrate.
 Oestrogen increases opioid activity in the brain & is know to be important for memory.

Dementia:-oestrogens is thought to protect the function of central nervous system.

Dementia & mainly Alzheimer disease are more common in post menopausal women.

Skin and hair:-

There is thining loss of elasticity & wrinking of the skin.

“purse string” wrinkling around the mouth “crowfeet” around the eyes are the characteristics.

 Oestrogen receptors are present in the skin and maximum are present in the facial skin.
 Oestrogen replacement are present in the skin,during menopause.
 After menopause ,there is some loss of public and axillary hair & slight balding.

Sexual dysfunction:-

 Oestrogen deficiency is offen associated with decreased sexual desire.

This may be due psychological changes as well as atrophic changes of the genito
 Urinary system.

DIAGNOSIS OF MENOPAUSE:-

 Cessation of menstruation for consecutive 12 months during climacteric.

 Appearance of menopausal symptoms “hot flush” and night sweats.
 Vaginal cytology-showing maturation index of at least 10/85/5(features of low oestrogen.
 Serum oestradiol: <20pg/ml.
 Serum FSH and LH:> 40 mlu/ml(three values at weeks interval required.)

MANAGEMENT:-

Prevention:-

spontaneous menopause is unavoidable however artificial menopause induced by surgery or by

radiation during reproductive period can to some extent be preventable or delayed.

Counseling:-

Every women with post menopausal symptoms should be adequately explained about the
physiologic events.

This will remove her fears. and minimise or diped the symptoms of anxiety, depression and
insomnia reassurance is essential.

Treatment:-

Non-hormonal treatment:-

 Nutritious diet- balanced with calcium & protein is helpful.

 Supplementary calcium-daily intake of 1-1.5 gm can reduce osteoporosis and fracture.
 Exercise – weight bearing exercises, walking, jogging
 vitamin D - supplementation of vitamin.D3(400-800 IU)day along with calcium can
reduce oesteoporosis and fractures.
 Exposure to sunlight enhances synthesis of cholecalciferol (vitamin D3)in the skin.
 Cessation of smoking and alcohol.

BIPHOSPHONATES:-

Prevent oesteodastic bone resorption.commonly used drugs are

etidronate and alendronate.

  Biphosphonates when used alone cannot prevent hot flushes.atrophic changes and
cardiovascular disease.
 It is taken is empty stomach.
 Nothing should be taken by mouth for at least 30 minutes after oral dosing.
 Patient should remain upright for 30 minutes side effects include gastric and oesophageal
ulceration.

Fluoride:-

Fluoride prevents osteoporosis and increases bone matrix.

 It is given at a dose of 1 mg /kg for short-term only.

 Calcium supplementation should be continued.
 Long-term therapy induces side effects.

Calcitorin:-

Inhibits bone resorption.

 Simultaneous therapy with calcium and vitamin D should be given.

 It is given either by nasal spray(200 IUdaily)by injection(S.C)(50-100 IU daily)
 It is suitable when oestrogen therapy is contraindicated.

Selective oestrogen receptor modulators:-

Are tissue specific in action of the many SERMS.

 Reloxifene has shown to increase bone mineral density, reduce serum LDL and to raise
HDL2 level.
 Reloxifene inhibits the oestrogen receptors at the breast and endometrial tissues.
 Risks of breast cancer and endometrial cancer are therefore reduced.
 Reloxifene does not improve hot flushes or urogenital atropahy.
 Risks of venous thrombo embolism is increased.

Clonidine:-

clonidine an alpha adrenergic against may be used to reduce the severily and duration of hot
flushes.

 It is helpful where oestrogen is contraindicated is hypertension.

Thiazides:-

Reduce urinary calcium excretion it increases bone density specially when combined with
oestrogen.
Paroxetine:-

A selective serotonin reuptake inhibitor is effective to reduce hot flushes both the frequency and
severily.

Gabapentine:-

Is an analogue of gamma-amino-bulyxic acid.

 It is found also to be effective.

Phytoestrogens:-

containing iso-flavones are found to lower the incidence of vasomotor symptoms oesteoporosis
and cardiovascular disease.

