1. Menopause and Midlife Health Changes
Presented by: dr. menna shawkat
Prepared by: Dr. Mohamed fahmy tolba
Lecturer of Geriatrics and Gerontology
Ain Shams University

2. To know and understand... Learning objectives
The significance of menopausal transition
Menopause symptoms and their clinical features
Role of gynecologist in assessment and appropriate referral of perimenopausal females.

3. Menopause transition
The transition from active reproduction to the cessation of significant estrogen secretion because of the depletion of functional ovarian follicles; which starts with the onset of menstrual irregularity or skipped menses and ends 12 months following the final menstrual period (FMP).

4. Significance???
An increasing number of women seeks treatment for symptoms associated with menopause and for chronic conditions that have their origin in midlife.
Thus, it is important to understand the events of the menopause transition and that these events are likely to affect health and the contribution of the gynecologist to health maintenance.

5. Why in geriatrics education?
Exposure to declining levels of ovarian hormones appears to modify risk factors associated with development of debilitating diseases and health concerns of the geriatric patient.
Furthermore, the menopause transition may represent an optimal time for clinical intervention.

6. Who do we target??
These clinical interventions can address two potential groups:
Women who already have some evidence of disability and for whom active interventions are critical
The majority of women who are not disabled and are open to information about preventive care, risk factor screening, and may be seeking care for menopausal symptoms.

7. Pathophysiology
When a woman’s ovarian reserve is depleted, ovarian-based hormones, including estrogens and progesterone, are no longer predictably produced.
A progressively greater rise in gonadotropin, such as follicle stimulating hormone (FSH), is observed.
It is likely that changes in lipid, bone, or immunological functioning, among others, are related to those marked changes in estradiol and FSH concentrations during the menopause transition.

8. Disaggregating Menopause Symptoms and Chronological Aging
The onset or exacerbation of a constellation of symptoms, including vasomotor problems, vaginal dryness and other sexual symptoms, urine leakage, changes in skin, fatigue, and problems with sleeping, negative mood, and decline in cognitive acuity, is frequently attributed to the menopause.
Further, many women choose to begin hormone replacement therapy in an effort to combat these menopausal symptoms and to replace the endogenous hormones.

9. Menopause Symptoms and Clinical Features

10. 1. Vasomotor Symptoms
Vasomotor symptoms, including hot flashes, cold sweats, or night sweats, occur in more than 70% of women during midlife, with more than 50% of women reporting their presence for more than five years.
More vasomotor symptoms are found in those with increasing body mass index (BMI), current smoking status, baseline depression, and premenstrual symptoms.

11. 2. Sleep Disturbances
Sleep problems are identified by 16% to 42% of premenopausal women, 39% to 47% of perimenopausal women, and 35% to 60% of postmenopausal women.
Gender differences in sleep disturbances that emerge at midlife suggest that the increase in sleep difficulties may not be simply an aging effect.

12. Factors that trigger sleep disturbances during the menopause transition include the onset and exacerbation of vasomotor symptoms, rate of changing hormone levels (especially FSH), and increases in symptoms of stress associated with acute and chronic ongoing life events.
There is considerable overlap between sleep disturbances and vasomotor symptoms.
The greater increase in sleep problems among women who used HT may be because of the preexisting characteristics of the women or to particular HT formulations or doses.

13. Worsening sleep during the menopausal transition is important because this sleep disturbance is associated with decreases in quality of life, poorer work performance, increased incidence of mood and anxiety disorders.
Further, sleep disruptions are associated with negative health outcomes, including immunosuppression, cardiovascular disease (CVD), and stroke.

14. 3. Sexuality Dysfunction
Atrophic changes in the vagina, including a decrease in lubrication and thinning of the endothelium, which are associated with dyspareunia have described.
Because the menopausal transition is a time of significant change in sex steroids and in sexual function, it has been speculated that the menopause leads to a diminution in sexual functioning, apart from the simultaneous potential effects of normal aging.

15. Favorable outcomes in sexual functioning are more strongly associated with having a husband and emotional satisfaction with the relationship than the most prominent hormone values.
Other highly important factors included increasing age of the woman, poor health status, smoking behavior, and body size.

16. 4. Depressed Mood
A number of factors, including hormones, reproductive factors, genetics, biology, and societal or cultural norms may increase the propensity for depressed mood in women.
The menopause transition may represent a period of heightened risk for the development of clinically significant depressive symptoms based on the declining estradiol concentrations.

17. While natural menopause may or may not be associated with depressed mood, other attributes associated with menopause (vasomotor symptoms, insomnia, and other sleep disorders) have a greater impact on depressed mood.
Additionally, other factors including BMI, smoking behavior, stress, and relationship problems are important factors in depressed mood.

