Menopause N6195 + Etc

Front 1

Menopause

Back 1

Permanent cessation of menstruation.

Front 2

Climacteric

Back 2

The phase of life which marks the gradual transition from the era of reproduction to that of senility.

Front 3

Menopause is just a ........
It is not considered to be a disease, but a ......

Back 3

Menopause is just a manifestation of the climacteric.
It is not considered to be a disease, but a physiological event.

Front 4

Natural Menopause:

Back 4

When it sets in at the normal age
(around 50 years old)

Front 5

Premature Menopause:

Back 5

Spontaneously appears at a younger age
(Younger than 40 years old)

Front 6

Artificial Menopause:

Back 6

When it is artificially induced
(surgical removal, destruction by deep radiation, or medically induced)

Front 7

Premature Menopause
It is when menstruation stops for .... period under the age of ...., with absence of ....., and with .....

Back 7

at least 6 months
40 years old
follicles in ovarian biopsy
a high menopausal level of FSH.

Front 8

Causes of premature menopause

Back 8

A- Constitutional or familial.
B- Chemical insult by chemotherapy, or by cytotoxic agents.
C- Infections destroying ovarian tissues (e.g. Mumps, or typhoid oophoritis, or bilateral ovarian abcesses)

Front 9

Delayed Menopause
It is when menstruation continues after the age of ....
Causes .....
Risks

Back 9

-55 Years old.
-(Constitutional or Familial / Associated with multiple fibroids / Functional Ovarian tumours / In Diabetic women / Obesity).
-(Associated with an increasedd risk of Endometrial carcinoma)

Front 10

Menopause is caused by (physiology):

Back 10

Depletion of both ovaries from all the primordial , and graafian follicles, which have undergone atresia, during her reproductive period of life (since menarche).

Front 11

When does it all start?
Menopause starts between ....

Climacteric starts...... than cessation of menstruation and lasts for .....

Back 11

-the age of 45 – 50 years.
- 1 - 2 years earlier
-2 - 3 years after it.

Front 12

The onset menopause may take any of the following ways

Back 12

Irregular bleeding.
Oligomenorrhea.
Polymenorrhea.
Sudden cessation of menstruation.

Front 13

Morphological changes of the menopause

Back 13

1- Local, genital.
2- General.
3- Hormonal.

Front 14

Local Changes (Genital)

Back 14

Ovaries shrink in size.
Breast become flabby and redundant.
Pubic hair become gray and scanty.
Labia majora lose their fat pads.
Enteroitus become patulous.
Dry vagina.
Vagina loses its rugae.
Dyspareunia
Portiovaginalis becomes atrophic and shrink in size.
Uterus becomes atrophic and shrink in size.
Ligamentous support become redundant.
Predisposition to genital prolapse.
Urinary problems related to continence.

Front 15

General Changes.

Back 15

Gradual disappearance of secodary sexual characters.
Tendencey to alopecia.
Increased facial hair.
Blood pressure increases.
Weakening of the bones (Osteoporosis).
Atherosclerosis with increased tendency for heart diseases.

Front 16

Hormonal Changes.

Back 16

Excess FSH excretion in urine.
Excessive androgen production by the suprarenal glands.
Increased thyroid function due to high TSH by the active pituitary gland.

Front 17

mechanism

Back 17

Depletion of follicles from both ovaries
No estradiol secretion from the follicles
Release of the anterior pituitary gonadotrophs from the inhibition of estradiol.
Increased level of FSH and LH.
Anterior pituitary gland works excessively
Increased ACTH production
Increased androgen production by the suprarenal gland.
Hirsutism

Front 18

Symptoms of menopause

Back 18

Vasomotor Symptoms
Nervous Symptoms:
Metabolic Symptoms:
Gastrointestinal Symptoms
Genitourinary Symptoms

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Vasomotor Symptoms:

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Hot flushes.
Palpitations.
Cold sweats.
Constipation.
Headcahes.
Dizziness.

Front 20

Nervous Symptoms:

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Insomnia.
Tinnitus.
Psychological changes.
Anxiety
Mood changes.
Depression.

Front 21

Metabolic Symptoms:

Back 21

Obesity.
Arthritic and bone pains.
Diabetes .
Hypertension

Front 22

Gastrointestinal Symptoms:

Back 22

Flatulence and constipation and altered appetite

Front 23

Genitourinary Symptoms:

Back 23

Dryness.
Dyspareunia.
Recurent urinary tract infections.
Urinary incontinence.

Front 24

Treatment of Menopause

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1- Reassurance.
2- General measures.
3- Hormonal Replacement Therapy

Front 25

1- Reassurance:

Back 25

Good comprehensive talk.

