The Menopause
Dr Chaambwa H
Livingstone Central Hospital
May 2019
Introduction
The term menopause is derived from Greek Menos (month) and
pausos (cessation). The word means cessation of menstruation.
Climacteric is period of life when fertility and sexual activity
decline. It is a wide term leading to:
Pre Menopause
Peri Menopause
Post Menopause
Dr Chaambwa, H. OBGY specialist
Definitions
Perimenopause
It is 3-5 years period before menopause with increased frequent
irregular anovulatory bleeding followed by episodes of amenorrhea
and intermittent menopausal symptoms.
Menopause
The point in time at which menstrual cycles permanently cease. It
is a retrospective diagnosis after 12 months of amenorrhea.
Mean age – 51 years.
Dr Chaambwa, H. OBGY specialist
Pathophysiology
The number of primordial follicle decline even before birth but dramatic
just before menopause.
Loss of follicle → low E2 and inhibin →Increase FSH from about 10 years
before menopause.
Close to menopause, There will be
Anovulation → inadequate Luteal phase → decrease progesterone → lead to
BEO and endometrial Hyperplasia
At menopause dramatic ↓E2 → menstruation ceases and symptoms of
menopause start.
Main postmenopausal oestrogen is oestrone produced by Peripheral fat
from adrenal androgen.
Dr Chaambwa, H. OBGY specialist
Other causes of menopause
Drugs eg. GnRH
Pelvic irradiation
Chemotherapy
Surgical removal of ovaries
Dr Chaambwa, H. OBGY specialist
Premature ovarian failure
Failure of the ovaries to generate adequate oestrogens
before the age of 40
Characterised by low E2 and high FSH, and LH with
postmenopausal appearance of ovaries
Maybe associated with autoimmune disorders, streak
ovaries, iatrogenic etc
AMH is a measure of ovarian reserve
Resistant ovary syndrome
Menopausal biochemistry but normally appearing
ovaries
Dr Chaambwa, H. OBGY specialist
Symptoms of Menopause:
Hot flushes cutaneous Psychological changes
vasodilation decreased level of central
Occurs in 75% of women neurotransmitters
More severe after surgical Depression
menopause Irritability
Continue for 1 year Anxiety
25% continue more than 5 years Insomnia
Urinary Symptoms Lose of concentration
Urgency
Frequency
Nocturia
Dr Chaambwa, H. OBGY specialist
Symptoms of Menopause
Atrophic Changes Decrease size of ovaries, become
Vagina non palpable.
Vaginitis due to thinning of Pelvic floor - relaxation →prolapse.
epithelium, pH and ↓ lubrication. Urinary tract →atrophy →lose of
Dyspareunia → due to decreased urethral tone →incontinence
vascularity and dryness Hypertonic Bladder - detrusor
Decrease size of cervix and mucus instability
with retract of squamocolumnar Decrease size of breast and benign
(SC) junction into the cysts.
endocervical canal.
Skin Collagen – ↓ collagen &
Decrease size of the uterus, thickness → ↓ elasticity of the skin.
shrinking of myoma &
Reversal of premenstural syndrome
adenomyosis.
Dr Chaambwa, H. OBGY specialist
Symptoms of Menopause
Osteoporosis:
Bone mass reach peak at the end of their 3rd decade of
life.
After 40 years bone resorption exceeds bone formation by
0.5% per year.
This negative balance increase after menopause to a lose
of 5% of bone per year.
About 50% will have an osteoporotic fracture
Trabecular bone affected more than cortical bone (distal
radius, proximal femur, vertebrae)
Dr Chaambwa, H. OBGY specialist
Risk factors for Osteoporosis
Life style
Gender: more in women
smoking
BMI
caffeine intake
Race
alcohol
highin white women
increasein protein diet
moderate in Asian
women decrease in Calcium and Vit D
intake
lowest in Black women
Family History +ve Steroids
Exogenous medication
Cushing Syndrome
Dr Chaambwa, H. OBGY specialist
Diagnosis of Osteoporosis
DEXA: Dual Energy X-ray Absorptiometry
For Assessment of bone densimetry to demonstrate if
bone density above or below fracture threshold.
