1. MENOPAUSE Dr. Malak Al Hakeem Prof. of Gynaecology & Obstetrics

2. DEFINITION: Permanent cessation of menstruation due to ovarian failure. Permanent cessation of menstruation due to ovarian failure.TYPES: 1) Natural: Between the ages of 45 and 50 years with an average of 50 years. Between the ages of 45 and 50 years with an average of 50 years. 2) Premature: Before the age of 40 years. Before the age of 40 years. 3) Artificial : After surgical removal of or irradiation to the ovaries. After surgical removal of or irradiation to the ovaries.

3. FACTORS AFFECTING THE AGE OF MENOPAUSE 1) Smoking: May result in early menopause by 1-2 years. May result in early menopause by 1-2 years. 1) Heredity: Daughters of mothers with PMM tend to have early menopause. Daughters of mothers with PMM tend to have early menopause.

4. PHYSIOLOGICAL CHANGES AT MENOPAUSE A) OESTROGEN HORMONE:  Markedly reduced.  Oestrone is the main oestrogen in postmenopausal women.  It originates from adrenal and ovarian androgens particularly androstenedione. They undergo aromatization in fatty tissues, liver and muscles to oesterone.

5. PHYSIOLOGICAL CHANGES AT MENOPAUSE (CONTINUE) B) GONADOTROPHIN HORMONES:  Both FSH and LH hormones are elevated to reach a maximum 1-2 years after menopause, then gradually decline.  This occurs secondary to low oestrogen and inhibin.

6. EFFECTS OF OESTROGEN DEPRIVATION I. Vasomotor instability ( hot flushes)  Feeling of intense heat over chest, neck, and face accompanied by palpitation and sweating which usually occur at night.  70 to 80% of PMW experience mild hot flushes for one or two years but in 10 to 15%, it is sever and continue for more than 5 years.

7. EFFECT OF OESTROGEN DEPRIVATION (CONINUE) II. Genital tract atrophy Vulva: Becomes thin with loss of fat. Vagina: 1. Loses its rouges. 2. Becomes shorter, narrower and inelastic. 3. The mucosa becomes thin with less glycogen content. 4. Reduced acidity (i.e. senile vaginitis). 5. Reduced vascularity causes dryness of the vagina.

8. EFFECT OF OESTROGEN DEPRIVATION (CONINUE) UTERUS: It becomes small and atrophic. Cervical ligaments: It becomes atrophic, predisposing to genital prolapse.

9. EFFECT OF OESTROGEN DEPRIVATION (CONINUE) Ovaries: Become small, fibrotic, and containing no follicles. Urinary bladder: The trigone and the urethra become atrophic  leading to dysuria, urgency, and frequency.

10. EFFECT OF OESTROGEN DEPRIVATION (CONINUE) III. OSTEOPOROSIS  Progressive reduction in the bone mass  leading to fractures on minor trauma.  The common sites of fractures are: vertebral bodies, femoral neck, and distal radius.  Oestrogen stimulates the osteoblastic cells and inhibits the osteoclastic cells. It enhances absorption of calcium by increasing production of vitamin D.

11. EFFECT OF OESTROGEN DEPRIVATION (CONINUE) IV. VASCULAR CHANGES  Atherosclerosis and coronary heart diseases are increased.  Oestrogen decreases LDL and increases HDL.

12. TREATMENT GENERAL: 1. Explanation and reassurance. 2. Avoid the factors that precipitate hot flushes.

13. TREATMENT (CONTINUE) HORMONE REPLACEMT THERAPY (HRT): ESTROGEN:  Conjugate equine oestrogen.  Oestradiol valerate.  Methods: 1. Orally. 2. Skin: patches, gel, or implants. 3. Vaginally: cream or pessaries.

14. HAZARDS OF ESTROGEN THERAPY 1. Endometrial hyperplasia and cancer:  It is dose and duration dependant.  Addition of progestogens for 10 – 14 days in each treatment cycle markedly reduces the risk. 2. It increases the incidence of breast cancer. 3. It increases the incidence of thromboembolic disorders (TED). 4. It increased the incidence of strokes.

15. NON-HORMONAL TREATMENT OF OSTEOPOROSIS 1. Increase of physical activities and calcium intake. 2. Drugs which prevent osteoporosis and help bone formation e.g. Calcitonin, Raloxifin, Alendronates, and Tobilone.

16. THANK YOU