28.Peri Menopausa

1. Peri-menopausal period syndrome
Zhanghuiying
Department Of Obstetrics & Gynecology
Tianjin Medical University General Hospital

2. Staging of women
climacteric period
adolescenceadolescence40yrs40yrs
Final periodFinal period
1yrs 1yrs
after after
the the
Final Final
periodperiod
60-6560-65
yrsyrs
LifLif
e e
stosto
pp
Pre menopausePre menopause Post Post menopausemenopause
Peri Peri menopausemenopause
Transitional phaseTransitional phase
((参考参考WHOWHO的定义的定义))
climacteric period

3. Definition
MenopauseMenopause
 the cessation of menses for a year or more. the cessation of menses for a year or more.
 It is caused by ovarian failure.It is caused by ovarian failure.
 It marks the end of a women’s reproductive lifeIt marks the end of a women’s reproductive life
 It occurs normally between the ages of 45– 55 It occurs normally between the ages of 45– 55
years and at a mean age of 51 years.years and at a mean age of 51 years.
 It is a physiological processIt is a physiological process
Peri-menopausePeri-menopause is a period before and after the is a period before and after the
menopause. Encompasses the years leading up to menopause. Encompasses the years leading up to
menopause-anywhere from 2-8 yrs-plus the first menopause-anywhere from 2-8 yrs-plus the first
years after final periodyears after final period

4. Peri-menopausal Period SyndromePeri-menopausal Period Syndrome peri-peri-
menopause accompanied by the symptoms of menopause accompanied by the symptoms of
climacteric, including hot flashes, excessive climacteric, including hot flashes, excessive
perspiration, night sweats, depression, agitation, perspiration, night sweats, depression, agitation,
vaginal dryness, insomniavaginal dryness, insomnia
Premature ovarian failurePremature ovarian failure ----- ----- the cessation of the cessation of
menses before the age of 40 years.menses before the age of 40 years.
Artificial menopauseArtificial menopause ------ ------ the cessation of the cessation of
menses is secondary to some causes, such as menses is secondary to some causes, such as
oophorectomy, radiation therapy.oophorectomy, radiation therapy.

5. The basic causes of the Peri-menopausal The basic causes of the Peri-menopausal
syndrome are a progressive decline in syndrome are a progressive decline in
ovarian production on estrogens and ovarian production on estrogens and
other sex hormonesother sex hormones

6. Negative Feedback
Secretion of estrogens decreased (ovary)Secretion of estrogens decreased (ovary)
↓ ↓
FSH increased (40-45 years old)FSH increased (40-45 years old)
↓ ↓
FSH,LH increased(45-50 years old)FSH,LH increased(45-50 years old)
↓ ↓
FSH increased 13 times LH increased 3 times FSH increased 13 times LH increased 3 times
(the first year menopause(the first year menopause))
↓ ↓
FSH, LH gradually decline (3 years after menopause)FSH, LH gradually decline (3 years after menopause)

7. Symptoms and signs
1. 1. Early Symptoms and signsEarly Symptoms and signs

1) 1) menstruation disorder menstruation disorder
Oligomenorrhea--- intervals greater than 35 Oligomenorrhea--- intervals greater than 35
days.days.
 Polymenorrhea---- intervals less than 21 daysPolymenorrhea---- intervals less than 21 days
 hypermenorrhea hypermenorrhea
 amenorrheaamenorrhea
 menopausemenopause

8. 2) 2) vasomotor symptomsvasomotor symptoms( hot flashes, ( hot flashes,
sweats)sweats)
 estrogen depletion result in instability in the estrogen depletion result in instability in the
vessels of the skin.vessels of the skin.
The hot flashes begins on the chest and spreads The hot flashes begins on the chest and spreads
quickly over the neck, face and upper limbs quickly over the neck, face and upper limbs
which lasts only seconds but may recur many which lasts only seconds but may recur many
times one day. Sweat often follows hot flashes.times one day. Sweat often follows hot flashes.

