1. M E N O P A U S E King Khalid University Hospital Department of Obstetrics & Gynecology Course 482

2. Menopause: Menopause: Is the permanent cessation of menstruation resulting from loss of ovarian follicular activity. Natural menopause is recognized to have occurred after 12 consecutive months of amenorrhoea.

3. Perimenopause: Perimenopause: Includes the period beginning with the first clinical, biological and endocrinological features of the approaching menopause (e.g. vasomotor symptoms, menstrual irregularity) and ending 12 months after the last menstrual period.

4. Climacteric is the phase in the ageing of women marking the transition from the reproductive to the non- reproductive state. Climacteric is the phase in the ageing of women marking the transition from the reproductive to the non- reproductive state. Post menopause dates from the final menstrual period and it’s determined after a period of 12 months of spontaneous menstruation. Post menopause dates from the final menstrual period and it’s determined after a period of 12 months of spontaneous menstruation.

5. Premature menopause is defined as menopause that occurs before the arbitrary cut off age of 40 years. Premature menopause is defined as menopause that occurs before the arbitrary cut off age of 40 years. Induced menopause is the cessation of menstruation which follows either surgical removal of both ovaries or iatrogenic ablation of ovarian function (e.g. chemotherapy or radiotherapy). Induced menopause is the cessation of menstruation which follows either surgical removal of both ovaries or iatrogenic ablation of ovarian function (e.g. chemotherapy or radiotherapy).

6. The menopause is caused by ovarian failure. The menopause is caused by ovarian failure. There is a gradual reduction in germ cells until the oocyte store becomes exhausted There is a gradual reduction in germ cells until the oocyte store becomes exhausted On average at the age of 51 years. On average at the age of 51 years. It occurs earlier in smokers than in non-smokers. It occurs earlier in smokers than in non-smokers. It also occurs early in women with Down’s Syndrome. It also occurs early in women with Down’s Syndrome.

7. Effects of the Menopause 1. Vasomotor Symptoms : Hot flushes and night sweats are episodes of inappropriate heat loss. Hot flushes and night sweats are episodes of inappropriate heat loss. They can occur at anytime and at night disturb sleep. They can occur at anytime and at night disturb sleep. Chronically disturbed sleep can in turn lead to insomnia, irritability and difficulties with short term memory and concentration. Chronically disturbed sleep can in turn lead to insomnia, irritability and difficulties with short term memory and concentration.

8. Effects of the Menopause 2.Mood disorders: The mood disorders that have been associated with the menopause include: depression, anxiety, irritability, mood swings, lethargy and lack of energy.

9. Con’t. Effects of the Menopause 3.Urogenital Atrophy: Premenopausally, the vaginal mucosa is colonized by lactobacilli which provides protection against gram- negative bacteria. Premenopausally, the vaginal mucosa is colonized by lactobacilli which provides protection against gram- negative bacteria. The vaginal mucosa often becomes quite thin. The vaginal mucosa often becomes quite thin. After the menopause the vagina is colonized by fecal flora. After the menopause the vagina is colonized by fecal flora.

10. Con’t. Effects of the Menopause 3.Urogenital Atrophy: Urogenital complaints such as Urogenital complaints such as Vaginal discomfort, Vaginal discomfort, Dysuria, Dysuria, Dyspareunia, Dyspareunia, Recurrent lower urinary tract infections and Recurrent lower urinary tract infections and Urinary incontinence are more common in women after the menopause and Urinary incontinence are more common in women after the menopause and More than 50% of post menopausal women suffer from at least one of these symptoms. More than 50% of post menopausal women suffer from at least one of these symptoms.

11. Con’t. Effects of the Menopause 4.Sexual dysfunction: Interest in sexual activities declines in both men and women with increasing age and this change appears to be more pronounced in women.

12. Con’t. Effects of the Menopause 5.Osteoporosis: This is a disease characterized by low bone mass and micro architectural deterioration of bone tissue This is a disease characterized by low bone mass and micro architectural deterioration of bone tissue Leading to enhanced bone fragility and a consequent increase in fracture risk. Leading to enhanced bone fragility and a consequent increase in fracture risk. One in three post-menopausal women has osteoporosis. One in three post-menopausal women has osteoporosis.