18. 5. Cognition and Memory
Memory complaints are common in the menopausal transition. It is also associated with depressed mood.
Whether HT can enhance cognitive performance is controversial. The benefits of HT on cognition have been identified in some but not all studies.
Further, the Women’s Health Initiative Memory Study (WHIMS), a substudy of the Women’s Health Initiative (WHI) trial, found a slight decline, not improvement, in cognitive function among late postmenopausal women assigned to HT compared to placebo.

19. 6. Cardiovascular Disease Risk
It has been hypothesized that loss of estradiol with the menopause transition is associated with a greater risk for CVD in women following menopause.
However, studies of menopause and CVD risk have yielded inconsistent results.
The findings from the WHI trial, in which the use of hormone preparations was associated with greater risk of heart disease events, further calls into question whether estrogen status is too simplistic a physiological explanation for the variation in heart disease risk in women compared to men.

20. 6. Cardiovascular Disease Risk
Atherosclerosis in abdominal aorta is more likely to occur among women with bilateral oophorectomy or early natural menopause.
Menopause transition may contribute to four axes associated with CVD (lipids, blood pressure, carbohydrate metabolism, and hemostatic/inflammatory factors).
Because both menopause and lipids are highly correlated with age, it remains uncertain whether lipid changes at the time of menopause are independent of age effects.

21. Increases in LDL-C and triglycerides and declines in HDL-C were greater during perimenopause; that is, changes were more pronounced between the premenopausal and first year of postmenopausal evaluations than between the first and fifth years of postmenopausal evaluations.
These findings define a potential time frame for both early prevention and intervention activities that could affect the health of the aging woman.

22. 7. Diabetes Risk
There is limited evidence that diabetes is a direct consequence of the changes during menopause transition (although there may be an indirect association).
There are two factors that may contribute to diabetes incidence during the menopause transition:
(1) Obesity (particularly central obesity)
(2) Altered androgen : estrogen ratio

23. 8. Obesity and Body Composition
Among pre- or perimenopausal women, there is an annual increase in weight, BMI, fat mass, and waist circumference.
In contrast, there is decrease in lean mass and skeletal muscle mass.

24. 9. Bone Loss
It is common wisdom that the immediate postmenopause is a time of accelerated bone loss.
Bone mineral density (BMD) levels are lower in pre- and early perimenopausal women with greater FSH levels.
Bone loss accelerates in the late perimenopausal period, and continues into the early postmenopausal period. The rate of loss appears to decelerate approximately 10 years after the FMP.

25. Bone mineral density testing should be performed:
In women aged 65 and older
In postmenopausal women above age 50–69, based on risk factor profile
In postmenopausal women aged 50 and older who have had an adult age fracture, to diagnose and determine degree of osteoporosis
BMD is measured by dual-energy X-ray absorptiometry (DXA).

26. 10. Physical Function
About 12-25% of newly menopausal women already have substantial functional limitations with long-term physical disability in the fifth through the seventh decades.
Menopause transition could represent the time of initiation and exacerbation of functional limitations because of the increasing prevalence of diabetes, less favorable lipid profile, decline in sensory function including hearing and vision, and obesity.
Women are more likely to have functional limitations than men, have a greater rate of decline in physical function than men, and are less likely to recover from disability than men.

27. 11. Osteoarthritis
Between the ages of 40 and 55 years, the incidence of osteoarthritis of the knee (OAK) increases 2% to 3% per year.
During the menopause transition, collagen loses its flexibility.
Since viable interventions for OAK are restricted to joint replacement, the menopause may be a time in which there should be substantial focus on preventive strategies.

28. 12. Skin and Collagen
Skin changes include increasing wrinkling, sagging, thinness, changes in collagen, elastin, and water content, atrophy, prolonged wound healing and impaired granulation tissue formation.
Sebum production decreases, leading to an increased frequency of dry skin.
As skin is more fragile skin, careful suturing is required to prevent skin tears.

29. Hormone replacement (topical estradiol cream) has been used to treat conditions of the aging skin.
Transdermal estrogen delivery systems have been used to avoid the first-pass hepatic metabolism of oral estrogen. While effective, these methods may have adverse effects including allergic/inflammatory reactions.

30. What to do? Just examples!
Have a good knowledge about menopause-associated health conditions.
Symptom inquiry: vasomotor, sexual, sleep, memory, mood, physical function.
Examine: obesity, hypertension, skin.
Screen: diabetes, osteoporosis (DXA).
Advice: exercise, nutrition.
Appropraite referral: for preventive and/or therapeutic intervention.

31. Summary
Menopause transition is likely to affect women health and wellbeing.
Vasomotor symptoms are a hallmark of perimenopausal transition. Additionally, there are many other symptoms/health conditions, both gynecological and non-gynecological.
The coming generations will have higher expectations about quality of life, including those that ensue from the menopausal transition.

32. Summary
Midlife is an optimal time to consider a reorientation to disease prevention and health promotion by the health care team.
The gynecologist has a very important role in assessment and appropriate referral of perimenopausal females with menopause associated symptoms and health conditions.

33. Thank You