menopause.pptxfor bscnursing students pdf.

Education

1. Menopause

2. 2 MENOPAUSE “The anchor point that is defined after 12 months of amenorrhea following the final menstrual period (FMP), which reflects a near complete but natural diminution of ovarian hormone secretion.” Soules et al. Menopause 2001

3. 3 NATURAL (SPONTANEOUS) MENOPAUSE “ Occurs after 12 consecutive months of amenorrhea, for which there is no other obvious pathologic or physiologic cause.” (Average age in Western world is 51 years) Utian . Climacteric 1999.

4. 4 PREMATURE MENOPAUSE “ Menopause that occurs in women at or under 40 years old.” Utian . Climacteric 1999.

5. PERIMENOPAUSE A period of 3years before menopause & followed by 1 year of amenorrhoea Assosiated with mild ovarian hormonal deficiency Leads to anovulation , menorrhagia 5

6. 6

7. 7 MENOPAUSE The time of cessation of ovarian function resulting in permenant amenorrhoea For confirmation: 12 months CLIMACTERIC: Phase of waning ovarian activity 2-3yrs before and 2-5 yrs after menopause

8. Demography; Indian perspective 8 60 million women in India are above 55yrs Majority of women spend 1/3rd of their life in postmenopausal period

9. Age 9 Usual age 45 to 50yrs average being 47yrs. Premature menopause - before 40 yrs Late menopause – menstruation beyond 52 yrs

10. 10 DELAYED MENOPAUSE Due to good health and better nutrition. Also seen in women with uterine fibroids . Also in women with high risk of endometrial cancer

11. 11 Menopausal age is directly associated with smoking and genetic disposition. Smoking induces premature menopause.

12. PATHOPHYSIOLOGY 12 During climacteric, ovarian activity declines. Initially, ovulation fails, no corpus luteum forms and no progesterone is secreted by the ovary. Later, graffian follicle fails to develop, estrogenic activity decreases and endometrial atrophy leading to amenorrhea. Increased secretion of FSH and LH by anterior pituitary.

13. 13 FSH 50 times increase, LH 3-4 times increase. Menopausal urine has become and important commercial source of gonadotropins . Later gonadotropin activity of anterior pituitary ceases and fall in FSH level eventually occurs.

14. 14

15. HORMONE LEVELS 15 50% reduction in androgen production and 66% reduction in oestrogen production.. Some estrogen produced by ovary ( oestrone , E1) FSH appears in large concentrations. Low oestrogen levels(below 20pg/ml) predisposes to osteoporosis and ischemic heart disease.

16. Risk factors for menopausal related problems are as follows: 16 Early menopause Surgical menopause or radiation. Chemotherapy esp alkylating agents. smoking., caffeine, alcohol. Family history of menopausal diseases. Drugs related such as GnRH , heparin, corticosteroids and clomiphene (anti- oestrogen ) when given over prolonged peiod can cause oestrogen deficiency.

17. ANATOMICAL CHANGES 17 SITE CHANGES Genital organs Atrophy and regression Ovary Shrink,surfaces:grooved , furrowed Tunica albuginea Thickens Size of ovary <2*1.5*1cm in US Plain muscle in fallopian tube : Atrophy Cilia Disappear Uterus Smaller Endometrium As basal layer: deeply stained stroma and a few glands

18. 18 SITE CHANGES Cervix Smaller Vaginal fornices Disappears Vagina Narrow Epithelium Pale, thin,and dry: senile vaginitis Vulva Atrophy (+narrow vagina:dyspareunia ) Skin of labia minora and vestibule Pale,thin,dry Labia majora Reduction in fat Pubic hair Reduced and grey Breast More pendulous(fat dep ) Glandular tissue <5% Pelvic cellular tissue Becomes lax Ligaments supporting the uterus and vagina Lose their tone:prolapse of genital organs, stress incontinence of urine, and fecal incontinence

19. Menopausal symptoms 19 Mensural symptoms Other symptoms Neurological Libido Urinary tract Genital

20. MENOPAUSAL SYMPTOMS 20 Menstrual 3 classic ways in which the menstrual period ceases are as follows: Sudden cessation. Gradual diminution in the amount of blood loss with each regular period until menstruation stops. Gradual increase in spacing of periods until they cease for at least a period of one year.

