Menopause means permanent cessation of menstruation at the end of reproductive life due to loss of ovarian follicular activity. Average age is47.5 yrs. Clinical diag. is confirmed after stoppage of menses for 12 consecutive months without any other pathology Therefore menopause is a retrospective diagnosis.

Premature menopause- occurs before 40 yrs.

Natural or spontaneous menopause is after 12 months of amenorrhea for which there are no obvious pathological and physiological causes.

Pre-menopause refers to the entire reproductive period, up to the final menstrual period.

Pen-menopause: It is the period immediately prior to and up to 1 year after the final menstrual period. If may last for 3-5 yrs.

Post-menopause: span of time from the final menstrual period.

Delayed menopause is two SDs above from the natural average age of menopause in a given population ie.> 54 yrs.

Induced menopause is that follows bilateral oophorectomy or iatrogenic ablation of ovarian function.

Post-menopausal bleeding: vaginal bleeding following a woman's final menstrual cycle and not on cyclical hormone therapy. Bleeding that occurs 6 months after amenorrhea warrants investigation.

Diagnosis of Menopause

·       Cessation of menses for consecutive 12 months during climacteric.

·       Menopausal symptoms , hotilush and night sweats.

·       Vaginal cytology: Maturation index of atleast 10/85/5

·       Serum Oestradiol < 20 pg / ml

·       Serum FSH and LH more than 40 mlu / ml

·       (3 values at a week's interval' required)

Risk factors

·       Surgical menopause

·       Radiation menopause

·       Chemotherapy.

·       Smoking, caffeine, alcohol

·       Family history of menopausal diseases

·       Drug: gnrh, heparin,corficosteroids,clomiphene.

Risk factors for osteoporosis

1)              NON-MODIFIABLE RISK FACTORS:

Family history,Age, Race, Body weight (low BMI, small body frame)& estrogen deficiency.

2)              MODIFIABLE RISK FACTORS:

·       SEDENTARY HABITS

·       DIETARY: Decreased calcium&VIT D INTAKE Excessive intake of caffeine products,alcohal & smoking.

·       DISEASES: Thyroid disorders, Hyperparathyroidism,Chronic renal disease,Conditions requiring corticosteroids.

MENOPAUSAL SYMPTOMS

In majority, no symptoms but in some symptoms appear.

1).VAS O-MOTOR SYMPTOMS

•                          Grading:

Mild                - feeling of heat without sweating. Moderate                        - feeling of heat with sweating.

Severe                       - feeling of heat, sweating and palpitation that disrupts usual act

•                          Hot flushes which last for 2-5 minutes each. Sudden feeling of heat followed by profuse sweating

•                          Palpitation, anginal pains, fatigue and weakness, depression, lack of conc. and not         irritability may be present.

Thyroid function test should be done if vasomotor symptoms are Atypical or resistant to therapy.

2).NEAUROLOGICAL SYMPTOMS:

•                          VMS

•                          Feeling of Pins and needles on extremities. 3).URINARY TRACT SYMPTONS:

Atrophic   changes   may   cause:   Urethral   caruncle,   Dysuria   with    or without infection,Urge/stress incontinence

4) .GENITAL SYMPTOMS

•    Atrophic, dry vagina can cause dysparunia.

•    Loss of libido, vaginal bleeding. infection, Pruritis & leucorrhea.

5).SEXUAL DYSFUNCTION

•    Decreased libido

TREATMENT-

•    Treatment of anxiet depression.

•    Counselling.

•    sex therapist and exercises.

•     lubricants, androgens, combination of estrogens & androgens, transdermal

patch,    testosterone ointment 1% arm, lower abdomen or vagina).

6). PSYCHOLOGICAL CHANGES

•    Anxiety.

•    Headache.

•    Insomnia.

•    Irritability.

•    Dysphasia.

•    Depression.

•    Dementia.

•    Mood swings.

•    Inability to concentrate.

•    Crying spells.

7).SKIN:

•    Wrinkles

•    Purse-String (around mouth) & crow-feet (around eyes).

•   Oestrogen cream - Feminine forever cream delays skin changes, but beneficial temporarily & only for initial stages.

•    Pricking & itching skin sensation.

•    Crawling skin (feels as tiny insects marching along your body). It disappears

on its own.

8).HAIR

Some loss of pubic & axillary hair and slight balding.

9).DEMENTIA is more common in post-menopause.

10). ENDOCRINE SYSTEM

•    Mild virilisation& obesity.

•    Hypothyroidism, DM.

11).PYOMETRA may develop by cervical stenosis. Needs drainage

12). Others: Co nsti pation, Weight gain,Prolapse & stroke. 13).CARDIOVASCULAR DISEASES:

Oestrogen deficiency, can cause atherosclerosis, IHD and MI.

