Definition

• Menopause : A biological stage in a woman's life that occurs when she stops
menstruating and reaches the end of her natural reproductive life. Usually it is
defined as having occurred when a woman has not had a period for 12 consecutive
months (for women reaching menopause naturally). The changes associated with
menopause occur when the ovaries stop maturing eggs and secreting oestrogen and
progesterone.
• Premature ovarian insuffificiency : Menopause occurring before the age of 40
years (also known as premature ovarian failure or premature menopause). It can
occur naturally or as a result of medical or surgical treatment.
 Short-term
consequences
 Vasomotor symptoms
• Hot flushes
• Night sweats
 Sexual dysfunction
• Loss of sexual desire.
• Loss of sexual arousal.
• Problems with orgasm.
• Sexual pain such as painful sex or dyspareunia.
 Psychological symptoms
• Depressed mood.
• Anxiety.
• Irritability and mood swings.
• Lethargy and lack of energy.
 Long-term
consequences
 Osteoporosis
• Osteoporosis affects 1 in 3 women, and 1 in 12 men.
• It is as ‘a skeletal disorder characterized by compromised bone strength
predisposing to an increased risk of fracture’

The most common sites of osteoporotic fractures are:

• Lower end of radius (wrist or Colles’ fracture).
• Proximal femur (hip).
• Vertebrae.
 Urogenital atrophy

• The lower urinary and genital tracts have a common embryological origin
• Oestrogen deficiency after menopause causes atrophic changes within the urogenital
tract and is associated with urinary symptoms, such as frequency, urgency, nocturia,
incontinence, and recurrent infection.
• These symptoms may coexist with those of vaginal atrophy, including dyspareunia,
itching, burning, and dryness.
 Investigations
• FSH only helpful if diagnosis is in doubt, such as below age 40
and levels in menopausal range (>30IU/L).
• Luteinizing hormone, oestradiol, and progesterone are of
no value in the diagnosis of ovarian failure.
• Thyroid function tests (free T4 and thyroid-stimulating hormone)
as abnormalities of thyroid function can be confused with menopausal symptoms.
• Testosterone levels are of uncertain value.
• BMD if signifi cant risk factors for osteoporosis
 Hormone replacement therapy
• Oestrogens : oestradiol, oestrone, and oestriol

• Progesterone :
17-Hydroxyprogesterone
• Dydrogesterone.
• Medroxyprogesterone acetate.
19-Nortestosterone derivatives
• Norethisterone.
• Levonorgestrel.
 Side effects of systemic HRT
• Oestrogen-related: fluid retention, bloating, breast tenderness or
enlargement, nausea, headaches, leg cramps, and dyspepsia.
• Progestagen-related: fluid retention, breast tenderness, headaches or
migraine, mood swings, depression, acne, lower abdominal pain, and
backache.
• Combined HRT: irregular, breakthrough bleeding
• All types of HRT: weight gain (but not proved in randomized trials).
Benefit/Risk of HRT
(NICE Guidelines)
 Venous thromboembolism
• The risk of VTE is increased by oral HRT
compared with baseline population risk
• The risk of VTE associated with HRT is greater for oral
than transdermal preparations
• The risk associated with transdermal HRT given at standard therapeutic
doses is no greater than baseline population risk.
• Consider transdermal rather than oral HRT for menopausal women who are
at increased risk of VTE, including those with a BMI over 30 kg/m2.
 Cardiovascular disease
• HRT does not increase cardiovascular disease risk
when started in women aged under 60 years
• HRT does not affect the risk of dying from cardiovascular disease
• The presence of cardiovascular risk factors is NOT a contraindication
to HRT as long as they are optimally managed.
• HRT with oestrogen alone is associated with no,
or reduced, risk of coronary heart disease
• HRT with oestrogen and progestogen is associated with
little or no increase in the risk of coronary heart disease.
 Breast cancer
• The baseline risk of breast cancer for women around menopausal age varies from
one woman to another according to the presence of underlying risk factors
• HRT with oestrogen alone is associated with
little or no change in the risk of breast cancer.
• HRT with oestrogen and progestogen can be
associated with an increase in the risk of breast cancer
• Any increase in the risk of breast cancer is related to
treatment duration and reduces after stopping HRT.
Thank You