Prevention of Osteoporosis
Improve lifestyle
Regular exercise
Eliminate smoking & alcohol
Dr Chaambwa, H. OBGY specialist
Cardiovascular Disease
CVD is now the leading cause of death among post menopausal women
before menopause, risk of heart attack is 1/3 that of man. after
menopause the risk increase and become the same as that of man
Effect of oestrogen before menopause
increase HDL & decrease LDL.
decrease atherogenic plague formation by direct action on vascular
endothelium.
After menopause:
HDL : LDL ratio become closer to male ratio.
Hence increase in stroke and myocardial infarction risk
Dr Chaambwa, H. OBGY specialist
Urogenital System
Embryologically female genital tract & lower urinary system
develop in close proximity from primitive urogenital sinus.
The Urethra and vagina have a high concentration of
oestrogen receptors and there is significant evidence to
support one use of oestrogen in treatment of urogenital
symptoms such as (recurrent UTI, vaginitis and dysparunia).
Dr Chaambwa, H. OBGY specialist
CNS; Dementia
Prevalence of Dementia as high 50% by age 85 years.
Alzheimer’s disease account for 60-65% of cases.
Observation studies –decreased risk of Alzheimer’s by 1/3
among women taking HRT.
Dr Chaambwa, H. OBGY specialist
Diagnosis and Investigations for
menopause
The Triad of: No indication to perform
Hot flushes bone density
Amenorrhea Endometrial Biopsy
increase FSH > 15iu/L but any bleeding should
be investigated before
Before starting treatment: a starting any treatment.
patient should have
Breast examination
Mammogram
Pelvic exam (Pap Smear)
Weight, Blood pressure
Dr Chaambwa, H. OBGY specialist
Treatment of Menopause
Non-hormonal treatments
selective serotonin-reuptake inhibitors (SSRI) and
gabapentin
The bisphosphonates are the principle class of drug that
inhibit osteoclastic activity
Calcitonin inhibit osteoclastic activity
Calcium Supplement & Vit D.
Raloxifene is selective oestrogen receptors modurator
[SERMs] that bind with a high affinity to oestrogen
receptors. It has some oestrogen like effect e.g. ↑ bone
density, ↓LDL Cholesterol but act as oestrogen antagonist
on endometrium and breast.
Dr Chaambwa, H. OBGY specialist
Treatment of Menopause
Hormone replacement therapy –HRT
Oestrogen is the main hormone
Progestogen
Testosterone
Dr Chaambwa, H. OBGY specialist
HRT -Oestrogen
Different oestrogens are used in HRT
Oestradiol (transdermal, gel, implant)
Oestradiol valerate (oral, gel)
Conjugated equine oestrogens (oral, gel)
Oestrone sulphate Oestriol (vaginal only)
Dr Chaambwa, H. OBGY specialist
HRT -Progestogens
Different progestogens used in
In women with uterus, HRT
progestin is added to
prevent endometrial Norethisterone (transdermal)
hyperplasia Levonorgestrel (transdermal,
Theses can be: intrauterine)
Cyclically Dydrogesterone
Continuously Medroxyprogesterone acetate
Cyproterone acetate
Drospirenone Progesterone
Dr Chaambwa, H. OBGY specialist
Micronized progesterone
Testosterone
women who undergo a surgical or chemoradiation-
induced menopause
Tibolone
this has oestrogenic, progestogenic, and
androgenic activity
Dr Chaambwa, H. OBGY specialist
Benefits of HRT
Vasomotor symptoms subsides
Vagina-↑ vaginal thickness of epithelium →↓ dyspareunia &
vaginitis.
Urinary tract – enhancing normal bladder function.
Osteoporosis – decrease fractures by more than 50%
Reduced risk of CVA and CHD
Colon Cancer decrease up to 50%
Dr Chaambwa, H. OBGY specialist
Contraindication to HRT
Absolute Relative
Present or suspected Presence of uterine
pregnancy fibroids
Suspicion of breast Past history of benign
cancer breast disease
Suspicion of
Unconfirmed VTE
endometrial, cancer
Chronic stable liver
Acute active liver
disease disease
Uncontrolled Migraine
hypertension The presence of any
Confirmed VTE of the conditions
Dr Chaambwa, H. OBGY specialist
Post Menopausal Bleeding
Vaginal bleeding occurs after 12months of Amenorrhea in middle age
women who are not receiving replacement therapy.
Causes
Atrophic Endometritis
Endometrial Polyp
Endometrial Hyperplasia
Endometrial Cancer
Dr Chaambwa, H. OBGY specialist
Dr Chaambwa, H. OBGY specialist