Soyprotein:-

is also found effective to reduce vasomotor symptoms.soy protein acts as

SERMS.

HORMONE REPLACEMENT THERAPY(HRT):-

Indication of hormone replacement therapy

i. Relief of menopausal symptoms.

ii. Prevention of oesteoporosis.
iii. To maintain the quality of life in menopausal years.

Special group of womens:-

- Premature ovarian failure.

- Gonadal dysgeneis.
- Surgical or radiation menopause.

Benefits of hormone replacement therapy(HRT):-

 Improvement of vasomotor symptoms (70-80%)

 Improvement urogenital atrophy.
 Increase in bone mineral density(2-5%)
 Decreased risk in vertebral and hip fractures (20-50%)
 Reduction in colorectal cancer.(20%)
 Possibly cardio protection.

Risk factors for osteoporosis in a woman:-

 - Family history.
- Age –elderly.
- Lack of oestrogen.
- Body weight – low BMI
- Early menopause –surgical ,radiation.
- Dietary-↓ calcium and ↓vitamin D

↑ caffeine ,↑ smoking

- Sedentary habit.
- Drugs-heparin,corticosteroids.
- Diseases – thyroid disorders. Hyperparathyroidism malabsorption multiple myeloma.

Risk factors for cardiovascular disease:-

 Hypertension.
 Smoking habit.
 Impaired glucose tolerance.
 Familial hyperlipidemia.

Hormone replacement therapy(HRT) and osteoporosis:-

The major cause of post menopausal osteoporosis appears to be an increase in bone resorption.

 HRT prevents bone loss and stimulate new bone formation.

 Oestrogen is found to play a direct role. As receptors have been found in the oesteoblasts.
 Women receiving HRT should supplement their diet with an extra 500 mg of calcium
daily.
 Total daily requirement of calcium in postmenopausal women is 1.5 gm.
 HRT is thought to be cardiovascular protective LDL.on oxidation produces vascular
endothelial injury and foam cell formation.
 These endothelial changes ultimately lead to intimal smooth muscle prolification and
atherosclerosis.
 Oestrogen prevents oxidation of LDL.as it has got antidant properties.
 In postmenopausal women there is some amount of insulin resistance and
hyperinsulinaemia.
 Hyperinsulinaemia induces atherogenesis.
 Oestrogen improve glucose metabolism.

Risks of hormone replacement therapy:-

a) Endometrial cancer:-
 when oestrogen is given alone to a woman with intact uterus,it causes endometrial
proliferation.hyperplasia and carcinoma.
It is therefore advised that a progestogen should be added to ERT to counter balance such
resks.

b) Breast cancer:-

combined oestrogen and progestron replacement therpy,increases the risk of breast

cancer,slightly.

Adverse effects of hormone therapy are related to the dose and duration of therapy.

c) Venous thromboembolic:-disease

Has been found to be increased with the use of combined oral oestrogen and progestin.
Transdermal oestrogen use does not have the same risk compared to oral oestrogen.

d) Coronary heart disease:-

Combined HRT therapy shows a relative hazard of coronary heart disease .hypertension
has not been observed to be a risk of HRT.

e) Lipid metabolism:-

An increased incidence of gall bladder disease has been observed following

ERT due to rise in cholesterol.

f) Dementia Alzheimer:-disease
are increased.

CONTRA INDICATIONS TO HRT:-

 Active liver disease.

 Gall bladder disease.

 History of venous thrombo embolism.

 Oestrogen dependent neoplasm in the body.

  Undiagnosed genital tract bleeding.

AVAILABLE PREPARATIONS FOR HORMONE REPLACEMENT THERAPY:-

Hormone used in HRT is oestrogen this is ideal for a woman who had her uterus removed
(hysterectomy)already.

But a woman with an intact uterus ,only oestrogen therapy leads to endometrial hyperplasia &
even endometrial carcinoma.

 Addition of progestins for last 12-14 days each month can prevent this problem.

 Oestrogen are conjugated oestrogen(0.625 -1.25mg/day) or micronised oestradiol(1-2

mg/day).

