Menopause

Clinical diagnosis of Menopause is absence of menstruation for 12 consecutive months without any other pathology .This is also known as retrospective menopause

Firm diagnosis of menopause:

• FSH is elevated around the period of menopause (around 45 -55yrs)
• <20pg/ml estrogen indicates complete menopause

Premature menopause:

This is an unphysiological event

Cessation of menstrual cycle in less than 40 years of age , this is mostly idiopathic

Fsh levels are useful in diagnosis of premature menopause

Hormonal changes in menopause :

•Increased FSH(estrogen gets decreased so FSH gets increased by negative feedback)

•Estradiol level decreases

•Total amount of androgen gets decreased

•Postmenopausal women have estrone in the blood (which is a form of estrogen)

Consequences :

•Menstrual cycle changes
•Hot flushes
•Dry vagina
•Mood changes
•Hirsutism ( this is probably because of androgen gets less reduced in comparison to estrogen in blood during the time of menopause)
•Skin changes
•Sleep pattern changes

Let us study some consequences in detail ,

–Atrophic changes of genitourinary epithelium

•Females are likely to suffer dyspareunia
•They may have post coital bleeding
•Frequent vaginal infections
•Frequent incidences of urinary tract infection

–Hot flushes

•These can happen any time , these become the main reason or problem due to which women seek HRT (hormone replacement therapy) , peaks in 1 – 2 years after menopause
•Lasts up to 4 – 5 years
•Symptoms include- Sudden redness of face with intense heat and warmth , sweating , increased heart rate all this may occur frequently at night

The main reason behind this is estrogen withdrawal

–Cardiovascular health after menopause

•Natural estrogen is cardioprotective (because estrogen decreases lipid levels in blood)

•After menopause this effect gets lost and risk of coronary artery disease increases with increasing age

•Serum HDL level are best indicator of coronary artery disease in post menopausal women

–Bone health after menopause

•Estrogen is responsible for mineralisation of bone
•Smoking also leads to estrogen breakdown which results in decrease of bone health

And hence, Risk of osteoporosis increases , mostly trabecular bones such as, vertebral compression , fracture of wrist and neck of femur

Care of post menopausal women –

•Screening for physical examination
•Opportunity to screen for cancers
•Healthy diet and preventive care
•Requirement of vitamin D 1000- 2000 IU / day
•Ca2+ requirements 500mg /day

Evaluation before starting HRT –

•Take history and perform physical examination
•Blood pressure measurement
•Breast and pelvic examination
•Serum TSH
•Mammography
•Lipid profile (if triglycerides levels are >500 mg /dl it should be considered as absolute contraindication for HRT)

STANDARD HRT (hormone replacement therapy) –

1) If uterus is present – :

Use Estrogen & progesterone (as alone estrogen will trigger cancer)

17, beta estradiol + dydrogesterone

2) If uterus is absent – :

Use only Estrogen

In case where estrogen is contraindicated we prefer non hormonal HRT – :

SSRI (Paroxetine) and SNRI (venlafaxine)

Other treatment for hot flushes –

Patient may get partial relief by

Clonidine
Gabapentin
Isoflavones
Vitamin E

Advantages of HRT –

•Relief form genitourinary symptoms
•Prevention of osteoporosis
•Specially needed for premenopausal women
•Decreases risk of colon cancer

Disadvantages of HRT –

•Risk of coronary artery disease(only natural estrogen is cardioprotective HRT is not cardioprotective )
•Not preferred in greater than 60 years aged women
•Not preferred in those who are already suffering from atherosclerosis
•Risk of breast carcinoma
•Risk of venous thromboembolism
•Risk of endometrial carcinoma ( when only estrogen is given unopposed)
•Risk of ovarian cancer
•Risk of gallstones and cholecystitis

Prevention of osteoporosis –

•HRT provides prevention from osteoporosis
• Use of Calcium and Vitamin D supplements
But if a women already has osteoporosis none of the above is useful , Then in such cases Drug of choice becomes,
Bisphosphonate group of drugs

None of the drug listed above should be taken without proper consultation of the doctor.This post is just for educational purpose and not for any clinical purpose.

Contributor- Medico Shashank Gupta