Menapause

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Menapause
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Introductin

• The time when menses cease, is a time of
  transition
• for a woman, marking the end of her
  reproductive
• abilities.
• Climacteric, or change of life (often used
  synonymously with menopause), refers to the phase
  of womans reproductive life in which gradual
  cessation in ovarian function results in
  decreased sex steroid producton and its sequelae.

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• Today the median age at menopause is 51.3
• years, and the average life span of a woman
  in the United
• States is over 80 years.
• Thus the average woman will live one third of her
  life after menopause.
• A womans psychologic adaptation to menopause
  and the climacteric is multifactorial.
• She is influenced by her own expectations and
  knowledge, physical well-being, family views,
  marital stability,
• and sociocultural expectations.

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Definition of Menopause

• The World Health Organization has defined the
  natural menopause as
• The permanent cessation of menstruation
  resulting from loss of ovarian follicular
  activity.
• Natural menopause is recognized to have occurred
  after 12 consecutive months of amenorrhea.

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Definitions from WHO

• Early menopause is menopause that occurs at age
  less than 40 year of womens age.
• Induced menopause is the cessation of menstrual
  period as a result of surgical removal of ovaries
  or ablation of ovarian functions by chemotherapy
  or radiation

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• Perimenopause is the term applied to the period
  preceding menopause, usually about 2 to 8 years,
  when ovarian function wanes and hormonal
  deficiencies begin to produce
• symptoms.

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Risk factors of Early Menopause

• Early age at menarche
• Menstrual irregularity
• Nulliparity
• Never use of oral contraceptive
• Short period of breastfeeding
• Use of assisted reproductive techniques.
• Cigarette smoking
• Marital status
• Low socioeconomic status
• Family history
• Genetic factors

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Women Menopausal Transition

• Women vary in their experiences of menopausal
  transition, reporting of menopausal symptoms, and
  how they deal with menopausal changes.
• This also varies from society to another, and
  from culture to another.
• Some women view menopause as a natural event,
  others adopting the medical view of menopause.
  Whereas others display negative attitudes
  toward menopause, thereby increasing the burden
  on them during menopausal transition

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• The physical characteristics of menopause are
  linked
• to the shift from a cyclic to a noncyclic
  hormonal pattern.
• The age at onset may be influenced by
  nutritional, cultural, or genetic factors.
• The onset of menopause occurs when estrogen
• levels become so low that menstruation
  stops.
• Generally, ovulation ceases 1 to 2 years before
• menopause, but individual variations exist.

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• Atrophy of the ovaries occurs gradually.
  Follicle-stimulating hormone levels rise, and
  less estrogen is produced.
• Menopausal symptoms are
• atrophic changes in the vagina, vulva, and
  uretha.
• vasomotor disturbance commonly known as hot
  flashes, a feeling of heat arising from the chest
  and spreading to the neck and face.
• sweating and sleep disturbances.
• dizzy spells, palpitations, and weakness, and
  irritability.

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• The uterine endometrium cervical and myometrium ,
  atrophy,
• The uterine cavity constricts.
• Vaginal mucosa becomes smooth and thin, and the
  rugae disappear, leading to loss of elasticity
• painful intercourse

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• Dryness of the mucous membrane can lead to
• burning and itching.
• The vaginal pH level increases as the
• number of Döderleins bacilli decreases.
• decrease in libido at this time.
• Vulvar atrophy occurs late, and the pubic hair
  thins,
• Pelvic fascia and muscles atrophy, resulting in
  decreased pelvic support.

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physical changes

• Osteoporosis, a decrease in the bony skeletal
  mass.
• risk of coronary heart disease.
• Loss of protein from the skin and supportive
  tissues causes wrinkling.
• Weight gain , which may be due to excessive
  caloric intake or to lower caloric need with
• the same level of intake.

