MENOPAUSE DEFINITIONS Menopause transition Menopause Peri-menopause or climacteric Premature menopause
Period of time from when the ovaries start to fail until the last menstrual period Starts around 47.5 years & lasts for about 3-5 years About 10% of women will not experience this transition, but will cease menstruation abruptly MENOPAUSE No periods for a 12 months duration after the last menstrual period It is a normal and gradual period of change when a woman’s body goes from a reproductive to a nonreproductive state. Menopause is an experience that is unique to each woman. Average age 51 years old Risk factors Smoking Surgery Retrospective diagnosis Some women notice little difference in their physiology while others find the change extremely troublesome and upsetting. In Asians: 45-50 years old Smoking: bring forward the age of menopause by 2.5 years
PERI-MENOPAUSE Phase surrounding the menopause Period from when the ovaries start to fail until 12 months after last menstrual period Symptoms Irregular periods Hot flushes PREMATURE MENOPAUSE Menopause occurring before 40 years old Causes Chromosomal anomalies (Turner’s, Down’s syndrome) Hereditary Auto-immune disorders Radiotherapy or chemotherapy Surgical WHAT DOES IT MEAN?
No reproductive potential Some patients may experience bothersome symptoms. These are usually transient. Long term implications on the cardiovascular and bone health.
SYMPTOMS: Menstrual Changes Menstrual changes are usually the first signs of approaching menopause. - Change in Cycle length: longer or shorter Amount of flow: usually slight increase Duration: usually shorter Can vary a great deal. Fluctuating hormone levels can lead to heavy bleeding, but there are other conditions that can cause this as well. See a doctor if heavy bleeding continues.
SYMPTOMS: Menstrual Changes Red Flags Abdominal mass or distension Abdominal pain Bleeding after menopause Loss of appetite or loss of weight Bleeding beyond 55 years old Severe bleeding (heavy or prolonged) that causes low blood counts SYMPTOMS: Hot Flushes How? - Intense feeling of heat/flushing or reddening of the face, neck and upper body - Perspiration or drenching sweats - Cold chills and night sweats - Sleep disturbances - Feelings of anxiety, nausea, dizziness or palpitations When? - Lasts for a few seconds or minutes - Can start when your periods are still regular, or they may start later - Lasts for a few months or years
SYMPTOMS: Hot Flushes
SYMPTOMS: Urogenital As estrogen levels fall, the vaginal walls will become thinner and less elastic, known as atrophic vaginitis. Vaginal secretions will decrease and become less acidic, which increases the chance of developing a vaginal or bladder infection. Vaginal lubrication during intercourse may be slower and reduced in amount.
SYMPTOMS: Urogenital - Vaginal atrophy - Discomfort - Dryness - Itching - Pain or discomfort during sex - Frequent desire to pass urine - Stress & Urge Incontinence - Recurrent urinary tract infections - Prolapse Consult a doctor: - Blood in the urine - Loss of weight or loss of appetite - Severe bladder pain or pain in the loin - Fever - Recurrent symptoms
SYMPTOMS: Muscloskeletal Aching muscles and joints Hair: Thinner, lacks luster Breasts: Droop Skin: Drier and rougher Wrinkles Itching or ‘crawling’ sensation Weight gain and loss of muscle mass Bones lose mass and become more brittle
LONG TERM CONSEQUENCE: Osteoporosis Post-menopausal women lose bone more rapidly than men of the same age Affects 1:3 women and 1:12 men. Median age for hip fractures in women is 79 years Peak bone density is reached during the 20s and declines from the mid-40s onwards, with an accelerated period of decline for 6-10 years after the menopause followed by a period of slower bone loss Risk of osteoporosis dependent on peak bone density, rate of loss and life span
Non-Modifiable Risk Factors Personal history of a fracture Females Early menopause 50 years old: Once in 2 years Gynaecological checks PAP smears Once in 3 years +/-Ultrasounds MANAGEMENT: Screening
MANAGEMENT: Prevention of Osteoporosis Whole body exposure to 10–15 minutes of midday sun in summer (about 1 minimal erythemal dose [MED]) is comparable to taking 15 000 IU (375 !g) of vitamin D orally. Therefore, exposure of hands, face and arms (around 15% of body surface) to around 1/3 MED (about 5 min) should produce around 1000 IU of vitamin D (cholecalciferol)
Smoking- Lowers amount of calcium absorbed from intestine, alters body’s handling of vitamin D, lowers body weight Alcohol-excessive alcohol intake is associated with decrease calcium levels, bone loss and increased risk of fractures MANAGEMENT: Prevention of Osteoporosis
MANAGEMENT: Prevention of Osteoporosis
The Woman's Health Initiative found that 5 years of HRT (Prempro®) reduced the risk of vertebral and hip fractures by 34%. - However, the FDA recommends that when their use is considered solely for prevention of osteoporosis, approved non-estrogen treatments should first be carefully considered. Calcitonin Miacalin® is a synthetic nasal spray (200 IU om) Calcitonin is effective in women who are at least 5 years postmenopausal, who are already suffering from osteoporosis, and who are not candidates for estrogen therapy. Bisphosphonates Alendronate (Fosamax ®) and Risedronate (Actonel ®) reduce the activity of the cells that cause bone loss thereby increasing the amount of bone present. Clinically proven to increase bone mass and reduce fractures at spine, hip, wrist SERM Selective Estrogen Receptor Modulators -- Evista® Evista is a non-hormonal medication for the postmenopausal women who is not having hot flashes but is at risk for osteoporosis. Evista has estrogen like effects on bone and cholesterol but lacks estrogens negative effects on the breast and uterus. Clinically proven to increase lumbar spine bone mass and reduce the risk of vertebral fracture Like estrogen, Evista should not be used if there is a chance you may get pregnant, have problems with blood clots in your veins or liver disease. Evista can make hot flashes worse.
HORMONE REPLACEMENT THERAPY Bones: decrease bone loss, increase bone mass, decrease fracture risk. Estrogen must be taken for a long time to prevent bone loss. Slowing down bone loss doesn’t necessarily prevent you from fracturing a bone. you need to take estrogen for at least seven years for it to have a long-term effect on bone density - any beneficial effect is lost after age 75. Taking hormone therapy (HRT or ERT) for over 10 years increases your risk of breast cancer by 30-40%. ADVANTAGES: Reduces hot flushes/night sweats Improves vagina dryness Improves urinary symptoms Increases good cholesterol Reduces bad cholesterol Good for bones DISADVANTAGES: Increase risk of breast and uterine cancer Increases blood clotting tendencies Increased risk of gall bladder disease
HORMONE REPLACEMENT THERAPY: To Take Or Not To Take? North American Menopause Society The primary indication for systemic hormone replacement therapy is to treat moderate to severe menopause symptoms (eg: vasomotor symptoms). It should be used at the lowest effective dose for the shortest time period consistent with treatment goals and ideally less than 5 years. When symptoms are controlled or cease, continued hormone therapy can still be considered for bone effects, weighing its benefits and risks against those of alternate therapies. Initiation of HRT before 60 years old or within 10 years after menopause for a low risk individual appears to be safe CONCLUSION - Menopause is a NORMAL phase in a women’s life. - Lead a healthy lifestyle and keep a positive attitude - Symptoms are usually transient but if it is bothersome, do not suffer in silence… - Use this opportunity to screen for chronic diseases and cancers