 Progestins used are medroxyprogosterone acetale(2.5-5mg/day).micronised progesterone

(100-300mg/day)or dydrogesterone(5-10mg/day)

 Hormone therapy should be used with the lowest effective dose and for short period of
time.
 Low dose oral conjugated oestrogen 0.3 mg daily is effective and has got minimal side
effects.

 Dose interval may be modified as daily for intial 2-3 months then it may be changed to
every other day for another 2-3 months and then every third day for the next 2-3 months.

 It may be stopped there after if symptoms are controlled.

Oral oestrogen regimen:-

- Oestrogen conjugated equine oestrogen 0.3 mg or 0.625mg is given daily for woman who
had hysterectomy.

Oestrogen and cyclic progestic:-

- For a woman with intact uterus oestrogen is given continuously for 25 days and progestin
is added for last 12-14 day.

Contious oestrogen and progestin therapy:-

Continued combined therapy can prevent endometrial hyperplasia.there may be irregular
bleeding with this regimen.

Subdermal implants:-

Implants are inserted subcutaneourly over the antexior abdominal wall uring local
anaesthesia.17B oestradiol implants 25 mg 50 mg or 100 mg are available & can be kept for 6
months.this method is suitable in patients after hysterectomy.implants maintain physiological E2
to E1 ratio.

percutaneous oestrogen gel:-

1 gm applicator of gel delivering l mg of oestradiol daily,is to be applied on to the skin over the
anterior abdominal wall or thighs.effective level of oestradiol (90-120 pg/ml)can be maintained.

Transdermal patch:-

 It contains 3.2 mg of 17 β oestradiol.releasing about 50 µg of oestradid In 24 hours.

 Physiological level of E2 to E1 is maintained

 It should be applied below the waist line and changed twice a week,skin reaction
irritation and itching have been noted with their use.

Vaginal cream:-

Conjugated equine vaginal oestrogen cream 1.25 mg daily is very effective specially when
associated e- atrophic vaginitcs.

- It also reduces urinary frequency .urgency and recurred infection.

Progestins:-

Patients with history of breast carcinoma or endometrial carcinoma.progestins may be used.

- It may be effective in suppressing hot flushes and it prevents osteoporosis medroxy

progesterone acetate 2.5 – 5 mg/day can be used.

- Levonorgestrel IUs with daily release of 10 microgram of levonorgestrel per 24 hours.it

protects the endometrium from hyperplasia & cancer.

- Oestrogen can be given by any route.

It can serve as contraception & HRT when given in a perimenopausal women.
TIBLOLNE:-

Tiblolne is a steroid having weakly oestrogenic progestrogenic &androgenic properties, it

prevents osteoporosis ,atrophic changes of vagina & hot flushes.endometrium is atrophic a dose
of 2.5 mg per day is given.

MONITORING PRIOR TO AND DURING HRT:-

 A base level parameter of the following and their subsequent checkup are monitory

 Physical examination including pelvic examination.

 Blood pressure recording.

 Breast examination and mammography.

 Cervical cytology.

 Pelvic ultrasonography to measure endometrial thickness(normal <5mm).

 Any irregular bleeding should be investigated thoroughly(endometrial biopsy

hysteroscopy.)

 Ideal serum level of oestradiol should be 100mg/ml during HRT therapy.

 Serum level of oestradiol is useful to monitor the HRT therapy rather than that of seraum
FSH

Duration of HRT:-

Use of HRT for a short period of 3-5 years have been advised.

 Reduction of dosage should be done as soon as possible.

 Menopausal women should maintain optimum nutrition,ideal body weight & perform
regular exercise.

Progress in hormone replacement therapy

low dose HRT:-

Women with intact uteras with 0.3 mg conjugated equine oestrogen and medroxy progesterone
acetate(MPA)1.5 mg is found effective to control the vasomotor symptoms. similarly 1 mg of
oestradiol and norethisterone acetate 0.5 mg orally.are also effective and have significant bone
sparing effect.
  Progestrogen is added in the HRT to mininise the adverse effects of oestrogen.

 Hormone therapy should be used with lowest effective dose and for the short period of
time as possible.

 Dose interval may be modified before stopping the therapy

 To minimise the systemic adverse effects of progestogen.levonorgestrel intrauterine

delivery system is being used.