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Tests Diagnosis

• Follicle-stimulating hormone (FSH) test
• Luteinizing hormone (LH) test
• Serum estradiol test.
• U\S reveals small ovaries without evidence of
  growing follicles
• Karyotype

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Management

• Fertility cannot be restored if the diagnosis is
  made after complete follicular depletion, so
  early diagnosis can be made by genetic
  investigation
• Estrogen therapy
• Calcium vitamin supplements

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Management of Menopausal Symptoms

• Hormonal replacement therapy (HRT) is known as
  the most popular treatment choice to alleviate
  menopausal discomfort for many years.
• But the intention to use HRT became questionable
  after releasing findings of Womens Health
  Initiative (WHI) study, which concluded that
  risks of HRT overweigh its benefits, and
  recommended not to use the HRT for prevention of
  chronic diseases, and to limit its use for short
  periods.
• (Writing group for womens health
  initiative investigators. 2002)

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Cont..

• 2. Complementary and Alternatives Therapies
• Alternatives therapies like herbs (black
  cohosh), dietary soy, acupuncture, life style
  modifications such as diet and exercise
• 3. Non- Hormonal Medications
• Several non-hormonal medications are used
  to relive menopausal symptoms such as
  neuroendocrine agents ( like methyldopa),
  a-adrenergic receptors agonists (such as
  clonidine)

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• Contraception remains a concern during
  perimenopause.
• Combined oral contraceptives are becoming
  increasingly
• popular among healthy nonsmokers because many
  women also benefit from the non contraceptive
  effects including
• regulation of menses,
• relief of symptoms of estrogen deficiency,
• a decreased risk of endometrial and ovarian
• cancers.

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Hormone Replacement Therapy

• Hormone replacement therapy (HRT), usually
  involving estrogen
• with or without a progestin, had for
  years been the
• treatment of choice for relieving menopausal
  symptoms,
• especially hot flashes, night sweats, and
  urogenital symptoms.
• effective in preventing the development of
  osteoporosis.
• Nevertheless the risks of HRT outweigh the
  benefits, especially for long-term use, because
  of the slightly increased risk of breast cancer,
  thromboembolic disease, and stroke

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The beneficial effect of long-term estrogen

• Reducing the incidence of Alzheimer disease (AD)
• the most effective short-term (1 to 2 years)
  therapy for women who experience severe
  menopausal symptoms.

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• Women taking estrogen should be advised
• to stop immediately if they develop headaches,
  visual changes, signs of thrombophlebitis, or
  chest pain.

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risks

• When estrogen is given alone, it can produce
  endometrial
• hyperplasia and increase the risk of
  endometrial cancer.
• Current research focuses on using lower doses of
  estrogen (less than 0.625 mg/day) consideration
• has also been given to using lower doses or
  less frequent administration of progestins to
  minimize progestin exposure

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Complementary and Alternative Therapies

• diet and nutrition, specifically a high-fiber,
  low-fat diet with supplements of vitamins D and
  E. Phytoestrogens (plant substances with estrogen
  properties)
• herbal remedies such as dong quai and black
  cohosh, which have been used in traditional
  Chinese medicine

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• Weight-bearing exercises such as walking,
  jogging,
• tennis,and low-impact aerobics help increase bone
  mass and
• decrease the risk of osteoporosis.
• Exercise also improves cholesterol profiles
• Stress management and relaxation techniques such
  as biofeedback, meditation, yoga, visualization,
  and massage
• herbal treatments for symptom relief.

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Bone mineral density (BMD) testing

• is useful in identifying individuals who are at
  risk for osteoporosis.
• ACOG recommends BMD testing for the following
• All postmenopausal women age 65 or older
• Postmenopausal women with a fracture
• Postmenopausal women under age 65 with one or
• more risk factors

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• Prevention of osteoporosis is a primary goal of
  care.
• Women are advised to maintain an adequate calcium
  intake.
• Women over age 50 should have a daily calcium
  intake of 1200 mg.

