Menopause By Dr. Khattab Omar Prof. & Head of Obstetrics and Gynaecology Department Faculty of Medicine, Al-Azhar University, Damietta

Menopause is permanent cessation of menstruation due to failure of ovarian function. “ Permanent ” means cessation of menstruation for at least 12 months. Menopause is a manifestation of climacteric. 'Climacteric' is a wider term of events leading up to and following the menopause, the pre- peri- and post-menopause. Definition

Life expectancy of women is increasing and about 1/3 of women ’ s life is spent oestrogen deficient. The mean age of menopause is about 50 (48-53). 95% of women will be menopausal by the age of 55. About 25% of women experience menopause before the age of 45. In most cases menstruation gradually decreases in amount & frequency. In about 10% menstruation stops suddenly. Physiology of the menopause

Types 1- Natural. 2- Premature: Before the age of Delayed: After the age of Artificial: surgical or radiation.

Phases 1- Partial ovarian failure: Ovulatory & corpus luteum failure starts y before the menopause. 2- Compensated ovarian failure: Hypothalamic – pituitary hyperactivity starts 5-10 y before the menopause. 3- Follicular failure starts at the menopause.

Diagnosis Diagnosis is almost confirmed if FSH 30U/ L level is demonstrated in 2 occasions 2 w apart to avoid the mid-cycle surge. Cessation of menstruation for 1 y >50; Cessation of menstruation for 2 y <50. Cessation of menstruation for 1 y <50 if associated with high levels of FSH. In general, hormonal assay is not necessary as levels fluctuate in the peri- menopausal period & they may not cor- relate well with the clinical picture. Diagnosis is best made clinically. Hormonal assay is of value in cases of premature menopause & in hysterectomi- zed women.

Events 1- The response of Gn to GnRH increases! 2- There is increase in the amplitude, but not the frequency of Gn pulses. The amount is similar to that of the mid-cycle surge. Rise in FSH levels precedes the rise in LH levels. While LH raises by 3-x, FSH raises by 13-x. After 5-10 y, levels of both Gn begin to decline. 3- Ovarian function commonly fades, recovers & fades again several times. Perimenopause and the early menopause are characterized by hyper-estrogenism & decreased progesterone production. This may be manifested by menorrhagia, fibroid … Androstenedione decreases markedly. Testosterone appears to be the major product of the postmenopausal ovary.

Health problems: Symptoms may occur some years before menop. The incidence of ischemic heart disease, osteoporosis, loss of collagen & psychological dis orders increases dramatically after menopause. Experience of menopause differs between women; it is affected by the following factors: Cultural factors: Attitude to menopause, ageing & to loss of fertility. Social factors: Career peak, growing children, ageing parents. Emotional and physical well-being: Lifestyle, existing medical conditions. Hormonal factors: Diet, degree of oestrogen deficiency.

Health problems could be classified as: Short-term effects as vasomotor instability, urogenital atrophy & psychological sympt. and Long-term effects as arterial diseases, osteoporosis & recognition problems.

Genitourinary atrophy begins few years after menopause. Labia majora are flattened, & hence, labia minora become more evident. The vagina loses its supports & becomes tent- shaped, smooth (due to loss of rugae) & thin. The pH becomes neutral or even alkaline. These changes predispose to senile & recurrent vaginitis The portio vaginalis may flash with the vault. Utero-cervical infantile proportion may return. Senile endometritis may occur. Weakness of cervical ligaments predisposes to prolapse. Vulvovaginal changes cause superficial dyspareun Atrophy of bladder & urethral mucosa → frequen, urgency, stress incontinence & recurrent UTI.

Psychological complaints (as headache fatigue, forgetfulness, lack of concent, poor memory, insomnia, irritability & depression) affect 25-50% of women. Peri-menopausal depression is at its worst in the 2-3 y before the periods stop. It is related to premenstrual depression as it becomes worse with age and with falling estrogen levels.

Vasomotor symptoms: -The aura & subjective sensation of hotness precedes a mean increase in skin temp by 2-3C. -Hot flushes occur in 80% of women, & may last for 5 years in 25% of women. Symptoms are severe enough in 25% of patients to warrant ttt. -The menopausal woman experiences a sensation of heat in the upper 1/2 of her body (may spread all over the body) associated with vasodilatation, excessive sweating, palpitation & tachycardia for few minutes. There may be insomnia & headache -Hot flushes come in attacks that may be very frequent (2-4/h) or infrequent (1-2/day). -They are attributed to autonomic instability.

Arterial disease is the main cause of death. HRT reduces the risk by 40-50%. Liability to osteoporosis. The female : male ratio of hip fractures after the age of 51 is 3:1. Mild hirsutism.

Differential diagnosis Pregnancy. Now, pregnancy forms a little conflict be- cause of the early diagnosis by immunoassay methods. PCOS. Prolactinoma, particularly in young women. Thyrotoxicosis.

Treatment For max benefits, preventative health measures should begin some 15 y before menopause. Oestrogen does not improve depression in postmenopausal women. For menopausal symptoms ERT is the treatment of choice.

Treatment Alternatives include progestins & clonidine. Medroxy progesterone acetate (MPA) given as 10-20mg/day orally or mg/3 months has been shown to be >70% effective in relieving hot flushes. Clonidine mg twice daily orally (Catapres) or 0.1 mg trans-dermally (Catapres-TTS-1) is 30% effective.

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