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2- General treatment:

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Diet control.
Life style changes (Exercises)
Sedatives and tranquilizers.
Non hormonal management of vasomotor smptoms (Clonidine / Beta blockes / Tibolone)

Front 27

3- Hormonal treatment:

Back 27

Estrogens.
Estrogen plus Progesterone.
Androgens, or progestogens alone or combined.
Calcitonin for osteoporosis.

Front 28

Hormone Replacement Therapy (HRT)

Back 28

Mostly Estrogen alone or in combination with Progesterone.
Improves quality of life of the patient.
Has many advantages.
Has many disadvanges.
Can be administered in several forms.

Front 29

Advantages of HRT.

Back 29

Prevention of vasomotor symptoms (Hot flushes)
Prevent or reverse the genital changes.
Prevent Osteoporosis.
Prevent the genitourinary complaints.
Prevent the emotional and psychological complaints.
Prevent the hypertension and heart diseases.
Increases life expectancy.

Front 30

Disadvantages of HRT

Back 30

Withdrowal bleeding (regular or irregular)
Endometrial hyperplasia and risk of endometrial carcinoma.
Increased risk Cancer breast.
Other effects (nausea / salt and water retension /weight gain / headaches)

Front 31

Forms of administration of HRT

Back 31

Oral pills.
Dermal patches.
Injections

Front 32

Duration of use:

Back 32

Should be used for life unless intolerance occurs, or patient suffers from side effects.

Front 33

Follow up during HRT

Back 33

Annual Uterine U/S for the endometrial thickness (Should be less than 4 mm thick).
Annual Pap smear for cancer cervix.
Annual Breast U/S and Mammography.

Front 34

Vaginal atrophy:
VMI:
The vaginal maturation index (VMI) on a pap refers to the proportion of superficial cells present. (Ratio of parbasal, intermediate (basal) and superficial squamous cells)

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 If the number of mature superficial squamous cells is below 5 = vaginal atrophy.
When the atrophic vagina becomes inflamed it is called atrophic vaginitis

Front 35

From PP
WHI finding for HRT

Back 35

 Coronary Heart Disease +29%
 Stroke +41%
 Venous Thromoboembolism +11%
 Breast Cancer +26%*
 Colon-rectal cancer -37%
 Hip fracture -34%
 *8 more invasive breast cancers per 10,000 women taking prempro for 1 year.

Front 36

Current arguments for HRT

Back 36

Age related findings:
 Those who start close to menopause may have greater benefits
 WHI were older and had more CV risk factors
 Instituting ET/EPT in older women may be either ineffective or harmful

Front 37

CV issues from PP

Back 37

 HT may reduce CHD risk when initiated in younger and more recently postmenopausal women
 Longer HT duration associated with reduced CHD risk and mortality
 Some evidence of lower CHD risk in women who used HT ≥ 5 y.
 Short-term HT may increase CHD risk in women farther from menopause at time of initiation
 Long-term HT associated with less accumulation of coronary artery calcium
 HT currently not recommended as sole or primary indication for coronary protection in women of any age

Front 38

PP
Types of estrogens

Back 38

Estrone
Estriol
Estradiol

Front 39

Estrone

Back 39

 Predominate type of estrogen found in post-menopausal women
 Made from body fat and in ovary
 May be related to increased risk of endometrial & breast cancer in obese older women

Front 40

Estriol

Back 40

 Weakest of estrogens
 Produced in pregnancy
 May relieve mild symptoms but does not prevent CVD and other long term health risks
 Effects on non-pregnant women are not well documented.

Front 41

Estradiol

Back 41

 Predominate human estrogen
 Produced by the ovary before menopause
 Active at cell surface and nucleus receptor sites

Front 42

Absolute contraindications for HRT

Back 42

 Pregnancy
 Undiagnosed vaginal bleeding
 Current GB disease
 Active thrombophlebitis
 Liver disease

Front 43

Absolute contraindications for HRT
Relative contraindications for HRT

Back 43

 History of breast cancer
 History of recurrent thrombophlebitis
 History of thromboembolic disorder

Front 44

Danforth : Chapter 14
Infertility
Basic work up

Back 44

• One year after stopping contraception
• Semen analysis
• Documentation of ovulation
• Uterine and tubal evaluation
• HSG

Front 45

For
• hypothalamic dysfunction
• Hyperprolactenemia
• PCOS

Back 45

• Hypothalamus problems: gonatotropins
• Hyperprolactenemia: dopamine agonist
• PCOS: clomiphene citrate, SX, injectable gonatotropins, , insulin sensitizing medications,

Front 46

Uterine and tubal factors for infertility

Back 46

SX or IVF if severe