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PHYTOESTROGENS

• Phytoestrogens are naturally occurring plant
  sterols that have an estrogen-like effect.
• Herbs that contain phytoestrogen include
  ginseng,
• agnus castus, beth root, black cohosh,
  dong quai, fenugreek, licorice, red sage,
  sarsaparilla, and wild Mexican yam.
• Phytoestrogens are also found in soy products
  such as soy milk and tofu.

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gensing
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agnus castus
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beth root
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black cohosh
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fenugreek
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Midwife Management

• Most menopausal women deal well with this
  developmental
• phase of life, although some women may need
  counseling
• to adjust successfully.
• Midwiveses and other health professionals can
  help menopausal women achieve high level
  functioning at this time in life.
• Of major importance is the midwifes ability to
  understand and provide support for the womans
  views and feelings.
• Use an empathetic approach in counseling, health
  teaching, and providing physical care.

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• Explore the question of the womans comfort
  during sexual intercourse.
• Then go on to explain that dryness and shrinking
  of the vagina can be addressed by use of a
  water-soluble jelly.
• Use of estrogen, orally or in vaginal creams, may
  also be indicated.
• Increased frequency of intercourse will maintain
  some elasticity in the vagina.

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• The crucial need of women in the perimenopausal
  period of life is for adequate information about
  the changes taking place in their bodies and
  their lives.

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VIOLENCE AGAINST WOMEN
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Domestic violence
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Violence against women

• Any act of gender- based violence that results
  in/ or is likely to result in physical, sexual
  or mental harm or suffering to women.
• Domestic Violence (intimate partner violence),
  may involve
• Physical abuse such as hitting, slapping,
  beating, kicking, threatening her with harmful
  instrument. Suspected with evidence of trauma,
  especially to the head and neck or trunk
  associated with a history of violence, or when an
  explanation of trauma doesnt seem appropriate.

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• Sexual abuse may involve being physically forced
  to have sexual intercourse against her will.
• Emotional Psychological abuse involve being
  made to feel bad about oneself, being blamed and
  punished in front of others.
• Verbal abuse.

Fusco.R,Fantuzzo.J(2008) domestic violence
crimes and children, children and youth services
review.
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Cycle of violence
Honey moon phase

• Violent phase

Tension building phase
Fusco.R,Fantuzzo.J(2008) domestic violence
crimes and children, children and youth services
review.
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Facts about Domestic violence

• -Between 15 71 of women around the world have
  suffered physical or sexual violence committed by
  an intimate male partner at some point in their
  life, which has serious consequences for womens
  health. WHO 2007
• -Intimate partner violence is the most common
  form of violence in womens life, the greatest
  amount of violence was reported by women living
  in rural areas
• -Domestic Violence continues to be accepted as
  normal within too many societies.

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• -The greatest challenges found is that abuse
  remain hidden.
• -The abused women were twice as likely as non-
  abused women to have poor health and physical and
  mental problems which includes suicidal thoughts
  and attempts, mental distress, and physical
  symptoms like pain, dizziness and vaginal
  discharge.
• -Women who reported physical or sexual domestic
  violence were also more likely to report having
  had at least one induced abortion or miscarriage.
• WHO- 2005

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• -Women who are divorced, with no education or
  elementary were more likely to report violence
  during pregnancy.
• Help seeking behavior
• - The results of survey indicate that about
  one-fifth of women who had experienced violence
  at least once wanted assistance to deal with
  violence.
• -Women were almost 3 times as likely to seek help
  if violence had occurred often 40 rather than
  sometimes 15.

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• -Most of women who asked for help looked to
  relatives for assistance ( 23 from their
  mother).
• - 7 of women who reported frequent violence
  asked for help from police while 3 from medical
  personnel or lawyer.

