Novak 29 Menopause -1-

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Novak 29 Menopause -1-

• ??? ????
• 2003-11-04
• R2 ? ? ?

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• 30 of female population of U.S.A.
  postmenopausal, increasing
• each womans response to menopause may be
  different ? management must be individualized to
  each womans needs

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• Menopause permanent cessation of menses for 1
  years, physiologically correlated with decline in
  estrogen secretion resulting from loss of
  follicular function
• Perimenopausal period
• encompasses the time before, during, and after
  menopause
• usually begins in the mid- to late 40s
• often insidious uneventful but may be abrupt
  and symptomatic Sx that begin with the
  menopausal transition usually continue into the
  postmenopausal period

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Perimenopausal Phases

• period surrounding the menopause before,
  during, and after
• length varies, usually considered to last
  approximately 7 years

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Menopausal Transition

• varying degree of somatic changes that reflect
  alterations in the normal functioning of the
  ovary
• early recognition of the Sx and use of
  appropriate screening tests minimize the impact
  of this potentially disruptive period
• In some women, menstrual irregularity most
  significant Sx of the menopausal transition
• Ut bleeding associated with this transition
  period 2 to normal physiologic estrogen
  fluctuations rather than underlying pathology and
  may be treated medically

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Menopause

• Cessation of menses resulting from the loss of
  ovarian function natural event, a part of the
  normal process of aging. Resulting from loss of
  ovarian follicular function, should be
  characterized as an event rather than a period of
  time
• Time of menopause is determined genetically and
  occurs at a median age of 51 years, related
  neither to race nor nutritional satatus
• Menopause occurs earlier in nulliparous women, in
  those who smoke tobacco
• Modern laboratory testing, menopause may now be
  more precisely defined as amenorrhea, with signs
  of hypoestrogenemia, and an elevated serum FSH
  level of greater than 40 IU/L

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Postmenopausal Period

• This period comprise more than one-third of the
  average womans life
• Hormone replacement therapy one of primary
  concerns of many postmenopausal womens health
  care

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Premature Ovarian Failure(1)

• Loss of ovarian function is usually a gradual
  process that occurs over a number of years
• Ovarian function is lost earlier and more
  suddenly than expected in some women as a result
  of natural causes, chemoTx, or surgery
• Defined as menopause occurring spontaneously
  before 40 years of age
• Both psychological and hormonal support may be
  necessary, possibility of associated endocrine
  abnormalities should also be considered

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Premature Ovarian Failure(2)

• More than 40 of women who have hysterectomies,
  both ovaries are removed relatively young age
  of these women and the abrupt onset of associated
  Sx create special problems
• Most obvious problem with surgical menopause is
  the acute onset of hot flashes ? after several
  months, followed by signs of vaginal atrophy,
  long-term surgical menopause has been associated
  with significantly higher risk for both
  osteoporosis and cardiovascular disease than has
  natural menopause
• Relative risks and benefits of oophorectomy in
  conjunction with estrogen replacement therapy
  should be thoroughly discussed with any woman
  considering bilat oophorectomy at the time of
  hysterectomy

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Hormonal Changes
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Menopausal Transition

• Ovarian follicle become increasingly resistant to
  FSH stimulation even though levels of estradiol
  remain relatively constant
• Progesterone produced almost exclusively by
  granulose cells and is highest in the med luteal
  phase, During menopausal transition, ovulation
  becomes less frequent, with a decrease in overall
  progesterone production

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Menopause(1)

• Hormones most affected are those produced by the
  ovaries and include estrogen, progesterone, and
  androgens

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Menopause(2)

• Estrogen
• Even though the amount of estrogen secreted by
  the postmenopausal ovary is negligible,
  postmenopausal women continue to have measurable
  amounts of both estrone and estradiol
• Androstenedione is produced by the adrenal and
  ovary and is aromatized to estrogen primarily by
  muscle and adipose tissue
• Obese women increased level of circulating
  estrogens, unopposed estrogen places them at an
  increased risk for endometrial cancer, not appear
  to protect them form acute menopausal Sx
  however, higher levels do provide some skeletal
  protection
• Thin women decreased level of circulating
  estrogens, increased risk for developing
  osteoporosis

