MENOPAUSE ; an overview

Clinical Spectrum & Management

Definition:” Cessation of ovarian function due to depletion of
ovarian follicle resulting in permanent amenorrhea beyond 12
months. It is a retrospective diagnosis”

Menopause “Indian Perspective”

Population ageing is major challenge of 21st Century!

Elderly - 7 % (70 Million in2001)

- 13 % (160 Million by 2025)

Menopausal Women-43 million in 2001 & will be 103 million in

2026.

Magnitude of problem of menopause in Indian context is growing as a

significant public health issue!

Types of menopause
Natural Menopause 45 to 55 (47)
Premature Menopause <40
Early Menopause 40 to 45
Delayed Menopause >55
Induced Menopause at any age
(Surgical, Radiation, Chemotherapy)
Blood Production Rates of Sex Steroids (mg/day)

Sex Steroids Reproduction Age Postmeno-pause

Estrogen 0.350 0.045

Testosterone 0.2-0.25 0.05-0.1

Androstenedione 2-3 0.5-1.0

DHEA 6-8 1.5-4.0

DHEA-S 8-16 4-9

Staging of Menopause
Dr. Behram. S. Anklesaria, 1997

STAGES Stage I Stage Stage II B Stage 111

IIA
YEARS Roughly 3-5 years before ONE Up to From five years
the menopause YEAR five after menopause
years after the up to her life
menopause time.

EVENTS I A: Menstrual M C * Local III A: Late

irregularity E 0 atrophic atrophic changes
I B: Vasomotor N N changes 111 B: Ischemic
instability 0 F * Late heart disease
1 C: Early psychosomatic P I psychosomatic III C:
symptoms A R symptoms Osteoporosis
U M III D: Very late
S A complications:
E T e.g.. Cerebro –
I Vascular
0 accidents,
N Alzheimer's
disease, etc.

ACTION ESTABLISH TREATS PREVENT !

COMMUNICATIONS

STAGE I
From the earliest perimenopausal symptom ( usually vasomotor
instability or menstrual irregularity to menstrual cessation

• Declining Fertility
• Menstrual Irregularities
- Oligomenorrhoea-70%
- Sudden Amenorrhoea-12%
- Menorrhagia-18%
 Vasomotor- Hot flushes, Night sweats, Headaches, Migraine,
Insomnia, Palpitation, Breathlessness, Faintness and Dizziness.
Formication, Muscle pain
• Psychological – Depression, Anxiety, Panic Attacks, Irritability,
Forgetfulness, Difficulty in concentrating, Fatigue, Tired on
waking ,Restless Legs, Urinary Urgency, Loss of
Libido.

STAGE II
Urogenital atrophy – Itchy labia, Dyspareunia, Vaginal
discharge, Urinary urgency, Dysuria,
incontinence
Generalized connective tissue atrophy –
Muscular atrophy, Bone and joint pain,
Shoulder stiffness, Pins and needles,
Dry thin skin, Dry eyes, Brittle nails,
loss of hair
STAGE III
 Long Term Effects

Osteoporosis
Cardiovascular Disease
Cerebrovascular Disease
Alzheimer's disease

CVS
Postmenopausal women have a two fold higher risk of developing the
disease than Premenopausal women, after adjustment for age.
Premature menopause < 35 yrs, 2 to 3 fold increase of MI.
Oophorectomy < 35 yrs, 7 fold increase in MI
At all ages HDL values in women are 10 ml/dl higher than men.

Osteoporosis
Major risk factor for type-I or postmenopausal osteoporosis is
estrogen deficiency.

Low bone mass, micro architectural deterioration of Bone Tissue

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

A BMD value 2.5 SDs below that a healthy young adult is diagnostic
of osteoporosis (WHO)

Incidence
Osteoporosis fracture in women is 2-3 times
Greater then man?
 1. Peak bone mass is lower
2. Accelerated loss after menopause
3. Women outlive men !

