[Link] Kumari R.

Assistant Professor
Parul Institute of Nursing
 MEANING OF MENOPAUSE
• The transition from reproductive to non-
reproductive .
• The word "menopause" literally means the
"end of monthly cycles" from the Greek
word pausis (cessation) and the root men-
(month).
• Menopause is an unavoidable change that
every woman will experience.
 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 occurs.
OR
• Menopause is the permanent cessation of
the primary functions of the human ovaries.
 Terminology
• Climacteric is the period of time during
which a woman passes from the
reproductive to the non-reproductive
stage. This phase covers 5-10 years on
either side of menopause.
• Perimenopause is the part of the
climacteric when the menstrual cycle is
likely to be irregular.
• Postmenopause is the phase of life that
 AGE OF MENOPAUSE
Age at which menopause occurs is
genetically predetermined. The age of
menopause is not related to age of
menarche or age at last pregnancy,
lactation, use of oral pill, socioeconomic
condition, race, height or weight.
 The age of menopause ranges
between 45-55 yr and average is 50 years.
 ABNORMAL MENOPAUSE

• Premature menopause : A woman's

ovaries stop working at a very early age,
ranging anywhere from the age of puberty
to age 40, and this is known as premature
ovarian failure (POF).
• Delayed menopause : if the menopause
fail to occur even beyond 55 years it is
called delayed.
 ENDOCRANIOLOGY OF CLIMACTRIC AND MENOPAUSE

• In younger women, during a normal menstrual cycle

the ovaries produce estradiol, testosterone and
progesterone in a cyclical pattern under the control of
FSH and luteinising hormone (LH) which are both
produced by the pituitary gland.
• Estradiol: there is a significant fall in the level of
serum estradiol from 50-300 pg/ml before menopause
to 10-20 pg/ml after menopause.
• Oestrogen: The sources fail to supply the precursor of
oestrogen and about 5-10 years after menopause,
there is a sharp fall in oestrogen and also the trophic
hormones.
• Androgens: After menopause, the stromal cells
of ovary continue to produce androgens
because or increase in LH.
• Progesterone: A trace amount of progesterone
detected is probably adrenal in origin.
• Gonadotrophins: The secretions of both FSH
and LH are increased due to absent negative
feedback effect of oestradiol and inhibin or due
to enhanced responsiveness of pituitary to
GnRH.
 Menstruation pattern prior to menopause

– any of the following patterns are observed:

1. Abrupt cessation of menstruation (rare) .
2. Gradual decrease in both amount and
duration. It may be spotting or delayed and
ultimately lead to cessation.
3. Irregular with or without excessive bleeding.
One should exclude genital malignancy
prior to declare it as the usual
premenopausal pattern.
• Vascular instability
1. Hot flashes or hot flushes, including night
sweats and, in a few people, cold flashes
2. Possible but continuous increased risk of
atherosclerosis
3. Migraine
4. Rapid heartbeat
• Urogenital atrophy, also known as vaginal atrophy
1. Thinning of the membranes of genitals
2. Itching
3. Dryness
4. Bleeding
5. Watery discharge
6. Urinary frequency
7. Urinary incontinence
8. Urinary urgency
9. Increased susceptibility to inflammation and infection,
for example vaginal candidiasis and urinary tract
infections
[Link] dryness and vaginal atrophy
• Skeletal
1. Back pain
2. Joint pain, Muscle pain
3. Osteopenia and the risk of osteoporosis
gradually developing over time
• Cardiovascular and cerebrovascular
effects
1. Risk of Ischemic heart disease
2. Coronary artery disease and stoke
increased
3. Atherosclerotic changes
4. Vasoconstriction
5. Thrombus formation
• Skin, soft tissue
1. Breast atrophy
2. breast tenderness +/- swelling
3. Decreased elasticity of the skin
4. Formication (itching, tingling, burning, pins
and needles, or sensation of ants crawling
on or under the skin)
5. Skin thinning and becoming drier
• Sexual
1. Dyspareunia or painful intercourse
2. Decreased libido
3. Problems reaching orgasm
 Psychological changes

• Depression or unstable mood

• Anxiety
• Fatigue
• Irritability
• Memory loss and problems with concentration
• Mood disturbance : specially mood swing is
common.
• Sleep disturbances
• Insomnia
• Sleepiness
• Aggressiveness
• Tension
• Phobias
• Low self-esteem
• Tearfulness
• Causes of mood swing :
1. Hormonal changes
2. Sleeplessness
3. Stresses
4. sexual dysfunction
5. changes in the body and negative attitude
towards aging
 Social aspects
• The cultural context within which a woman lives
can have a significant impact on the way she
experiences the menopausal transition.
• Social location affects the way women perceive
menopause and its related biological effects.
• The way she views menopause it depends upon
Ethnicity and geographical location
 DIAGNOSIS OF MENOPAUSE