14): OSTEOPOROSIS & FRACTURES

•    At 40 years - Total bone calcium amounts to 1200 gms.

•    At critical level of 750 gms, female is susceptible to fracture.

•    Vertebral bone compression leads to:

•    Dowgers Hump

•    Decreased height

•    Back Pain

•    Fracture of neck of femur, wrist &vertebrae

Investigations

1.   Complete blood picture, ESR,Urine C/E

2.   RBS

3.   Serum calcium,

4.   Lipidprofile

5.   Serum TSH.

6.   Stool for occult blood.

7.   PAP smear

8.   TVS

9.   Mammogram/ultrasound.

10.   Eye checkup

11.   Preferably fasting serum phosphorus

12.   Serum creatininé, Serum albumin.

13.   Alkaline phosphatase

14.   25hydroxyvitaminD

15.   X-ray of thoracolumbar spine (lateral view)

16.   PTH (Based on clinical iudgmenf)

Perimenopausal bleeding

1.   Sonohysferography is superior to TVS to defect intra-cavitary lesions.

2.   Perform Endomefrial tissue sampling in patients with AUB older than 40 yrs.

3.    TVS is primary screening test for AUB, consider MRI when diagnosis is inconclusive.

Post menopausal bleeding.

1.   Initially do TVS & endometrial biopsy.

2.   Women with PMB with ET of < 4 mm in TVS do not require endometrial sampling unless high-risk for endometrial carcinoma or bleeding is episodic.

3.   If ET is > 4 mm in TVS, consider endometrial sampling.

In women with homogeneous and normal morphology, women on HI and hypertensive medication, the acceptable combined thickness is 6 mm.

4.   D&C and fractional curettage are useful in low resource settings.

5.  Saline infusion sonography and 3D USG play a limited role in PMB evaluation. Osteoporosis

Diagnosis of an osfeoporotic fracture is by the presence of fragility fracture and or by BMD. BMD can be studied by

1.   CT

2.   DUAL energy X-Ray absorptiometery (DEXA or DXA) DEXA of the hip & spine is primary technique for BMD assessment.

WHO BMD(t-score) based diagnosis of osteoporosis for postmenopausal women

•    Normal 1-score above (i.e., better than) -1.0

•    Osteopenia or low bone mass 1-score between -1.0 and -2.5

•    Osteoporosis 1-score below (i.e., worse than) or equal to -2.5 Severe osteoporosis 1-score below -2.5 with fragility fracture. WHEN HRT IS CONSIDERED, DOCUMENT:

1 - Base-line pelvic ultrasoundwhich includes

-OVARIAN SIZE

- ENDOMETRIAL THICKNESS

2-Mamography. 3-E 2, FSH levels

Management/Prevention

1.   Spontaneus menopause is unavoidable.

2.   Artificial menopause can be delayed or prevented.

•    HOLISTIC APPROACH

1.   Adopt a holistic approach & selectively prescribe HRT.

2.   Use Minimal dose of HRT required, it avoids risks while giving the beneficial effect.

Counselling

•    Family members should be sympathetic.

•    Explain about physiologic events.

•    Counselling will minimise fear, depression & insomnia

•    Advice on contraceptives.

Life-style changes

•    Active detachment plays constructive role in family affairs.

•    Watch I V, read books and do .prayers.

•    Wear light, loose, layered clothes.

•    Comfortable Room temperature.

•    Avoid alcohal, smoking, caffeine.

•    Develop hobbies.

Tranquilisers & antidepressants

Mild tranquilisers relieve anxiety, sleeplessness and depression.

Vasomotor symptoms

1.   Life-style modifications.

2.   Most effective is HI

3.   Low dose OCP can be used in transition phase.

4.   Non-hormonal agents may relieve VMS, but have side-effects. Can be considered when HI is contraindicated or not desired.

Non-Hormonal Treatment- 1- NUTRITIOUS DIET

-  Low in fat, sugar, salt & animal products.

-  Adequate intake of water.

-  Non-fattening diet with calcium & protein

-  Soyabeans.

2-  SUPPLEMENTARY CALCIUM

-     Diet should include at least 1.2 gms calcium.

-     Vit. A,C,E

-     Daily intake of 1 to 1.5 gms. of calcium reduce osteoporosis & fractures.

3-  EXERCISE:

-  Weight-bearing exercises prevent or delay osteoporosis.

-  Yoga, meditation, social work reduce mental stress.

-  Acupuncture.

4-  VITAMIN D:

•    D Vitamin D3 (400-8001U/day) with calcium reduce osteoporosis and fractures.