9. 3) mood changes and sleep disturbances3) mood changes and sleep disturbances
 insomnia, headache, backache, depression, insomnia, headache, backache, depression,
hatehate
 having difficulty falling asleep and waking up having difficulty falling asleep and waking up
soon after going to sleepsoon after going to sleep
4)urinary tract problem4)urinary tract problem
 atrophic change in the urinary epitheliumatrophic change in the urinary epithelium
 decreased elastic of reproductive and urinary decreased elastic of reproductive and urinary
tract supporting structurestract supporting structures

10. 5)5) vaginal dryness and genital tract vaginal dryness and genital tract
atrophyatrophy
atropic vaginitis, dyspareuniaatropic vaginitis, dyspareunia
the vaginal skin become thin and loses its the vaginal skin become thin and loses its
rugose appearancerugose appearance
small red spots appear on the vaginasmall red spots appear on the vagina

11. 2. Late symptoms and problems2. Late symptoms and problems
6)osteoporosis6)osteoporosis
Accelerated bone loss in women is clearly Accelerated bone loss in women is clearly
related to the loss of ovarian function.related to the loss of ovarian function.
Studies show that a rapid decrease in Studies show that a rapid decrease in
bone mass occurs within 2 months of bone mass occurs within 2 months of
ovariotomyovariotomy

12. There is now general agreement that There is now general agreement that
postmenopausal osteoporosis is related to postmenopausal osteoporosis is related to
estrogen deficiencyestrogen deficiency
Estrogen reduce bone resorption more than Estrogen reduce bone resorption more than
they reduce bone formationthey reduce bone formation
Other factorsOther factors
lack of exerciselack of exercise
Malabsorption of calciumMalabsorption of calcium

13. 7) cardiovascular lipid changes7) cardiovascular lipid changes
 perimenopaual women have a lower incidence of perimenopaual women have a lower incidence of
coronary heart disease than men of same age.coronary heart disease than men of same age.
After the menopause a woman’s risk increase After the menopause a woman’s risk increase
progressively until age 70 when it become equal to progressively until age 70 when it become equal to
that of menthat of men
HDLHDL（（high density lipoprotein）（）,LDL,LDL­­, ,
total cholesterol total cholesterol ­­
This observation led to the supposition that This observation led to the supposition that
estrogen might be a key factor.estrogen might be a key factor.
Estrogen has protection against heart disease Estrogen has protection against heart disease

14. Diagnosis
1)1) HistoryHistory
menstrual abnormalitymenstrual abnormality
2)2) Symptoms:Symptoms: vasomotor symptoms, vasomotor symptoms,
vaginal dryness, urinary frequency, vaginal dryness, urinary frequency,
insomnia, irritability, anxiety, skin insomnia, irritability, anxiety, skin
change, breast changes, urinary tract change, breast changes, urinary tract
problem, pelvic floor change( cystocele. problem, pelvic floor change( cystocele.
Rectocele. Prolapse), skeletal Rectocele. Prolapse), skeletal
change(backache, ) and so on.change(backache, ) and so on.

15. 3)Physical examination:
The clinical findings vary greatly depending on The clinical findings vary greatly depending on
the time elapsed since menopause and the the time elapsed since menopause and the
severity of the estrogen deficiencyseverity of the estrogen deficiency
Skin: thin ,drySkin: thin ,dry
Breast loss turgorBreast loss turgor
The labia are smallThe labia are small
The uterus becomes much smallerThe uterus becomes much smaller
The muscles of the pelvic floor are looser and The muscles of the pelvic floor are looser and
thinerthiner
 Prolapse may be presentProlapse may be present

16. 4) 4) Laboratory diagnosisLaboratory diagnosis
Cytologic smear from the vaginal wallCytologic smear from the vaginal wall
E2, FSH, LH determinationE2, FSH, LH determination