AMERICA
25 Million accounting for 70%of all Fractures in women 45 years of
age.
INDIA
Every 4th women after 60 years is suffering from Osteoporosis

Common Sites of Fracture are vertebral body, proximal femur,distal

radius. Trabecular bone is lost more rapidly than cortical bone
Common Symp. : Shortened Stature, Kyphosis, Lordosis, Fractures,
Acute back pain

Menopause and adipose tissue

Fat Distribution
» Redistribution of fat
» > 20 to 30 % of fat

Central and Android Adiposity leading to metabolic syndrome

» Visceral Adiposity
» Insulin Resistance
» HTN
» Adverse Lipid Profile

Diagnosis of menopause
 History – symptoms

 Signs – vaginal pH, vaginal smear

 Lab
S.FSH > 30 mIu/ml
S.Estradiol < 20 pq/ml
S. Inhibin B
 Trial of Medication
Progesterone withdrawal
HT

Pre - HRT Assessment

General (Screening for high risk factors for CAD,CA,OP)
Past Medical / Family History / Personal
Physical exam:WH ratio, BMI, B P
Breast / Pelvic examination / Pap smear

Special Essential
CBC, CUA,/ lipid profile/ FBS
Mammography / USG pelvis
Optional as appropriate
Serum FSH /E2/ Thyroid function test
LFT,Stool for Occ.blood
Tumour markers
Hysteroscopy & Endometrial biopsy
Assessment of bone mass

General Principles of Clinical Practice

  Counseling: explanation & reassurance by primary physician /
Gynecologist / referral to Menopause specialist.
 Health Promotion
Nutrition
Exercise
Life Style
 Menopause management & disease prevention
MHT
 Disease specific drug & alternate / complimentary therapies.

Alternative
Medicines

HRT
Management SERMS
nutrition
exercise Technology
lifestyle
counseling
etc.
Treatment
with disease-
specific
drugs

Disease prevention principles

 Clinical Presentations As Indications for HT
Who Needs HT Prescriptions ?

1. Symptomatic or Asymptomatic.
• Premature menopause
• Hysterectomy + BSO
• Other hypo estrogenic amenorrhea’s.
• Established osteoporosis
2.Asymptomatic opportunistic women with risk for
osteoporosis.
(With caution in women with endometriosis and fibroids)

3. Natural Menopause
Relief of Vasomotor, Urogenital and Psychological
Symptoms

Contraindications

Absolute
Acute Endometrial / Breast Cancer.
Acute Phase myocardial infarction.
Undiagnosed breast Lump.
Undiagnosed abnormal vaginal bleeding.

Other Contraindications.
Primary CVA
Acute phase PE, DVT.
Recurrent thromboembolism on contraceptives.
 Spontaneous thrombosis.
Inherent abnormalities of Coagulation.
- Anti-thrombin III
- Fibrinogen & platelets.

Menopausal harmone replacement therapy

(type & route with min.doses)

Estrogen: * Oestriol - oral/vaginal

* Estradiol -oral/vaginal/transd./percut.
* C.E.E - oral/vaginal
Progesterone (oral):
* Dydrogestrone
* Medroxyprogestrone acetate
* Norethidrone actetate
* Natural micronised progesterone (O/V)
Tibolone(oral)

SERM’S * Raloxifene ( oral )

Androgens * Testosterone (oral/patch/Inj./implant )

Patient follow up and management

 Points are to be considered :1mth…3mth…6mth-yrly as
appropriate
 ? Adequate symptom control
? Timing & acceptability of withdrawal bleed
? Side-effects
? Weight & blood pressure changes.
? Questions by the patient regarding treatment
 6 Month-yearly
? lipid profile ,hormonal profile, clotting profile
? P/V Exam /TVS/EB
  ? Breast examination ,mammography
? BMD if indicated.
 2-3 Yearly -
? Pelvic examination/Biopsies
? Pap smear
? Mammography if family history of cancer breast.

Benefits of HRT outweighs its potential risks

Benefits from

Acute
¯ Bone loss
¯ VM symptoms
¯ Mood disturb
¯ risk of CVS
Long Term
¯ Risk & Delay onset of Alzheimers disease.
¯ Osteoarthritis
¯ Tooth loss and adult Mac. Deg.
¯ Colon Ca

Risks
Risk of breast, endo ca (unopposed)
(Type, dose and duration dependent)
Risk of venous Thromboembolism & stroke

Prescribing HT
Six Step Approach
I. Define the type &stage of menopause.
II. Define the goals for-using HRT, consider the strength of
evidence that HRT will help & identify alternative strategies.
III. Assess for medical conditions on which HRT may have
adverse effects.
IV. Assess the woman’s concerns & discuss potential risks.
V. Make a collaborative decision,, balancing potential risks
& benefits.
VI. If HRT is chosen, select and appropriate regime, select an
optimal duration of use & re-evaluate it at least annually.