13. Con’t. Effects of the Menopause Osteoporosis: Osteoporosis: Following the menopause there is an accelerated period of bone loss, which lasts for 6-10 years. Following the menopause there is an accelerated period of bone loss, which lasts for 6-10 years. Osteoporosis affects both sexes, but in general men have fewer fractures than women. Osteoporosis affects both sexes, but in general men have fewer fractures than women. The main clinical manifestation of osteoporosis are fractures of the wrist, hip and vertebrae. The main clinical manifestation of osteoporosis are fractures of the wrist, hip and vertebrae. In clinical practice, the most important risk factors are early ovarian deficiency and corticosteroid use. In clinical practice, the most important risk factors are early ovarian deficiency and corticosteroid use.

14. Con’t. Effects of the Menopause 6.Cardiovascular disease : The primary end points of cardiovascular disease are myocardial infarction and stroke. The primary end points of cardiovascular disease are myocardial infarction and stroke. After the sixth decade, it is the most common cause of death in women. After the sixth decade, it is the most common cause of death in women. The incidence of coronary heart disease (CHD) increases after the menopause. The incidence of coronary heart disease (CHD) increases after the menopause.

15. Treatment Options The three main options available are The three main options available are Oestrogen based hormone replacement therapy or HRT, Oestrogen based hormone replacement therapy or HRT, Biphosphonates or Biphosphonates or Selective oestrogen receptor modulators. Selective oestrogen receptor modulators. In the HRT, oestrogen is combined with a progestogen to reduce the risk of endometrial neoplasia in women whose uterus is intact. HRT can be delivered by a variety of routes: Oral, transdermal, subcutaneous, vaginal and intranasal. In the HRT, oestrogen is combined with a progestogen to reduce the risk of endometrial neoplasia in women whose uterus is intact. HRT can be delivered by a variety of routes: Oral, transdermal, subcutaneous, vaginal and intranasal.

16. Treatment Options The benefits of HRT include The benefits of HRT include Relief of vasomotor symptoms, Relief of vasomotor symptoms, Prevention of osteoporosis, Prevention of osteoporosis, Reducing the risks of cardiovascular disease and coronary heart disease. Reducing the risks of cardiovascular disease and coronary heart disease.

17. Cont…Treatment Options The risks of HRT include: The risks of HRT include: An increased risk of breast cancer especially in those who take oestrogen progestin preparations compared to those who take oestrogen alone, An increased risk of breast cancer especially in those who take oestrogen progestin preparations compared to those who take oestrogen alone, Increased risk of endometrial cancer in those who still have a uterus and do not take progestin and Increased risk of endometrial cancer in those who still have a uterus and do not take progestin and An increased risk of venous thrombo embolic disease. An increased risk of venous thrombo embolic disease.

18. Post Menopausal Bleeding Can be caused by simple or pathological conditions including cervical polyps, cystic hyperplasia, endometrial hyperplasia, cervical dysplasia, cervical endometrial and ovarian carcinomas or even tubal carcinoma. Can be caused by simple or pathological conditions including cervical polyps, cystic hyperplasia, endometrial hyperplasia, cervical dysplasia, cervical endometrial and ovarian carcinomas or even tubal carcinoma. The older the patient and the more frequent the episodes of bleeding, the more likely there is to be an underlying endometrial malignancy. The older the patient and the more frequent the episodes of bleeding, the more likely there is to be an underlying endometrial malignancy.

19. Post Menopausal Bleeding Clinical Examination: a.Enlarged lymph nodes in the groin or supra clavicular fossa. b.Metastatic focus in the vagina c.Enlarged Uterus d.Breasts – for possible secondaries from uterus or ovaries

20. Investigations 1.Transvaginal ultrasound – endometrial malignancy is unlikely if the endometrial thickness is less than 5 mm 2.Cervical smear 3.Colposcopy and cervical biopsy 4.Pipelle sampling for endometrial biospy 5.Hysteroscopy 6.MRI

21. Treatment 1.Atrophic vaginitis, cervicitis, endometritis may need local oestrogen preparations 2.Malignant cervical, uterine or ovarian pathology will require specific treatment.