•    Sunlight enhances synthesis of cholecalciferol (VII. D3) in the skin. D

5-.FAMILYFEUDs: Should be attended & members counselled for cordial relations.

•    BIPHOSPHONAIES:

1).  Commonly used drugs:

-Alendronate

-Ibandronate (150 mg/ month FOGSI

-Risedronate ( 35 mg/ week or 5 mg /day FOGSI)

-Pamidronate & Clodronate can be given IN 2).

2).  SIDE EFFECTS

-  Oesophageal ulcers.

-  GIT distress.

-Arthralgia, myalgia.

3).  Are taken empty stomach.

4).   Alendronate (5 mg/day or 35 mg/week) & Risedronate (5 mg/day or 35 mg/week has been approved by FDA for prevention of osteoporosis.

•           Alendronate is 1000 times more potent than efidronate with no side effects.

•           It is marketed as OSTEO : FOS-1 0.

•           Dose : 35 to 70 mg /week (NOVAK)

10 mgl day (FOGSI).

•           Etidronafe

•           10 mg/Kg ( Appx. 400 mg /orally daily) is given for two weeks followed by a gap -of two weeks x 3 months( 3 months course).

•           Course is repeated for 10 such cycles.

•           Don't give with calcium, tea, coffee or juice.

•           Calcium should be taken in the morning and etidronate swallowed ( NOT CHEWED) in the afternoon on an empty stomach with water in the upright position. Nothing to be taken orally at least for 30 minfues.

•           To remain upright for 30 mm.. This reduces oesophageal irritation.

•           Milk & antacids can reduce gastric irritation.

•           Overdose causes hypocalcaemia.

•           FLUORIDE:

•           prevents osteoporosis & increases bone matrix.

•           1 mg /kg for short term only.

•           Calcium to be continued.

•           Long term therapy induces side effects( brittle bones). The role of Calcitonin & Fluoride are not established.

•           CALCITONIN

•           injection is costly.

•           Simultaneous calcium (ig) & vitamin D3 (8001U) should be given daily.

•           Not first line drug but recommended in patients with substantial pain of osteoporotic fracture because of its Analgesic action.

•           Once substantial pain subsided or not subsided in 4 weeks, give other therapy.

•           CLONIDINE THERAPY

•           To treat HOT FLUSHES.

•           In hypertensive patients, not responding to oestrogen therapy (SHAW) or if oestrogens are contraindicated.

•           0.2 to 0.4 mg/ daily.

•           NOVAK: - Orally: 0.1 to 0.2 mg / daily or - weekly transdermal patch 0.1 mg/day.

•           Side effects: Orthostatic hypotenfion & drowsiness

•           PAROXETINE

•           Is a selective serotonin reuptake inhibitor (SSRI's).

•           Reduce hot flushes.

•           PAROXETINE CR ( PAXIL): 12.5 and 25 mg/ day

Side effects: headache, nausea & insomnia.

•              Other drug is FLUOXETINE: 20 mg / day.

•           PHYTOESTROGENS

Phytoestrogens,    containing isoflavones lower incidence of VMS, osteoporosis & CVDs

•           Soy beans contain isoflavone which is strongly oestrogenic,

•           45 to 60 mg soy protein daily is protective

•           It also decreases Cholesterol, LDL & Triglycerides with a marginal increase in HDL.

•           It has : Antiviral,Antifungal,-Anticarcinogenic                effects

•           SELECTIVE OESTROGEN RECEPTOR MODULATORS (SERMS)

Out of many SERMS, RALOXIFENE increases BMD, reduces serum LDL & raises HDL- 2 level.

RALOXIFENE (EVISTA) is approved by FDA

•           It is one of the first line drugs for prevention of osteoporosis.

•           Has very low risk of endometrial & breast cancer.

•           It is given 60 mg daily with Ca and Vit D.

SIDE EFFECTS

1.   Hot flushes

2.   Cramps

3.   Venous thrombosis.

4.   Retinopathy

5.   Haemopfysis

6.   Headache, migrane

7.   Loss or change in speech

8.   Vision problems

9.   Pain or numbness in arms, chest, legs

10.   Shotness of breath CONTRAINDICATIONS:

1.    Venous thrombosis.

2.     Not given with oestrogens, lndomethacin, Naproxen, lbuprofen, Diazepam

3.  Hepatic dysfunction.

4.     STOP THE. DRUG 72 HRS BEFORE SURGERY

•   BELLEGRAL.

•   Reduces hot flushes.

•   Bellergal- S - 0.2 mg BD (FOGSI)

•   Surgery/medical managemen for:

-  Arthritis,                 - UTI, SUI

-  cataract ,                   - Urinary fistula

-  osteoporosis,                     - Rectovaginal fistula