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Menopause(3)

• Progesterone
• After menopause, progesterone production ceases
• Associated with the absence of premenstrual Sx
• Decreased progesterone levels affect organs that
  are responsive to gonadal hormones, such as
  endometrium and breast ? higher risk of
  endometrial hyperplasia and cancer, development
  of breast cancer

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Menopause(4)

• Androgens
• Third class of steroids produced by the ovaries,
  most notably testosterone and androstenedione
• Prior to menopause, ovaries produce approximately
  50 of the circulating androstenedione and 25 of
  the testosterone produced by a womans body
• After menopauses, total androgen production
  decreases, mainly because ovarian production
  decreases but also because adrenal production
  decreases
• ovaries are responsible for 20 of the
  androstenedione and 40 of the testosterone as a
  result of continued gonadotropin stimulation of
  ovarian stromal cell
• oophorectomy also results in a marked reduction
  in androgen production, significance of these
  decreases will remain uncertain until the
  physiologic role of these hormones becomes more
  fully elucidated

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Patient Concerns about Menopause(1)

• the loss of fertility and menstrual function may
  have an impact on a womans sense of well-being ?
  physician should be sensitive to the potentially
  significant emotional distress faced by women
  entering menopause and be prepared to offer
  psychological support

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Patient Concerns about Menopause(2)

• Loss of Childbearing Capacity
• loss of fertility may cause great distress
• Loss of Youth
• the degree to which this may affect a woman may
  be related to the value she places on personal
  appearance
• aging may not be important to many women, but the
  possibility that this may cause anxiety or
  depression should be considered
• Skin Changes
• estrogen therapy may help to maintain skin
  thickness
• estrogen therapy cannot completely prevent the
  effects of aging in skin, nor can it counteract
  the effects of environmental stresses on skin,
  such as sun exposure and cigarette smoking

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Patient Concerns about Menopause(3)

• Changes in Mood and Behavior
• Depression
• common problem for women and older patients
• belief that depression is increased during the
  perimenopausal period, studies have failed to
  show a relationship between clinical depression
  and hormonal status
• many psychiatric Sx occurring during this period
  may be more related to psychosocial events
• Anxiety and Irritability
• many women report an increased level of anxiety
  and irritability during the perimenopausal period
• multiple studies, however, have found no evidence
  to suggest that psychological Sx experienced
  during the menopausal transition are related to
  estrogen changes
• increased anxiety and irritability associated
  with the perimenopausal period are more clearly
  associated with psychosocial factors than with
  estrogen status

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Patient Concerns about Menopause(4)

• Decreased Libido
• major concern for some women is a decrease in
  libido or sexual satisfaction that may occur with
  natural or surgical menopause
• Sexual activity, however, remains relatively
  stable in menopausal women
• Vaginal changes associated with menopause may
  also contribute to decreased sexual satisfaction,
  also lead to dyspareunia ? treated easily with
  oral or vaginal estrogen therapy
• The role androgens play in libido before and
  after menopause is uncertain

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Menopausal Transition(1)

• Beginning at the age of 40 years, routine health
  maintenance should include screening for problems
  related to hormonal changes

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Menopausal Transition(2)

• Abnormal bleeding
• Menstrual irregularity occurs in more than
  one-half of all women during the menopausal
  transition
• Ut bleeding can be irregular, heavy, or prolonged
• in most cases, this bleeding is related to
  anovulatory cycles
• disruption of normal menstrual flow has been
  attributed to a gradual decrease in the number of
  normally functioning follicles and is reflected
  by a gradual increase in early follicular-phase
  FSH levels
• although anovulation is one of the more common
  causes of abnormal Ut bleeding, pregnancy must
  always be considered
• Malignant precursors such as complex endometrial
  hyperplasia become more common during the
  menopausal transition
• perimenopausal women with abnormal Ut bleeding
  should undergo an endometrial Bx to exclude a
  malignant condition

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Menopausal Transition(3)

