MENOPAUSE
Dr.SwatiSitaramAndhale,Dr.VijaykumarNawale1PGScholar,PTSRDepartment,SMBTAyurvedCollege,Nashik,India.
2Professor,StrirogaandPrasutitantraDepartment,SMBTAyurvedCollege,Nashik,India.
Menopausemeanspermanentcessationofmenstruationattheendofreproductivelifeduetolossofovarianfollicularactivity Itisthepointoftimewhenlast& finalmenstruationoccurs.MenopauseisassociatewithelevatedserumFSHlevels&variablelengthofmenstrualcycleormissedmenses.
Ageofmenopause:Rangesbetween45-55yrs,Average-50yrs
Theclinicaldiagnosisisconfirmedwhenstoppageofmenstruationfor(twelve) 12monthswithoutotherpathology.
2stages: 1. Premenopause–thetimebeforemenopause.
2. Postmenopause–thetimeaftermenopause.
Processofmenopause:
Attimeofmenopause,theovarianactivityreducestheovulationfails;nocorpus luteum is formed & hence no progesterone secretion, hence the cycles are anovulatory&irregular Laterestrogenicactivityalsoreduce&thustheatrophic endometriumleadstomenopause:
Organ Changes
Ovaries
Fallopiantube
Uterus
Cervix
Shrinkinsize
wrinkled
white
Thinningofcortexwithincreaseinmedullary component
Atrophy,
Musclecoatbecomesthinner
Ciliadisappear
BecomesSmaller
Uterus:Cervixratiobecomes1:1
Endometrium–thinandatrophicMaybe proliferativeorhyperplastic
Scantycervicalsecretion
Intheupperpartofthevagina.Thecervical secretionbecomesscanty
Thecervicalcanalbecomesnarrowandinsome casesisobliteratedbysurroundingfibrosis. Senilehaematometraorpyometramaythenoccur duetodeficientdrainage.
Breastfat Ÿ
Atrophy
Decreaseinnipplesize
Flatandpendulousbreast
Lossofmuscletone Ÿ Pelvicrelaxation
Uterinedescent
Anatomicalchangesinurethraandneckof bladder
Scantypelviccellulartissues
Lossinligamentssupportinguterusandvagina
Bonemetabolism Ÿ
Osteoporosis– Reductionofbonemassbutbone mass4tomatrixratioisnormal. Ÿ
Estrogenincreasescalciumabsorptionfromgut andstimulatescalcitoninsecretionfromCcellsof thyroidwhichleadstomineralisationofbone.
B) CardioVascularChanges:
Heart,vessels EstrogenpresentsCardiovasculardiseasesinseveralways: Ÿ ↑HDL,↓LDLandtotalCholesterol Ÿ Inhibitsplateletaggrevation Ÿ Stimulatesreleaseofnitricoxide(NO)and prostacyclinefromvascularendotheliumtodilateblood vessels.PreventsatherosclerosisbyitsAntioxidant property
C) GeneralChanges:
1) Womanbecomescoarserinbuildandappearance.
2) Shedevelopsfeaturessuggestiveofamilddegreeofacromegaly 3) Theshouldersbecomeflatandthewaistlineislost.
4) The skin becomes wrinkled, thin, and more prone to damage and infectionasskincollagencontextisreducedinMenopause.
5) Aslightgrowthofhaircanbeseenonthefaceespeciallyroundthelips andchin.
6) Bodyhairbecomespareslaterinlifeandthisisapartofsenilechanges affectingallorgans.Axillariesandpubichairarenotmuchshedbecause thesedependontheadrenal5ratherthantheovary
Vagina
Narrowerduelossofelasticity
Vaginalepitheliumbecomesthin3
AbsenceofDoderlein'sbacillus
VaginalpH–alkaline
Maturationindex–10/85/5(Parabasal, Intermediate,Superficialcells)
7) Fatisdepositedaroundthebreasts(infattywomen),hipsandabdomen. Soincreaseinweightiscommonattheclimacteric,butitisnotinevitable asitgenerallybelieved.Itisrelatedtoanincreaseappetiteortoaresortto eating in the face of emotional stresses as much as to an alteration in metabolism,whichlowersthenutritionalrequirements.
8) In most cases, the blood pressure rises and cardiac irregularities and tachycardiasometimesoccur
Fornices
Vulva
Thefornicesgraduallydisappearasthecervix regresses.
Atrophy
Vestibuleandtheskinofthelabiaminora becomespale,dry,thinatrophicandmoreprone toinfections.
Flattenedlabia
Scantierpubichairs
NarrowintroitusleadstoDyspareunia
9) Arthritic changes often develop in the joints and in some women osteoporosis may be seen, particularly in the spine and pelvic girdle, whichrendersthesebonesliabletofracture.
MenopausalSyptoms:
BladderandUrethra
Thinepitheliumpronefordamage,infection
Dysuria
Stressincontinence
Prolapseofurethro-vesicularjunctionoccurdue todecreasedpelvicsupport.
Diagnosis:
1) Vaginalcytology-showmaturationindexofatleast10/85/5(featuresoflow estrogen), 2) Serumestradiol-<20pg/ml.
SerumFHS&LH>40MIU/ml
Treatment: 1. Counseling 2. Nonhormonaltreatment 3. Hormonaltreatment
Casupplements
VitaminD
Sedativeand Hypnotics
Fluoride
Calcium
SERMSs
Estrogenonly Estrogen+cyclic progesterone ContinuousEstrogen +Progesterone Testosterone
Transdermal patches
Transdermalgel Subcutaneous impants
Vaginalgels/creams
Vaginal supposistories/ tablets
Vaginalrings
Sideeffects: Endometrialcancer,breastcancer,venousthromboembolicdisease,CHD,Lipid metabolism,DementiaandAlzheimerdisease.
NonhormonaltreatmentŸ Lifestylemodification(exercise) Ÿ
Reducecoffeeintake,smoking,alcohol.
Nutritionaldiet:Calcium,soyproteins,proteinrickdiet,vitaminE.
Supplementarycalcium1-1.5g
VitaminDsupplement(1500-2000IU/day)
Cessationofsmokingandalcohol.
Hormonaltreatment-
Oralestrogen.
Estrogenandcyclicprogesterone.
IndicationandContraindicationofHRT:
Indication
Naturalmenopause;
Hotflushes
Highriskforosteoporosis like,family
history,smoking,lowbody weight,
Vaginalatrophy
Urinarytracksymptoms
radiographicevidence
Prematureovarianfailure
Turner'ssyndrome
Gonadaldysgenesis
Highriskforcardiovascular diseaselike,
Contraindication
Absolute
Oestrogendependentcancerinthe body(e.g.endometrialcancer)
Activethrombophlebitis
Currentgallbladderdisease
Pregnancy
Undiagnoseduterinebleeding
Activeorchronicliverdisease
Relative
Endometriosis
Hypertriglyceridemia
Historyofbreastcancer