 It is primary used as a contraceptive oestrogen component is delivered by oral or by

transdermal route or as an implant.

 A small size lNG-IUs has been developed that releases 10 µg LNG per day.

 This reduced size LNG IUS is suitable for the post menopausal women as the size of the
uterus is also small.

Abnormal menopause

Premature:

-if the menopause occurs at or below the age of 40 it is said to be premature,often there is
familial diathesis.

- Treatment by substitution therapy is of value.

Delayed menopause:-

If the menopause fails to occur even beyond 55 years it is called delayed.

 The common causes are constitutional.uterine fibroids,diabetes mellitus and

oestrogenic,tumor of the ovary.
 The cases should not be neglected.
 In the absence of palpable pelvic pathology.diagnostic curettage should be done and an
early decision of hysterectomy should be taken in the face of increased incidence of
endometrial carcinoma.

Artificial menopause
Permanent cessation of ovarian function done by artificial means e.g surgical removal of ovaries
or by radiation is called artificial menopause.

Surgical:-

Menstruating women who have bilateral oophorectomy.experience menopausal symptoms.it is

sometimes more troublesome than natural menopause.

While most women go through natural menopause about 50 years of age, there are some who
undergo menopause in their 40s and even as early as 20s and 30s. Surgical menopause happens
to more women than one might think. Approximately 600,000 women in the US have a
hysterectomy which is the second most common major surgery among women. About 55% of
women who have had hysterectomies also undergo bilateral oophorectomy. This means they
experience surgical menopause as well.

Definition

The ovaries produce estrogen, progesterone and androgens which are essential to the regulation
of the menstrual cycle. When a hysterectomy occurs, these hormones get suddenly interrupted
and their levels fall resulting in symptoms of menopause. This is termed surgical menopause.
Although removal of ovaries becomes unavoidable in most hysterectomy surgeries, every effort
is made by the surgeon to leave the ovaries intact in order to avoid the sudden absence of
hormones. Surgical menopause occurs in women who have not yet had natural menopause.

Causes

Most often, surgical menopause is caused quite dramatically when there is surgical interference
like

 hysterectomy,
 bilateral oophorectomy, where both the ovaries are removed. Hysterectomy with removal
of ovaries is referred to as TAHBSO, total abdominal hysterectomy and bilateral salpingo
oophorectomy. This removal of ovaries and fallopian tubes lead to surgical menopause
condition.

A subtotal hysterectomy is when the uterus is removed leaving cervix in place. In total
hysterectomy the body and cervix are removed. In a Wertheim's hysterectomy, the womb, part of
the vagina, Fallopian tubes, ovaries, peritoneum, lymph gland and fatty tissues in the pelvis are
removed.

In the case of hysterectomy when the uterus is removed and ovaries remain, menstrual periods
stop but significantly the menopausal symptoms occur at the same age as would naturally.
Surgery is warranted in conditions such as endometriosis, ovarian cysts, fibroids, ovarian cancer
and pelvic organ prolapse.

Planning a surgical menopause

 Surgical menopause is a difficult decision especially at a younger age. The younger the
woman, the more problems she will encounter.

 A complete hormonal check up is essential for every woman who has to undergo
hysterectomy. This way a baseline reading of the hormonal needs is obtained and one can
always try to achieve these normal levels with the right hormones again.

 Post care has to be planned and it is important for a young woman undergoing
hysterectomy to be under the care of a hormonal therapy specialist who can handle the
side effects of surgical menopause.

 Research is still at an infant stage seeking to determine the long time effects of surgical
menopause on heart disease, osteoporosis and general health especially on younger
woman.

Symptoms

It is observed that a woman undergoing surgical menopause experiences certain symptoms more
profoundly than women going through menopause normally. Since there is abrupt disruption of
hormones after hysterectomy, the menopausal symptoms are more severe, more frequent and last
longer when compared to natural menopause. The symptoms are triggered by the body's sudden
inability to make certain hormones due to the removal of ovaries.

Hot flushes and night sweats are the commonest symptoms of surgical menopause.

It is estimated that about 75 - 90% of women who have had surgical menopause experience
them.