21. Other symptoms 21 60-70% women go through menopausal period without problems Rest needs guidance and treatment

22. HOT FLUSHES Early and acute symptom of estrogen deficiency. These are waves of vasodilatation affecting the face and neck and last for 2-5 mins each. Followed by severe sweating. Occurring at night may disturb sleep . 22

23. 23 Sometimes preceded by headache. Palpitation and anginal pain maybe felt. Mental depression due to lack of sleep, irritability and lack of concentration. With passage of time severity of hot flushes decreases.

24. Cause of hot flushes Caused by noradrenalin, which disturbs the thermoregulatory system. Oestrogen deficiency reduces hypothalamic endorphins, which release more norepinephrine and serotonin. This leads to inappropriate heat loss mechanism . 24

25. Neurological 25 Vasomotor symptoms and paraesthesia take the form of sensations of pins and needles in the extremities.

26. Libido 26 E and androgen deficiency causes urogenital atrophy , which affect sexual function. Leads to a decline in sexual interest.

27. 27 The symptoms which develop a little later are : Urinary Dysuria Stress incontinence and urge Recurrent infection Genital Dry vagina Dyspareunia Loss of libido Faecal incontinence

28. URINARY TRACT 28 Oestrogen deficiency causes Urethral caruncle Dysuria with or without infection Urge Stress incontinence( due to poor vascularity and loss of tone of internal urethral sphincter). These symptoms are clubbed together under the term urethral syndrome .

29. 29 Atrophic vagina reduces the vaginal secretion, and dry vagina cause dyspareunia . Loss of libido adds to sexual dysfunction.

30. 30 COMPLICATIONS

31. 31 Vasomotor symptoms. HTN Osteoporosis. Arthritis Osteoporosis of vertebral bones, upper end of hip joint,wrist frature

32. 32 Cardiovascular disease. ischaemic heart disease, MI, HTN Stroke Cardiac irregularities Tachycardia

33. 33 Urogenital atrophy . Prolape genital tract Stress incontinence of urine & feces Ano -colonic cancer Cognitive decline and Alzheimer's disease. Cataract, glaucoma, macular degeneration Skin changes and Tooth decay

34. Other risk factors 34

35. CARDIOVASCULAR DISEASE 35 Estrogen is cardioprotective (antioxidant property also) After menopause HDL ,LDL, total cholesterol , Estrogen deficiencyatherosclerosis , ischemic heart disease, MI Risk factors: obese women with hypertension , previous thromboembolicepisodes

36. Stroke 36 Incidence of stroke also increase in menopausal women

37. Skin changes 37 Collagen content is reduced , causing skin to wrinkle The loss of collagen is more rapid in the first few years after menopause 30% of skin collagen is lost within the first 5 years. The rate is 2% per year for the first 10 years after menopause.

38. CNS 38 ER are abundant in the brain. E have a role in many brain processes, and it’s absence result in physiologic and symptomatic changes. E is important for cerebral blood flow cerebral glucose administration

39. 39 synaptic activity, neuronal growth survival of cholinergic neurons complex functions as cognition. The role of E deficiency in postmenopausal depression, declining cognitive function, dementia, and Alzheimer's disease is not clear.

40. Pyometra 40 Years after menopause, women may develop senile pyometra  cervical stenosis Rx : drainage by cervical dialatation under GA

41. Diagnosis 41 1 ) History menstrual abnormality

42. 42 2 ) Symptoms: vasomotor symptoms vaginal dryness urinary frequency Insomnia Irritability, anxiety skin change breast changes urinary tract problem pelvic floor change skeletal change(backache, ).

43. 3)Physical examination : 43 The clinical findings vary greatly depending on the time elapsed since menopause and the severity of the estrogen deficiency Skin: thin ,dry Breast loss turgor The labia are small The uterus becomes much smaller The muscles of the pelvic floor are looser in tone and are thin Prolapse may be present

44. 44 4) Laboratory diagnosis General examination: BP, Palpation of breasts, weight, hirsuitism Pap smear Mammography, pelvic US E2, FSH, LH determination Bone density study: Dual energy X-ray absorptiometry (DEXA) Single or dual photon absorptiometry

45. Treatment 45 1)   Counselling Mild tranquillizers 3)  Hormone replacement therapy(HRT)

46. Counselling The women often develops pregnancy & cancer phobia. Duty of gynaecologist - exm . &investigation. Pelvic ultrasound-ovarian size, endometrial thickness, mammography & as well as E2 &FSH levels, when HRT is considered.

