1. MENOPAUSE DR. AMEL EL-SAYED, FRCSC Assistant Professor & Consultant King Saud University King Khalid University Hospital

2. Definition: Complete cessation of menstruation for a complete year. The average age is 51 years. Perinmenopause: It is a 2 -3 year period of time before the actual onset of menopause, when cycles start to show different forms of irregularity

3. Hormonal Changes in the Perimenopause 1.  Estradiol level 2. Gradual  in FSH level 3. Delayed  in LH level This is due to the  performance of the remaining follicles. Despite these changes occasional ovulation is there, and the risk of unplanned pregnancy still exists.

4. Hormonal Changes of Menopause 1. Persistent  of FSH levels 2. Persistent  of LH levels 3.  Production of ovarian testosterone 4. Circulating estradiol is mainly derived from peripheral conversion of estrone which is derived from androsten dione This estradiol may be sufficient to sustain breast and other estrogen stimulated surfaces e.g. vagina, urethra

5. Clinical Features of Menopause: 1. Cessation of menstruation 2. Vasomotor instability (hot flushes + sweats) 3. Physiological symptoms: Anxiety,  tension depression, irritability 4. Sleep disturbance 5. Headaches, myalgia and changes in libido 6. Atrophic changes: Vagina, urethra, vulva, general skin atrophy and genital prolapse 7. Urinary difficulties: Urgency, abacterial urethritis and cystitis, incontinence 8. Health problems the most important of which are: a. Fractures 2 0 to osteoporosis b. Cardiovascular disease c. DUB, endometrial hyperplasia and endometrial carcinoma

6. Risk factors for the manifestations of Menopausal Symptoms: 1. Race: White race is more prone than the black race. 2. Built: Thin built is more prone than heavy weight. 3. Cigarette Smoking: Smokers are more prone than non smokers. 4. Exercise: Less prominent symptoms with regular exercise.

7. Management of the Menopausal Patient: 1. Diet: A healthy diet with 1000mg of ca supplement is needed. Vit D should be added for women who are not getting enough sun exposure. 2. Exercise: Regular exercise 3 times a week for at least 30 minutes is recommended. 3. Stop Smoking: If current smoker. 4. HRT: Combined estrogen + progestin for patients who still have their uterus. Estrogen alone for patients who had a hysterectomy

8. Given in a cyclic or continuous fashion 0.625 mg of estrogen day 1 – 21 5-10 mg of progestin x 13 days O.R 0.625 mg of estrogen daily + 2.5 mg of progestin daily Estrogen patches can be used but the oral route was proven to be superior 5. Monitor: BP, lipid profile and blood sugar 6. Any abnormal PV bleeding should be reported and investigated

9. 7. Calcitonin for patients with underlying parathyroid pathology 8. Drugs for Rx of oesteoprosis 9. Bone density 10. Regular breast exams If HRT is contraindicated other option for symptom control can be used eg clonidine

10.  Arguments about HRT  Breast cancer risk !  Early Menopause  Around the age of 40 years  More severe symptoms  Requires higher doses of HRT  Iatrogenic menopause  Surgery  Radiation  Radiation