This is due to the disturbance of the central thermostat located in the hypothalamus which is kept
stable by normal circulating estrogen.

Other symptoms of surgical menopause range from

 sleepless nights,
 vaginal dryness and
 itching to decrease in sexual desire and
 painful intercourse.
 Depression result of low estrogen level.
 Thyroid dysfunction,
  bladder infections
 incontinence,
 weight gain, migraine, and
 irritability are also symptoms of surgical menopause.

Management

According to the American Menopause Society,

 there are different treatment therapies available to cope with the symptoms of surgical
menopause.

 Estrogen is immediately given after surgery to try to prevent the intense changes
especially the hot flushes that can occur in woman undergoing hysterectomy.

 Estrogen replacement therapies like EstroGel have found to relieve many women
experiencing surgical menopause. This is an FDA approved bio-identical estrogen
replacement therapy which can help continue an active

 lifestyle after surgery. However the use of estrogen is itself controversial and it is not
usually recommended for women with existing or high risk of cardiovascular disease. A
lowest dose of estrogen for the shortest possible time is recommended.

Estrogen gel which is relatively a new preparation is prescribed. This is quite easy to use and it
has to be applied to the upper leg or stomach daily. The gel works by releasing a consistent
dosage of estrogen into the blood stream making the Hormone Replacement Therapy HRT
option effective.

 Vaginal ring is designed for women whose womb has been removed.
 Vaginal creams which can be applied directly to the vagina by an applicator give relief
locally on the lining of the vagina and are beneficial for vaginal atrophy conditions.
 HRT implants which are small pellets inserted under the skin periodically once in six
months supply hormones.
 These are surgically inserted into the fatty layers of the abdomen under a local anesthetic.
HRT patches come in various dosages and these are small plasters which can release
hormones into the blood stream transdermally.
 The patch needs to be changed twice weekly and possible side effects could be skin
irritation and allergy.
 Tablets are the most common form of HRT and they are for long term usage which needs
to be carefully considered.
 It is imperative to consider the usage of all HRT preparations very carefully and regularly
so as to ensure maximum benefit at the lowest possible dose with effective symptom
relief and protections.
  Exercise is another form of self help which is a positive therapy. Begin with small but
regular walks and then gradually move over to weight bearing exercises which help to
release endorphins from the brain that send feel good messages to the body.

SURGICAL MENOPAUSE RISKS

 Women with surgical menopause are seven times more prone to cardiovascular disease
risks.

 They run the risk of osteoporosis as estrogen plays a vital role in bone formation and
without estrogen calcium is lost from the bones which when not replaced breaks easily.

 It is found that after surgical menopause in particular, bones lose roughly 3% of their
mass per year for the first five years and then 1- 2% a year thereafter. Increased bone loss
associated with oophorectomy results in fracture risk as well.

 Some studies have found that reduced levels of testosterone in women are predictive of
height loss which may occur as a result of reduced bone density.

 Gum tissues are affected and regular dental check ups are advised to tide over this
problem.

 Women younger than 45 years of age and who have had their ovaries removed face a
mortality risk 170% higher than women who have retained their ovaries after
oophorectomy. Hormone therapy is commonly advised as it is believed by many doctors
to mitigate the mortality risks.

 There is a definite lowering of sexual desire in women who have undergone surgical
menopause. This reduction is greater than that seen in women undergoing natural
menopause.

Surgical menopause is definitely difficult and different when compared to the natural way. But it
is important to stay positive. One can also join a local or Internet menopause support group, take
breaks throughout the day, relax mentally and keep fit physically by exercising and eating a
healthy diet.

Radiation:-

The ovarian function may be suppressed by external gamma radiation in women below the age
of 40.
  The castration is not permanent.
 The menstruation may resume after 2 years and even conception is possible.
 Intracavity introduction of radium can cause castration effect by destroying the endo-
metrium and also by depressing the ovarian function.
 The menopausal symptoms are not so intense as found in surgical menopause or
menopause
 following external radiation.