47. The advice on contraceptives is necessary. Until the menopause is well established & amenorrhea has lasted for 12 month, couple is advice to use barrier method. Diet: least 1.2g of Ca, Vit A,C,E &400mg of Vit .D & Soya beans are good. Weight bearing exercise delay onset of osteoporosis.

48. Mild tranquillizers Anti depressants like sulpiride Releives anxiety, depression, sleeplessness

49. Hormone replacement therapy Not all women require HRT 70-85% of women remain healthy need only good nutrition and healthy life style.

50. Indications of HRT 1) Women having climacteric symptoms Vasomotor symptoms Urinary symptoms Sexual dysharmony Established osteoporosis on x-ray /B.M.D. Measurements

51. 2) All asymptomatic high-risk women having Premature menopause (surgical / spontaneous) Family history of osteoporosis Thin, small sedentary women Poor diet, excess alcohol CVD, Alzhemeir’s disease, colonic cancer Corticosteroid & other medications High urinary calcium / creatinine Low plasma estradiol 51

52. Contraindications of HRT Breast cancer, uterine cancer or family history of cancer. Previous history of thromboembolic episode. Liver & gall bladder disease.

53. DRUGS USED IN HRT Oestrogen Progesterone Other drugs: Tibolone Raloxifene Soya Bisphosphonates

54. Estrogen therapy Short term estrogen therapy 1) To releive symptoms like; hot flush, night sweats, palpitations, disturbed sleep In smallest effective dose for 3-6 months Natural estrogens Oral premarin (Conjugated equine estrogen (CEE): 0.625 mg daily) Ethinyl estradiol (0.01mg), Evalon (1-2mg), micronized oestrogen are effective.

55. Medroxyprogestrone (10mg) or primolut -N (2.5mg) daily for 10-12d each month. Combined hormone therapy( femet ). 2mg 17- β - oestrodiol & 1mg of norethisterone acetate.

56. 2) for dyspareunia , urethral syndrome and senile vaginitis Local estrogen cream( oestriol : 1/2g-everyday-10-12 days each month for- 3-6 months) Short acting Cyclic progesterone administration is not required. Postmenopausal withdrawal bleeding do not occur. Estring (vaginal ring releases 5-10microgram - 3months )

57. Long term therapy: For delaying osteoporosis Reduce the risk of CV disease Beyond 8-10yr

58. Oral Preparations of estrogen Oral: - Conjugated equine estrogen (CEE): 0.625 mg daily Ethinyl estradiol : 0.01mg Micronised estrogen : 1-2g

59. ESTROGEN: ORAL Advantages . *Easy to take & cheap. *Good control due to short ½ life . Disadvantages. *High dose required. *first pass effect in liver. * daily intake *tablet contain lactose& not suit to women who are allergic to lactose.

60. Transdermal Preparations of estrogen Transdermal ( estradiol ): - Patches: contains: 3-4mg; releases 50 micro gm / 24 hour twice weekly. Gel :for improving collagen in skin 75 micro gm / 24 hours daily.

61. ESTROGEN: TRANSDERMAL Advantages. Low dose, pure estradiol . Avoids intestine & liver metabolism. Reduces serum triglyceride & insulin resistance. No thromboembolic risk or hypertension Disadvantages. More expensive Not well tolerated in warm climates Variable absorption.

62. ESTROGEN: IMPLANTS Sub cutaneous implant ( estradiol ): - 25 / 50 / 100 mg. 6 monthly. Advantages. Pure estradiol , 6 monthly insertion, high level of estradiol in blood. Avoids first pass effects Better response in severe osteoporosis. Disadvantages. Needs surgical procedure Unable to control absorption Difficult to remove pellet

63. THE RISKS OF HRT Vaginal bleeding Thromboembolism Endometrial cancer if E2 is taken alone Brest cancer due to progestogen if HRT is taken over 5yrs. CHD in a women with CVD.

64. Progesterone Role in HRT Prevents endometrial hyperplasia and cancer in non- hysterectomised women Implant may replace oestrogen , where estrogen is c/I or sensitive Prevents breast cancer Improves bone mineral density primolut -N 2.5mg , medroxyprogestrone & duphaston Mirena IUCD- levonorgestrel

65. Tibolone Synthetic derivative of 19-nor-testosterone. Weak oestrogenic , progestogenic , & androgenic action. Endometrial hyperplasia Elevates the mood, relieves the VM symptom, improves sex drive & reduces bone resoption . Cardioprotection (red. TG) SE: wt gain, oedema , tenderness in breast, GI symptom& vaginal bleed.

