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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)
Staging of Menopause
Dr. Behram. S. Anklesaria, 1997
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.
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
Fat Distribution
» Redistribution of fat
» > 20 to 30 % of fat
Diagnosis of menopause
History – symptoms
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
Alternative
Medicines
HRT
Management SERMS
nutrition
exercise Technology
lifestyle
counseling
etc.
Treatment
with disease-
specific
drugs
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.
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.