• Cessation of menstruation for consecutive 12

months during climacteric.
• Appearance of menopausal symptoms ‘hot
flush’ and ‘night sweats’.
• Vaginal cytology – showing menstruation index
of at least 10/85/5 (features of low oestrogen).
• Serum oestradiol : < 20 pg/ml.
• Serum FSH and LH: 40 mlU/ml (three values at
weeks interval required.
 CONT….
• The point when the ovaries stop releasing eggs.
In the last 1 to 2 years of perimenopause, this
drop in oestrogen speeds up. At this stage,
many women have menopause symptoms. It
can last anywhere from a few months to
several years. Many women begin
perimenopause some point after their mid-40s.
Other women skip perimenopause and enter
menopause suddenly.
HORMONAL REPLACEMENT
THERAPY
• Hormone replacement therapy (HRT) is a
treatment used to relieve symptoms of
the menopause. It replaces hormones that
are at a lower level as you approach the
menopause.
• HRT also known as hormone therapy,
menopausal hormone therapy, and
oestrogen replacement therapy.
INDICATIONS OF
HRT
Relief of
menopausal
symptoms
Prevention of
osteoporosis
To maintain
the quality of
life in
menopausal
years
 BENEFITS OF HRT
• The main benefit of HRT is that it can help
relieve most of the menopausal symptoms,
such as:
• Hot flushes : excessive sweating during a day
• Night sweats : hot flushes occurs during night
• Mood swings : changing of mood
• Vaginal dryness : caused by hormonal changes,
tissue of vagina are not well lubricated , It can
cause pain or discomfort during intercourse
 CONT….
• Reduced sex drive : due to decrease hormone
level
• Many of these symptoms pass in a few years,
but they can be very unpleasant and taking
HRT can offer relief for many women.
• It can also help prevent weakening of the
bones (osteoporosis), which is more common
after the menopause. Because HRT increase
bone density.
 CONT…
• Sexual Function :- Estrogen, systemic or topical,
may improve sexual function in women. It is
particularly helpful in women with dyspareunia
secondary to vaginal atrophy, through its
proliferative effect on the vulvar and vaginal
epithelium and by improving vaginal lubrication.
• Urogenital Symptoms :- Estrogen treatment has
been shown to be effective in treating symptoms
related to vaginal atrophy, such as vaginal dryness
and superficial dyspareunia.
RISK OF OSTEOPOROSIS IN
WOMEN
• Family history
• Age – elderly
• Lack of oestrogen
• Body weight – low BMI
• Early menopause – surgical
• Dietary – decrease calcium & vitamin D,
increase caffeine & smoking
• Sedentary habits
 THERAPIES

THERAPIES

ESTROGE ESTRO
N PROGEST.
THERAPY THERAPY
 1. ESTROGEN THERAPY
• Doctors generally suggest a low dose of
oestrogen for women who have had a
hysterectomy. Oestrogen comes in
different forms. The daily pill and patch
are the most popular, but the hormone
also is available in a vaginal ring, gel, or
spray form.
ESTROGEN THERAPY
ESTROGE
N PILLS

TOPICAL
ESTROGEN

VAGINAL
ESTROGEN
 ESTROGEN PILLS
• Pills are the most common treatment for
menopausal symptoms.
• Most estrogen pills are taken once a day
without food.
• Oestrogen – conjugated equine oestrogen
0.3 mg or 0.625 mg is given daily for
women who have hysterectomy.
 TOPICAL ESTROGEN
• It is in the form of creams, gel and spray.
• Examples include gels (like Estroge and
Divigell), creams (like Estrasorb), and
sprays (like Evamist).
• As with patches, this type of estrogen
treatment is absorbed through the skin
directly into the bloodstream
 CONT….
• Estrogel is applied on one arm,
from the wrist to the shoulder.
Estrasorb is applied to the legs.
Evamist is applied to the arm.
 VAGINAL ESTROGEN
• Vaginal estrogen comes in a cream,
vaginal ring, or vaginal estrogen tablets.
• . In general, these treatments are for
women who are troubled specifically by
vaginal dryness, itchiness, and burning or
pain during intercourse.
• Premarin cream is in a form of vaginal
cream.
 CONT…
• It is also available in the form of tablets
like Premarin 0.3, Premarin 0.45, Premarin
0.625 and Premarin 1.25. Ovestin cream
(Oestriol 0.1%) vaginal cream also
available.
2. ESTROGEN/PROGESTIN
HORMONE THERAPY

BIRTH
CONTROL

INTRA
ORAL UTERIN
E
 ESTROGEN PROGESTINE
• This THERAPY
is often called combination therapy,
since it combines doses of estrogen and
progestin, the synthetic form of progesterone.
It’s meant for women who still have their
uterus. Taking estrogen with progesterone
lowers the risk for cancer of the endometrium,
the lining of the uterus.
• While generally used as a form of birth
control. Progesterone can help treat many
menopausal symptoms such as hot flashes
 ORAL PROGESTIN
• Taken in pill form, this medications include
medroxyprogesterone acetate (Provera)
and the synthetic progestin pills
(norethindrone, norgestrel).
 INTRA UTERINE
• PROGESTIN
Intrauterine devices (IUD) levonorgestrel
• If women had one of these IUDs when she
enter perimenopause, so doctor may
suggest that keep it in until after
menopause is complete.
 CONT…
When is estrogen therapy alone
appropriate?

• Estrogen alone is generally prescribed for

women undergoing surgical menopause
(the result of a hysterectomy).
 CONT…
When is estrogen/progesterone
therapy appropriate?
• The combination of estrogen and
progesterone is for women who still have
a uterus (that is, those who have not had
a hysterectomy).
 LONG TERM EFFECTS OF HRT
• Blood clots
• Cancer (such as breast, uterine, or endometrial)
• Heart or liver disease
• Heart attack
• Known or suspected pregnancy
• Stroke
• Thromboembolic disorders
• Undiagnosed vaginal bleeding
• Fibroids
 SIDE EFFECTS OF HRT
• Bloating
• Breast swelling or tenderness
• Headache
• Mood changes
• Nausea
• Vaginal bleeding
 EVALUATION OF HRT
SERUM
HISTORY & PE SERUM FSH
ESTRADIOL

ENDOMETRIA
USG
L SAMPLE