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FIRST MOSCOW STATE MEDICAL UNIVERSITY

I.M. SECHENOV

Department of Polyclinic

Perimenstrual

Name: Liyana Nadia Zulkifli

Group: 84

Year: 6th

Course (2013-2014)

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Definition

Menopause

the cessation of menses for a year or more. It is caused by ovarian failure. It marks the end of a womens reproductive life It occurs normally between the ages of 4555 years and at a mean age of 51 years. It is a physiological process

Peri-menopause

is a period immediately before and after the menopause. Transitional change from normal ovulatory cycles to complete cessation of menses Marked by menstrual irregularity May begin years prior to menopause Onset of menopausal symptoms Leads to anovulation, menorrhagia Peri-menopause is a period immediately before and after the menopause.

Delayed menopause Due to good health and better nutrition. Also seen in women with uterine fibroids . Also in women with high risk of endometrial cancer

Menopausal age is directly associated with smoking and genetic disposition.

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Other Causes to Consider :

Thyroid disorders Pheochromocytoma Leukemia Cancer Infection Smoking induces premature menopause.

Pathphysiology

During climacteric, ovarian activity declines.Initially, ovulation fails, no corpus luteum forms and no

progesterone is secreted by the ovary.

Later, graffian follicle fails to develop, estrogenic activity decreases and endometrial atrophy leadingto amenorrhea.

Increased secretionof FSHand LH by anterior pituitary.

Secretion of estrogens decreased (ovary)

FSH increased (40-45 years old)

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FSH,LH increased(45-50 years old)

FSH increased 14 times

LH increased 3 times(menopause)

FSH, LH gradually decline (3 years after menopause)

Peri-menopausal Period Syndrome

peri-menopause accompanied by the symptoms of climacteric, including hot flashes, excessive

perspiration, night sweets, depression, agitation, vaginal dryness, insomnia.

The basic causes of the climacteric syndrome are a progressive decline in ovarian production on

estrogens and other sex hormones

Symptoms and signs

1. Early Symptoms and signs

1) menstraution disorder

Oligomenorrhea--- intervals greater than 35 days. Polymenorrhea---- intervals less than 21 days hypermenorrhea amenorrhea menopause

2) vasomotor symptoms( hot flashes, sweats)

oestrogen depletion result in instability in the vessels of the skin. The hot flashes begins on the chest and spreads quickly over the neck, face and upper limbs

which lasts only seconds but may recur many times one day. Sweat often follows hot

flashes.

Hot Flushes

These are waves of vasodilatation affecting the face and neck and last for 2-5 mins each.

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Other factors: lack of exercise,malabsorption of calcium

7) cardiovascular lipid changes

atherosclerosis HDL decrease,LDL increase, total cholesterol increase. perimenopaual women have a lower incidence of coronary heart disease than men of same

age.

This observation led to the supposition that estrogen might be a key factor. But recent data suggest that Estrogen has no such protection against heart disease

COMPLICATION or LATE SEQUELAE

Menopause is a normal developmental process, but the decline in E can have clinical sequelae

Vasomotor symptoms.

HTN

Osteoporosis.

Arthritis Osteoporosis of vertebral bones, upper end of hip joint,wrist frature

Cardiovascular disease.

ischaemic heart disease, MI, HTN Stroke Cardiac irregularities Tachycardia

Urogenital atrophy.

Prolape genital tract Stress incontinence of urine & feces Ano-colonic cancer

Cognitive decline and Alzheimer's disease.

Cataract, glaucoma, macular degeneration

Skin changes and Tooth decay

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Diagnosis

1) History

menstrual abnormality

2) Symptoms: vasomotor symptoms, vaginal dryness, urinary frequency, insomnia, irritability,

anxiety, skin change, breast changes, urinary tract problem, pelvic floor change( cystocele.

Rectocele. Prolapse), skeletal change(backache, ) and so on.

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3)Physical examination:

The clinical findings vary greatly depending on the time elapsed since menopause and theseverity of the estrogen deficiency

Skin: thin ,dry Breast loss turgor The labia are small The uterus becomes much smaller The muscles of the pelvic floor are looser in tone and are thin Prolapse may be present

4) Laboratory diagnosis

Cytologic smear from the vaginal wall E2, FSH, LH determination Radiography, X-ray densitometry

Treatment

1)education, understanding, reassurance

2) hormone replacement therapy(HRT)

Estrogen therapy-The use of estrogens can relieve the menopausal symptoms.

-The hot flashes , sweats and other complaints disappear or improve within a few days of starting

estrogens therapy

Estrogen Benefits

Oral estrogen lowers: LDL Lipoprotein(a) Glucose Insulin Homocysteine levels Oxidation of LDL Increases HDL One HT study of women taking 0.625 or 1.25 mg of conjugated equine estrogens with 5 mg

medroxyprogesterone daily showed that total and low density lipoprotein cholesterol were

reduced to nearly the same extent as that of women treated with 10 mg simvastatin daily.

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HDL was increased to a greater extent than did simvastatin in this study.Harman The administration of estrogen without progestogen increases the risk of endometrial

cancer and breast cancer.

So, correct cyclical therapy, with 10 days progestogen per month , can reduces the incidenceof cancer.

What Now?

For women with moderate to severe vasomotor symptoms, depending on individual risk, and

patients willingness to accept risk, use the lowest dose of estrogen (with progesterone, if uterus

intact) effective for the shortest amount of time possible.

Estrogen Preparations

Premarinconjugated equine estrogenso Comprised mostly of estrone sulphateo 10 estrogens totalo Doses: 1.25 mg, 0.625 mg, 0.45 mg, 0.3 mgo Cenestinconjugated estrogens derived from plant sourceo Similar to premarino Contains 9 estrogens Enjuviaalso conjugated estrogens derived from plant source Estratab, Menestesterified estrogens derived from plant sourceo Result in serum estradiol and estrone levels similar to premarin Ogennaturally derived, purified estrone sulfate Estracemicronized preparation of estradiol Estratestesterified estrogens and methyltestosterone Transdermal Estrogen Topical Estradiol Preparations

Progesterone Preparations

Prometriumnatural micronized progesterone Medroxyprogesterone Drosperinone Megestrol acetate Testosterone derivatives (have some weak andronergic actions)o Norethindroneo Norgestrelo levonorgestrel

Progestin Therapy alone may also relieve hot flushes

Estrogen Risks:

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Estrogen also increases:

Triglycerides

Coagulation factors

C-reactive protein (inflammatory risk factor for CHD)

Contraindication

thrombo-embolism hypertension diabetes chronic liver disease myomo, endometriosis, breast disease gallbladder disease

References