66. raloxifene Non steroidal comp., SERM, reduses the risk of fracture by 50%, esp. vertebra by BMD by 2-3%. It causes 10% reduction in total cholesterol & LDL & HDL level. It does not raise the level of triglycerides.so cardio protective for long term. Reduces osteoporosis.

67. raloxifene Side effects *hot flushes, cramps, venous thrombosis, retinopathy. Cotraindications *venous thrombosis *should be given with oestrogen *hepatic dysfunction *stop the drug 72 hr before surgery * indomethacin,naproxen,ibuprofen,diazepam .

68. soya Isoflavone . Abt 11g soya- 2-4mg phytoestrogen-oetrogenic - non steroid plant product. 45-60mg soya daily –protective- breast cancer, liver disease &other side effect. cholesterol ,LDL,TG & marginal HDL. Antiviral, antifungal & anticarcinogenic .

69. Bisphosphonates etidronate , tiludronate reduce bone resorption through the inhibition of osteoclastic activity. Elidronate (10mg/Kg f body wt-2W followed by a gap of 2-3M & this course is repeated for 10 such cycles. Not given with Ca.(absorption ) Overdose- hypocalcemia . Milk &antacid - gastric irritation.

70. alendronate (5mg daily or 35mg weakly) overdose- hypocalcemia . Risedronate (5mg/D or35mg/M)- gastric side effect. Zolendronic acid(once yr i.v 5mg over 15min) SE: osteonecrosis of the jaw & visual dis. Calcitonin-inh . Osteoclast activity *nasal spray(single dose of 200IU daily for 3M)

71. *NS can cause flushes, rhinitis, allergic reaction &nasal bleeding. * fracture by 30% Subcutaneous inj. Of Calcitonin -GI symptoms , aneamia &inflammation of joint cause poor compliants so also the high cost. Teriparatide-rec . formation of PIH * abt 20 μ g once daily SC inj. Ver. Fracture-65% others-50% ,if used <2yr

72. *nausea, headache are the complication. Strontium ranelate (1-2g daily orally) BMD-50%, very expensive, not easily available. Clonidine - imidazole der. *treat hot flushes *effective in HT *dose 0.2-0.4mg daily.

73. PREMATURE MENOPAUSE Def: ovarian failure occurring 2 SD in year before the mean menopausal age in the population. Clinically: sec. amenorrhea for at least 3 months with raised FSH/LH & low E2 level in a women under 40 year of age. Inc. 1% -be. 30yr-1:1000 -at 35yr-1:250 -be.40yr-1%

74. AETIOLOGY 1.Genetic disorder chr . abnormalities (10-20%) –X sex chr . AD sex linked inheritance. Ovarian dysgenesis-30% 2.Autoimmune disease(30-60%) Mumps, thyroid dys.,hypo parathyroidism , & Addison’s dis. Ovarian biopsy –infiltration of follicle with plasma cells& lymphocytes. CD8 & CD4 autoimmune d. Antiovarian Ab are present.

75. 3.Tuberculosis 4.Smoking 5.Radiaton & chemotherapy Reversible Radiation up to 400 to 500 rads . restores normal ovarian fun. in 50% cases. Alkalytic agents. 6.Hystrectomy Kinking & blockage of ovarian vessels Tubectomy

76. 7.Prolonged GnRH therapy. 8.enz.defect-17 α - hydroxylase & galactosemia have adverse effect on oocytes – pri . Amenorrhea. 9.Resistant ovary Terminology is used less frequently these days. Follicles fail to respond to gonadotropin stimulation. 10.Induction of multiple ovulation in infertility.

77. PATHOPHYSIOLOGY Lack of receptors is explained as the cause of non response of follicle.

78. C/F Hot flushes Sweating Insomnia Headache Psychological Cancer phobia Pseudocyesis Irritability Depression Lack of conc.

79. INVESTIGATION FSH level: 40mIU/ml or more. E2 level: 20pg/ml or less Thyroid fun., Ca level, chr . study,& thyroid Ab. Blood sugar. X-ray pituitary fossa for the tumour . BMD study is not always necessary, it is an invasive procedure. Ovarian biopsy. Ultrasound. Prolactin level.