17. Treatment
1) education, understanding, reassurance
Every woman with climacteric symptoms Every woman with climacteric symptoms
deserves an adequate explanation of deserves an adequate explanation of
physiologic event she is experiencing ,in physiologic event she is experiencing ,in
order to dispel her fears and minimize order to dispel her fears and minimize
symptoms such anxiety , depression and symptoms such anxiety , depression and
sleep disturbance.sleep disturbance.
Reassurance should be emphasizedReassurance should be emphasized

18. 2) hormone replacement therapy(HRT )
Estrogen therapyEstrogen therapy
The use of estrogens can relieve the The use of estrogens can relieve the
menopausal symptoms.menopausal symptoms.
The hot flashes , sweats and other The hot flashes , sweats and other
complaints disappear or improve within a complaints disappear or improve within a
few days of starting estrogens therapyfew days of starting estrogens therapy..
3) traditional medicine therapy3) traditional medicine therapy

19. The administration of estrogen without The administration of estrogen without
progestogen increases the risk of progestogen increases the risk of
endometrial cancerendometrial cancer and and breast cancer.breast cancer.
So, correct cyclical therapy, with 10-14 So, correct cyclical therapy, with 10-14
days days progestogen per monthprogestogen per month , can reduces , can reduces
the incidence of cancer.the incidence of cancer.

20. Contraindication
vascular thrombosisvascular thrombosis
hypertensionhypertension
diabetesdiabetes
 chronic liver diseasechronic liver disease
myoma, endometriosis,myoma, endometriosis,
breast diseasebreast disease
 gallbladder diseasegallbladder disease

21. The common hormone of HRT
EstrogenEstrogen
 ProgestogenProgestogen
TiboloneTibolone

22. Estrogen
natural synthetic
estradiol
estrone
estriol
Conjugated estrogen
ethinylestradiol
mestranol

23. Progestogen
 Medroxyprogesterone Medroxyprogesterone
acetate(MPA)acetate(MPA)
 progesteroneprogesterone

24. Tibolone
Tibolone is a synthetic steroid having weak Tibolone is a synthetic steroid having weak
estrogenic, progestogenic,and androgenic estrogenic, progestogenic,and androgenic
properties.properties.
it reduces endometrail hypoplasia , improves it reduces endometrail hypoplasia , improves
symptoms of dryness and painful symptoms of dryness and painful
intercourse,improves libido.intercourse,improves libido.
Can be used in those with a personal history Can be used in those with a personal history
of breast cancerof breast cancer

25. Routes of administration of
HRT
OralOral
TransdermalTransdermal
SubcutaneousSubcutaneous
vaginalvaginal

26. The types of HRT
Combined sequential therapyCombined sequential therapy
 Continuous combined therapyContinuous combined therapy
Estrogen only –hysterectomised Estrogen only –hysterectomised
womenwomen
TiboloneTibolone

27. Combined sequential therapy
Estrogen are given continuously(30 days)
MPA 10-14 days
Withdrawal bleeding
Stop
Next month

28. Continuous combined therapy
Estrogen continuously
MPA continuously
No Withdrawal bleeding

29. Side-effects of HRT
Irregular uterine bleedingIrregular uterine bleeding
Breasts tendernessBreasts tenderness
Progestogen-related symptoms Progestogen-related symptoms
(abdominal bloating,edema)(abdominal bloating,edema)

30. Risk of HRT
Breast cancerBreast cancer
Endometrial cancerEndometrial cancer
 Venous thromboembolismVenous thromboembolism
Do evaluation every year may find any abnormals，
reduce the incidence of the above risk

31. Information
Next Monday afternoon clinic learningNext Monday afternoon clinic learning
22：：30 pm 30 pm
Tianjin Medical University General Hospital Tianjin Medical University General Hospital
outpatient department building 10outpatient department building 10
thth
floor floor
reproductive medicine center reproductive medicine center
Group II -1Group II -1
Teather : wang yanxiaTeather : wang yanxia