Postmenopausal Hormone Therapy and Risk of

Cardiovascular Disease by Age and Years Since
Menopause
JAMA. 2007;297(13):1465-1477. doi:10.1001/jama.297.13.1465
Text Size: A A A

ABSTRACT
Context The timing of initiation of hormone therapy may influence its effect on
cardiovascular disease.
Objective To explore whether the effects of hormone therapy on risk of cardiovascular
disease vary by age or years since menopause began.

Design, Setting, and Participants Secondary analysis of the Women's Health Initiative
(WHI) randomized controlled trials of hormone therapy in which 10 739 postmenopausal
women who had undergone a hysterectomy were randomized to conjugated equine
estrogens (CEE) or placebo and 16 608 postmenopausal women who had not had a
hysterectomy were randomized to CEE plus medroxyprogesterone acetate (CEE + MPA) or
placebo. Women aged 50 to 79 years were recruited to the study from 40 US clinical
centers between September 1993 and October 1998.

Main Outcome Measures Statistical test for trend of the effect of hormone therapy on
coronary heart disease (CHD) and stroke across categories of age and years since
menopause in the combined trials.

Results In the combined trials, there were 396 cases of CHD and 327 cases of stroke in
the hormone therapy group vs 379 cases of CHD and 239 cases of stroke in the placebo
group. For women with less than 10 years since menopause began, the hazard ratio (HR)
for CHD was 0.76 (95% confidence interval [CI], 0.50-1.16); 10 to 19 years, 1.10 (95% CI,
0.84-1.45); and 20 or more years, 1.28 (95% CI, 1.03-1.58) (P for trend = .02). The
estimated absolute excess risk for CHD for women within 10 years of menopause was −6
per 10 000 person-years; for women 10 to 19 years since menopause began, 4 per 10 000
person-years; and for women 20 or more years from menopause onset, 17 per 10 000
person-years. For the age group of 50 to 59 years, the HR for CHD was 0.93 (95% CI, 0.65-
1.33) and the absolute excess risk was −2 per 10 000 person-years; 60 to 69 years, 0.98
(95% CI, 0.79-1.21) and −1 per 10 000 person-years; and 70 to 79 years, 1.26 (95% CI,
1.00-1.59) and 19 per 10 000 person-years (P for trend = .16). Hormone therapy increased
the risk of stroke (HR, 1.32; 95% CI, 1.12-1.56). Risk did not vary significantly by age or
time since menopause. There was a nonsignificant tendency for the effects of hormone
therapy on total mortality to be more favorable in younger than older women (HR of 0.70
for 50-59 years; 1.05 for 60-69 years, and 1.14 for 70-79 years; P for trend = .06).

Conclusions Women who initiated hormone therapy closer to menopause tended to have
reduced CHD risk compared with the increase in CHD risk among women more distant
from menopause, but this trend test did not meet our criterion for statistical significance. A
similar nonsignificant trend was observed for total mortality but the risk of stroke was
elevated regardless of years since menopause. These data should be considered in regard
to the short-term treatment of menopausal symptoms

ASSIGNMENT:Role of nurse in surgical management of menopausal women

SUMMARY:-

Till now discussed about definition of menopause ,types clinical manifestation diagnostic
findings. management treatment hormone replacement therapy. Surgical management

CONCLUSION:

By knowing knowledge about menopause helps in preventing osteoporosis so ever one must
have idea about menopause

BIBLIOGRAPHY

Dc dutta textbook of gynaecology page no

Cs dawn textbook of reproductive andcontraceptives page no

Websites

www.surgical management of menopause.com

www.medline.com

www.indian nursingcouncil.org

www.ask.com

www.wikipedia .com.org
 SEMINAR
ON
MENOPAUSE

SUBMITTED TO SUBMITTED BY

MRS.JAYALAKSHMI.M MRS J.Sujatha

ASSISTANT PROFESSOR MSC(N) IST YEAR

DEPT OF OBG YASHODHA COLLEGE OF NURSING

YASHODHA COLLEGE OF NURSING

 STUDENT PROFILE

Title of the course :-MSC (N)

Name of the student :- J.SUJATHA

Name of the teacher :- Mrs.jayalakshmi

(Assistant Professor)

Topic :- menopause.