80. COMPLICATIONS The risks of osteoporosis & cardiovascular diseases increase in premature menopause.

81. MANAGEMENT 1.Cause of premature menopause should be ascertained & the cause treated. 2.Ovulation induction or oocyte donation in IVF programme has caused pregnancies to occur in some cases. 3.Progestogen challenge test will indicate if menstruation can be induced, provided endometrium is primed with oestrogen .

82. 4.Corticosteroid therapy is effective in autoimmune disease if Ab to sex hormone are present in the blood. Plasmapheresis has also been attempted. 5.A women with hypo- oestrogenism may require HRT or other drugs to prevent osteoporosis . oestrogen implant with progestogen or Mirena IUCD offers long-term HRT.

83. LATE MENOPAUSE Def: cond. in which menstruation cond. beyond 52 year. Late menopause occurs in women with fibroids and is seen in women who develop endometrial cancer. Often it is constitutional. Beyond 52 yr , endometrial biopsy is required to rule out endometrial pathology.

84. POSTMENOPAUSAL BLEEDING Normally-1 yr POA –after 40 yr. however, VB –anytime after 6 MOA in menopausal age postmenopausal bleeding & investigated. without amenorrhea / irre . Bleeding , if the women over the age of 52 yr cont. to menstruate, she needs investigation to rule out endometrial hyperplasia & mali . Of genital tract.

85. AETIOLOGY 1.vulva-trauma , vulvitis ,benign & malignant lesions. 2.vagina-foreign body such as ring pessary for prolapse , senile vaginitis , vaginal tumour (benign as well as malignant) postradition vaginitis . 3.cervix-cervical erosion, cervicitis , polyp, decubitus ulcer in prolapse &cervical malignancy.

86. 4.uterus-senile endometritis , tubercular endometritis , endometrial hyperplasia(10%) , polyp, endometrial carcinoma& sarcoma , & mixed mesodermal tumour . 5.Dysfunctional uterine bleeding, metropathia haemorrhagica , uterine polypi & endometrial hyperplasia. 6.Fallopian tube malignancy .

87. 7. ovary- benign ovarian tumour such as benner tumour , granulosa & theca cell tumour , & malignant ovarian tumour . 8. Hypertension & blood dyscrasia . 9. Urinary tract- urethral caruncle , papilloma &CA of bladder. May be mistaken for genital tract bleeding. 10.bowel- bleeding from haemorrhoid , anal fissures, & rectal cancer may be misleading.

88. 11.imp. Reason –indiscriminate. Prolonged use of oestrogen unopposed by progestogens , & HRT when applied clinically. Tamoxifen causes endometrial hyperplasia & cancer. 30-50% -PMB –malignancy of genital tract -most common –endometrial cancer , cervical cancer& ovarian tumour . Common benign conditions are endometrial hyperplasia and polypi .

89. Clinical Features HISTORY *age –menarche & menopause *taking oestrogen & tamoxifen * prolapse details *abdominal pain &foul smelling discharge- malignant tumours *urinary& rectal symptoms .

90. EXAMINATION *BP *GE- obesity& diabetes *abdominal pain *speculum & bimanual examination

91. INVESTIGATION Aim: Excluding malignancy 1.Blood count & smear- blood dyscrasia . 2.Blood sugar level. 3.Cervical cytology-cervical lesion. 4.Endometrial study. 5.Sonosalpingography –endometrial polyp. 6.ultrasound- endometrial thickness >4mm indicates the need of endometrial biopsy.

92. Several methods Dilatation & curettage (D&C) – fractional curettage comprising separate scrap of endometrium & endocervix not only allows the exact site of malignancy if present, but also detect the extent of the tumour & staging. Uterine cavity aspiration & endometrial sampling.

93. Vibra aspirator, Gravlee’s jet washer , Isaac’s aspirator & Pipelle aspiration –end. Sample. 7.Hystroscopy inspection& selective biopsy. 8.CT & MRI . 9.Diagnostic laparoscopy . 10.Cytoscopy & proctoscopy .

94. MANAGEMENT Treat the cause. When no cause is found, & if there has been only one bout of bleeding, the pt should be kept under observation. Abt 80% of cases do not bleed again. If cond. to bleed- laparotomy . An undiagnosed small tumour may be discovered & dealt appropriately. – AH with bilateral oophorectomy histopathological study.

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