• Evaluation
• Goal of evaluation of abnormal Ut bleeding is to
  achieve the greatest accuracy with the least risk
  and expense for the Pt
• With development of less invasive office
  procedures and more accurate outpatient surgical
  approaches, Ut curettage without hysteroscopy is
  seldom done
• Fig 29.1

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Menopausal Transition(4)
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Menopausal Transition(5)

• Vaginal Ultrasonography
• Vaginal USG established first step in the
  evaluation of perimenopausla bleeding
• With saline injection, sonohysterography can
  accurately visualize polyps and other focal
  intrauterine lesions
• Endometrial stripe lt 5mm thick associated with
  an extremely low risk of endometrial hyperplasia
  or cancer
• Endometrial Sampling
• The importance of the endometrial Bx cannot be
  overemphasized for the pre or postmenopausal
  woman with abnormal Ut bleeding
• well accepted that endometrial Bx performed in
  the office is just as accurate as DC and
  certainly more economical
• DC should be reserved for Pt with abnormal
  endometrial bx or for conditions that preclude
  performing an office bx , such as Cx stenosis

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Menopausal Transition(6)

• Hysteroscopy with Uterine Curettage
• Addition of hysteroscopy to Ut curettage
  greatly improved diagnostic accuracy in the
  evaluation of focal intrauterine lesions

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Treatment(1)

• Hormonal or surgical, depending on the pts Sx
  and Dx
• Anovulation is one of the most common cuases of
  abnormal Ut bleeding during menopause, hormonal
  therapy is the first approach after the presence
  of intrauterine pathology has been excluded

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Treatment(2)

• Hormonal Therapy

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Treatment(3)

• Oral Contraceptives
• Modern low-dose(0.35mg ethinyl estadiol) oral
  contraceptives offer many advantages with minimal
  risk use of OCs until menopause has been found
  to be safe in women with no risk factors for CVD
• Before starting the administration of OCs in the
  age group, pt should be free of the following
  risk factors
• hypertension
• hypercholesterolemia
• ciagarette smoking
• previous thromboembolic disorder
• cerebral vascular disease or coronary artery
  disease
• because the estrogen dose in these pills is
  approximately 4 times the dose used after the
  menopause, women taking this therapy should be
  switched to traditional estrogen therapy by 50
  years of age or sooner if Sx occur

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Treatment(4)

• Cyclic Progestins
• medroxyprogesterone 10mg daily for 10 days each
  month
• induce withdrawal bleeding and to decrease the
  risk of endometrial hyper

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Treatment(5)

• Surgical Therapy

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Treatment(6)

• Dilatation and Curettage
• endometrial polyps are determined to be the cause
  of abnormal Ut bleeding, curettage can be both
  therapeutic and diagnostic
• with exception of endometrial polyps, curettage
  has not been shown to have any long-term benefit
  in the Tx of abnormal Ut bleeding

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Treatment(6)

• Hysterecotmy
• Although removal of uterus is most common and
  effective surgical Tx for abnomal Ut bleeding,
  hysterectomy is associated with a certain degree
  of morbidity and cost
• Prior to recommending hysterectomy, an adequate
  preoperative evaluation must include endometrial
  sampling and adequate trial of hormonal therapy
  to control bleeding
• Standard practice for postmenopausal women
  undergoing hysterectomy to have their ovaries
  removed to avoid the subsequent risk of ovarian
  cancer
• Oophorectomy has been recommended in women older
  than 40 to 45 years for the same reson

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Treatment(7)

• Endometrial Ablation
• A relatively new and potentially advantageous
  approach to DUB during the menopausal transition
  endometrial ablation
• Minot surgical procedure involves destrying the
  functioning endometrium with electrical energy
  using a hysteroresectoscope
• Most Pt report either decreased bleeding or
  amenorrhea, and both intraoperative and
  postoperative complications are uncommon
• Risk of Ut malignancy after any type of
  endometrial ablation procedure remains uncertain
• subsequent endometrial cancer after endometrial
  ablation has been reported only in women who had
  preexisting endometrial hyperplasia
• ? thorough fractional curettage should be
  performed prior to the procedure
• until long-term data become available, women
  considering this therapy should be informed about
  the potential risk of endometrial ablation