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The cultural Meaning of Violence Against Women
Jordanian womens perspective. Gharaibaha. M Al
Maaitah. R. (2002)

• Descriptive qualitative study to explore the
  cultural meaning of violence from a theoretical
  and practical perspective focusing on the
  perception of Jordanian women.
• Convenience samples of 42 Jordanian married
  women participated in-depth unstructured
  interviews.
• The study findings indicated that Jordanian women
  viewed the meaning of violence to be composed of
  5 components physical abuse, sexual, emotional,
  social and economic abuse.

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• -The cultural meaning of violence perceived
  continuity and intensity of physical abuse,
  sexual desertion, marrying another woman, and no
  rights for ownership and financial independence.
• -Despite the fact that the woman perceived
  violence to be a multi-dimensional, about 50 of
  them believed that men have the right to
  physically hurt and sexually desert the woman.

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• Implications for nursing practice include
• (a) identifying abused women.
• (b) empowering them with knowledge to change
  their sociocultural perceptions of marital
  relationships. (c) designing interventions that
  address their needs.
• (d) educating health care providers to take a
  role in addressing spousal abuse.

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Risk factors for injury to marriedwomen from
domestic violence inHong Kong

• -Case control study in Regional public hospital,
  Hong Kong for All married women aged 18 to 60
  years
• The results showed that the risk factor for
  domestic violence are
• -Woman who is a new immigrant
• -Woman with no job
• - Husband with low educational level
• -Presence of extramarital relationships
• -Husbands unemployment
• -Husbands alcohol abuse
• -Husbands illegal drug abuse
• -Husbands mental illness.
• Tsui K etal. Risk factors for injury to married
  women from domestic violence in Hong Kong.Hong
  Kong Med J (2006)

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Impact of domestic violence on women

• NON-FATAL OUTCOMES
• Physical health outcomes
• Injury (from lacerations to fractures
• and internal organs injury)
• Unwanted pregnancy
• Gynecological problems
• Miscarriage
• Headache
• Permanent disabilities
• Irritable bowel syndrome
• Self-injurious behaviors

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• Mental health outcomes
• Depression
• Fear
• Anxiety
• Low self-esteem
• Sexual dysfunction
• Eating problems
• Obsessive-compulsive disorder
• Post traumatic stress disorder
• FATAL OUTCOMES
• Suicide
• Homicide
• Maternal mortality
• Fusco.R,Fantuzzo.J(2008) domestic violence
  crimes and children, children and youth services
  review.

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The  objectives of the strategy and action plan 
to control domestic violence against women

• Prevention and Earlier Intervention in cases of do
  mestic 
• Violence, looking at ways to change attitudes
  particularly looking at ways to change attitudes,
  particularly those of  young people, and ensuring
• that victims receive the information they need
  to improve  their safety.
• Protection and Justice for those affected by domes
  tic violence Providing a focus on the role of the 
  criminal 
• justice agencies and  how partnerships
  can work closely together.
• Domestic violence strategy 2006-2008,
  Nottinghamshire County Council

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The  objectives of the strategy and action plan 
to control domestic violence against women

• Prevention and Earlier Intervention in cases of do
  mestic 
• Violence, looking at ways to change attitudes
  particularly looking at ways to change attitudes,
  particularly those of  young people, and ensuring
• that victims receive the information they need
  to improve  their safety.
• Protection and Justice for those affected by domes
  tic violence Providing a focus on the role of the 
  criminal 
• justice agencies and  how partnerships
  can work closely together.
• Domestic violence strategy 2006-2008,
  Nottinghamshire County Council

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Strategy Objectives

• The strategy has four main objectives
• 1.To promote the effective coordination,
• delivery and evaluation of multiagency
  responses to domestic violence
• 2.To promote the prevention of and earlier
  intervention into cases of domestic violence  
• 3.To improve the protection and justice offered to
  victims of domestic violence 
• 4.To increase and improve the support 
• available to victims of domestic violence
• Domestic violence strategy 2006-2008,
  Nottinghamshire County Council  

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Thank you