Physiological changes of Menopause and Pathology

Menopause physiology and pathology

1. MENOPAUSE DR. JYOTI KUMBAR

2. Definition Menopause means permanent cessation of menstruation at the end of reproductive life due to loss of ovarian follicular activity. It is the point of time when last and final menstruation occurs.

3. Diagnosis Stoppage of menstruation (amenorrhea) for twelve consecutive months without any other pathology. Serum estradiol: <20 pg /ML Serum FSH & LH: >40 mlU /mL (three values at weeks interval required) Appearance of menopausal symptoms ‘hot flash’ and ‘night sweats’

4. Menopause Transition Period of time during which a woman passes from the reproductive to the non reproductive stage. This phase covers 4–7 years on either side of menopause. Perimenopause is the time starting few years before continuing after the period of onset of menopause. Climacteric refers to the time after the cessation of reproductive function. Postmenopause is the phase of life that comes after the menopause

5. Age of menopause The age of menopause ranges between 45–55 years, average being 47 years. Genetically predetermined Not related to age of menarche or age at last pregnancy. It is variably related to lactation, use of oral pill, socioeconomic condition, race, height. Early menopause- Thinner women, cigarette smoking, severe malnutrition, living in high altitude, following chemotherapy, ovarian resection Late menopause- women with high parity, higher BMI

6. Endocrinology

7. Organ Changes Ovaries: Shrink, wrinkled and white, thinning of the cortex with increase in medullary components, abundance of stromal cells Fallopian Tubes: Atrophy, muscle coat becomes thinner, the cilia disappear Uterus: Becomes smaller and the ratio between the body and the cervix reverts to the 1:1 ratio.

8. Endometrium: Thin and atrophic. In some women, however, with high endogenous estrogens, the endometrium may be proliferative or even hyperplastic. The cervical secretion becomes scanty. Vagina: Becomes narrower due to gradual loss of elasticity. The vaginal epithelium becomes thin. The rugae progressively flatten. There is no glycogen. Doderlein’s bacillus is absent. The vaginal pH becomes alkaline.

9. Vulva: Atrophy The labia becomes flattened Pubic hair becomes scantier. Narrow introitus. Breasts: Fat is reabsorbed and the glands atrophy. The nipples decrease in size. Ultimately, the breasts become flat and pendulous

10. Bladder and urethra: The epithelium becomes thin and is more prone to damage and infection. There may be dysuria, frequency, urge or even stress incontinence Loss of muscle tone leads to pelvic relaxation, uterine descent and anatomic changes in the urethra and neck of the bladder.

11. Bone metabolism: Following menopause, there is a loss of bone mass by about 3–5% per year. This is due to deficiency of estrogen. Osteoporosis is a condition where there is reduction in bone mass but bone mineral to matrix ratio is normal.

12. Bone Disease Based on Bone Mineral Density (WHO –2014) Normal BMD: T-score between + 2.5 and –1.0 Osteopenia: T-score between –1.0 and –2.5 Osteoporosis: T-score at or below –2.5 Severe osteoporosis: T-score ≤–2.5 with one or more fracture.

13. How Estrogen prevents osteoporosis? It inhibits osteoclastic activity and inhibits release of IL-I by monocytes. Estrogen increases absorption of calcium from the gut Stimulates calcitonin secretion from the C cells of the thyroid Increases 1, 25-dihydroxyvitamin D.

14. How Estrogen prevents Cardiovascular Diseases? Increases high density lipoprotein (particularly HDL2) Decreases low-density lipoprotein (LDL) Decreases total cholesterol. Inhibits platelet aggregation at the vascular intima. Stimulates the release of nitric oxide (NO) and prostacyclin from vascular endothelium to dilate the blood vessels. Prevents atherosclerosis by its antioxidant property

15. MENSTRUATION PATTERN PRIOR TO MENOPAUSE Abrupt cessation of menstruation (rare) Gradual decrease in both amount and duration Irregular with or without excessive bleeding.

16. MENOPAUSAL SYMPTOMS

17. MANAGEMENT Prevention: Counseling: Reassurance is essential Nonhormonal Treatment: Lifestyle modification Adequate calcium intake Reducing medications that causes bone loss (corticosteroids). Nutritious diet: Balanced with calcium and protein is helpful Supplementary calcium: Daily intake of 1–1.5 g can reduce osteoporosis and fracture.

18. Exercise: Weight-bearing exercises, walking and jogging. Vitamin D: Supplementation of vitamin D3 (1500–2000 IU/day) along with calcium can reduce osteoporosis and fractures. Exposure to sunlight enhances synthesis of cholecalciferol (vitamin D3) in the skin. Cessation of smoking and alcohol.

19. ABNORMAL MENOPAUSE Premature menopause : If the menopause occurs at or below the age of 40, it is said to be premature Delayed menopause: If the menopause fails to occur even beyond 55 years, it is called delayed menopause. Artificial menopause : Permanent cessation of ovarian function done by artificial means, e.g. surgical removal of ovaries by radiation or chemotherapy is called artificial menopause.

20. Surgical menopause : Menstruating women who have bilateral oophorectomy, experience menopausal symptoms Radiation menopause : The ovarian function may be suppressed by external gamma radiation in women below the age of 40. The castration is not permanent. The menstruation may resume after 2 years and even conception is possible.