Complications of Menopause Jianhong Zhou

Definition Menopause is defined by 12 months of amenorrhea after the final menstrual period (FMP). The median age of menopause is 51.4 years, with 90% becoming menopausal between the ages of 45 to 55 years of age. Premature menopause is defined as the permanent cessation of menses occurring before 40 years of age.

Various physiologic and hormonal changes occur A decrease in estrogen Increase in FSH Classic symptoms such as Hot flashes Night sweats Mood swings Vaginal dryness

How often and serious ? 10% of women will begin during perimenopause 50% will experience an increase in symptoms during menopause Symptoms may last during the first year or two of menopause Rarely do symptoms extend beyond the first 5 years of menopause

Etiology Menopause is heralded by menstrual irregularity as the number of oocytes capable of responding to FSH and LH decreases Anovulation becomes more frequent LH and FSH levels gradually rise because of decreased negative feedback from diminished E production

Inhibin Estradiol Hypothalamus Pituitary gland Ovary=No gonadal E FSH,LH FSH,LH Norepinephrine Dopamine Prostaglandins Uterus Vagina Breast Bone Cardiovascular system Hot flashes Insomnia Depression Osteoporosis Atherosclerosis Atrophy

Diagnosis History Physical exam Confirmed by testing FSH levels

Diagnosis -History Average age of 51 Complaining of amenorrhea, vasomotor instability, sweats, mood changes, depression, dyspareunia, and dysuria Disappear within 12 months generally Remain for years

Diagnosis-PE Decrease in breast size and change in texture Vaginal, urethral, cervical atrophy Be consistent with decreased E

Diagnosis-FSH If there is any question about the diagnosis, an elevated FSH is diagnostic of menopause During the perimenopausal period, the FSH level may be increased or decreased. FSH is best reserved for patients with a combination of amenorrhea or oligomenorrhea and menopausal symptoms

Pathogenesis Long-term consequences of the estrogen decrease Osteoporosis -bone resorption accelerates Atherosclerosis-increased risk for coronary artery disease

HRT and ERT HRT –hormone replacement therapy-refers to the use of a combination of estrogen and progesterone to treat menopausal related symptoms in women who still have their uterus in situ Menopausal symptoms are due to decreased E levels The E component on HRT supplies the patient with an exogenous source of E and thereby treats the symptoms of menopause

HRT and ERT Unopposed estrogen exposure can result in endometrial hyperplasia or cancer Progestins must be used to decrease the risk of endometrial hyperplasia and cancer in women who still have a uterus in situ Estrogen replacement therapy-ERT can be used for women with menopausal symptoms who have undergone a hysterectomy

HRT and ERT The other major value of HRT is the prevention and treatment of osteoporosis A important preventative measure—since 15% of women over age 50 will be diagnosed with osteoporosis and 50% with osteopenia A woman can lose 20% of her original bone density in the first 5 to 7 years after menopause

HRT and ERT The risks and benefits have been the center of numerous studies over the past few decades Each patient’s symptoms, risk factors, and related risks and benefits should be individually evaluated

Contraindications to HRT Chronic liver impairment Pregnancy Known estrogen-dependent neoplasm History of thromboembolic disease Undiagnosed vaginal bleeding

Additional therapeutic regimens Alternative regimens for postmenopausal women who are unable or unwilling to take HRT, should be targeted toward the individual’s symptoms and treatment goals Vasomotor flushes Vaginal atrophy The prevention and treatment for osteoporosis

How to treat vasomotor flushes Be managed with clonidine Selective serotonin reuptake inhibitors (SSRIs)

How to treat vaginal atrophy Locally use with lubricants and moisturizers Vaginal estrogen with only minimal systemic absorption

Prevention and treatment for osteoporosis Calcium and vitamin D supplementation Calcitonin Raloxifene Weight-bearing exercise Reduction in smoking and in caffeine and alcohol intake

THANK YOU FOR YOUR ATTENTION 参考八年制教材 中华绝经学组围绝经期诊治指南（2009） Postmenopausal Hormone Therapy （An Endocrine Society Scientific Statement 2010) 国际绝经协会关于绝经后激素治疗和中年女性健康预防策略的最新建议（2011）