2Objective:-Climacteric and menopause is one phasein woman”s lifeIt is associated with health changes anddiseasesHormone replacement therapy needed toimprove quality of life and prevent medicalcomplications which follow menopause
3Menopause is the last menstrual period the average age is 51 years. Climacteric is transition from fertility to infertility from years.Women live 40% of her life in menopause.The first endocrine change in menopause is fall in inhibin(glycoprotein) from ovaries which inhibit the release of FSH and LH from pituitary,so FSH and LH rise.
4Causes of menopauseA)Premature ovarian failureMenopause occuring before 45 years,low oestrogen,high FSH&LMay be associated with autoimmune pathology.B) Surgical menopauseMenopause after oophorectomy,after hysterectomy menopause occurs about 3 years earlier the natural menopause.
5C) After chemotherapy or radiotherapy as breast cancer or lymphoma. Diagnosis of menopauseHistory(age,disease,surgery,treatment)Clinical examinationInvestigationsLow oestrogen(E pg/ml)High FSH&LH >10IU/LTotal cholesterol increaseHDL cholesterol decreaseLDL cholesterol increase
7D.Diagnosis:- 1.Early changes:- PMS Depression Thyroid disease Phaeochromocytoma,carcinoid syndrome.Clinical features1.Early changes:-Vsomotor symptoms(disturbance in the thermoregulator in the hypothalamus) occur in 70% of women.Frequency – few to several times per day.
8Duration –weeks to years. Hot flushes followed by sweating.Psychological symptomsInsomnia,poor concentration,irritability,anxiety and lethergy.2. Intermediate changes(2-4 years,collagen )Wrinkled skin,small breasts.Genital tract,thin and dry vagina,acidityreduced infection,dysparunia andgenital prolapse.Urinary symptoms,frequency,dysuria,urgency,and stress incontnence.
93.Late changes(>10 years) Bones,osteoporosis(colle’s fracture,fractureof neck femur and vertebral crush fracture)CVS,stroke and heart attacks.Treatment:Hormone Replacement TherapyPrinciplesDepend on the presence and severity ofsymptons.Patient decision.Careful counselling before treatment.
11Examination:- BP,breast examination(mammogram) Pelvic examination,look for oestrogensensitive tumours(fibroid,endometriosis,endometrial carcinoma)Benefits of HRTCure early symptons of menopause.Prevent fractures in about 50%.Reduce heart attacks in about 40%.Reduce bladder dysfunction.May prevent against bowel carcinoma andAlzheimer’ disease.
12Contraindications of HRT Absolute:- Present or suspected pregnancySuspicion of breast cancerSuspicion of endometrial cancerActive liver diseaseUncontrolled hypertensionCofirmed VTERelative:-Presence of fibroidPast history of benign breast diseaseUconfirmed VTEChronic liver diseaseMigraine
13Preparations of HRTNatural oestrogens(from plants or animal)Oestradiol valerate 1-2mgCongugated equine oestrogensOestrone 1.25mgProgestogensMedroxyprogesterone acetate 10mgDydrogesterone 10mgNorethisterone 1mgNorgesterel mg
15Post-hysterectomy : use only oestrogens Add progestogens at least for 12 days of28 days for non-hysterectomized patient.Combined oral oes. And prog. (pills 28 days)Combined oes. And prog. In patch(weekly)Oestrogen patchOestrogen gel rubbed into the skin dailyInplant s\c for one yearVaginal(cream,pessary,tablet for local symptoms)
16Tibolone:- Raloxifene SERM:- Synthetic steroid Has oestrogenic,progestogenic and androgenic effectUsed 1year after menopause 2.5mg dailyRaloxifene SERM:-Selective oestrogen receptor modulatorPrevent osteoporosisDoes not stimulate breast and endometrialreceptorsMay worsen vasomotor symptons
17Side effcts of HRT(first 12 weeks) Breast tenderness and nipple sensitivityAppetite rise and weight gainCalf crampsPatient must reviewed 6 months then annually(BP,breast,pelvic examination)