Unit :- x

Duration :- 2hours

Date :- 04.07.2012

Time :- 2-4pm

Place :- 1st year msc (n) classroom

Number of students :- 6

Method of teaching :- lecture cum discussion method.

A.V aids black board OHP,LCD,HANDOUTS,Chart

 OBJECTIVES

General objectives:

At the end of the seminar students will be able to gain knowledge in depth regarding the
menopause apply this skills in clinical area

Specific objectives

By the end of the seminar students will be able to

 define menopause

 list out the types of menopause

 explain the endocrinological changes of climactric and menopause

 discuss the changes in bone metabolism and cardiovascular system due to menopause

 illustrate the menopause symptoms

 list out the diagnostic findings of menopause

 explain the management of menopause treatment and HRT

 discuss the risk of HRT

 explain the abnormal ,artificial menopause

 describe the surgical management of menopause

AVAILABLE PREPARATIONS FOR HORMONE REPLACEMENT THERAPY:-

Hormone used in HRT is oestrogen this is ideal for a woman who had her uterus removed
(hysterectomy)already.

But a woman with an intact uterus ,only oestrogen therapy leads to endometrial hyperplasia &
even endometrial carcinoma.

 Addition of progestins for last 12-14 days each month can prevent this problem.

 Oestrogen are conjugated oestrogen(0.625 -1.25mg/day) or micronised oestradiol(1-2

mg/day).

 Progestins used are medroxyprogosterone acetale(2.5-5mg/day).micronised progesterone

(100-300mg/day)or dydrogesterone(5-10mg/day)

 Hormone therapy should be used with the lowest effective dose and for short period of
time.
 Low dose oral conjugated oestrogen 0.3 mg daily is effective and has got minimal side
effects.

 Dose interval may be modified as daily for intial 2-3 months then it may be changed to
every other day for another 2-3 months and then every third day for the next 2-3 months.

 It may be stopped there after if symptoms are controlled.

Oral oestrogen regimen:-

- Oestrogen conjugated equine oestrogen 0.3 mg or 0.625mg is given daily for woman who
had hysterectomy.

Oestrogen and cyclic progestic:-

- For a woman with intact uterus oestrogen is given continuously for 25 days and progestin
is added for last 12-14 day.

Contious oestrogen and progestin therapy:-

Continued combined therapy can prevent endometrial hyperplasia.there may be irregular

bleeding with this regimen.

Subdermal implants:-

Implants are inserted subcutaneourly over the antexior abdominal wall uring local
anaesthesia.17B oestradiol implants 25 mg 50 mg or 100 mg are available & can be kept for 6
months.this method is suitable in patients after hysterectomy.implants maintain physiological E2
to E1 ratio.

percutaneous oestrogen gel:-

1 gm applicator of gel delivering l mg of oestradiol daily,is to be applied on to the skin over the
anterior abdominal wall or thighs.effective level of oestradiol (90-120 pg/ml)can be maintained.

Transdermal patch:-

 It contains 3.2 mg of 17 β oestradiol.releasing about 50 µg of oestradid In 24 hours.

 Physiological level of E2 to E1 is maintained

 It should be applied below the waist line and changed twice a week,skin reaction
irritation and itching have been noted with their use.

Vaginal cream:-

Conjugated equine vaginal oestrogen cream 1.25 mg daily is very effective specially when
associated e- atrophic vaginitcs.

- It also reduces urinary frequency .urgency and recurred infection.

Progestins:-

Patients with history of breast carcinoma or endometrial carcinoma.progestins may be used.

- It may be effective in suppressing hot flushes and it prevents osteoporosis medroxy

progesterone acetate 2.5 – 5 mg/day can be used.

- Levonorgestrel IUs with daily release of 10 microgram of levonorgestrel per 24 hours.it

protects the endometrium from hyperplasia & cancer.

- Oestrogen can be given by any route.

It can serve as contraception & HRT when given in a perimenopausal women.

TIBLOLNE:-

Tiblolne is a steroid having weakly oestrogenic progestrogenic &androgenic properties, it

prevents osteoporosis ,atrophic changes of vagina & hot flushes.endometrium is atrophic a dose
of 2.5 mg per day is given.