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CASE 10: MENOPAUSE

MENOPAUSE

Absence of menstruation for a year

Defined by Last Menstrual Period

Age of menopause is genetically determined

Filipina: 48 - 52 years old (Book: Age 47 48)

Average Age: 51 y/o

Perimenopausal, Premenopausal, Climacterium


Before the onset of menopause
Transition period

Change in the Peri-menopause:


There is a change in the interval of the cycles to
ANOVULATORY (AUB)
Cause: Depletion of the # of follicles
The HPO axis is no longer be responsive which
would E. If E, nothing will inhibit hypothalamus
from secretion of GnRH which also
gonadotrophin hormones. This would explain one of
the criteria of menopause as FSH.

STRAW: Stages of. Reproductive Aging Workshop

Menopausal Transition
Initial phase
1. Irregular cycles
2. HOT FLUSHES
3. Insomnia, Mood swings, night sweats
Late Phase: Osteoporosis
Symptomatic: 50%
In 90s: all must be treated until she dies
But now according to WHI (Womens Health
Initiative) ONLY treat the symptomatic menopause
with duration no more than 5 years because after
time there is presence of cardiovascular problems.
Try to treat symptomatic patients with shortest
possible time.
PELVIC EXAM:
Atrophic vagina:
Normal menstruating woman: (+) Rugae
In menopause: Loss of Rugae

At risk for Vaginitis: acidity (pH Alkaline)

Pale/ thin Vaginal Mucosa


Due to effects of hormones on the vagina
Estrogen: Thickness of the vaginal mucosa
CHMI: Cytohormonal Maturation Index:
Count 100 vaginal cells & classify into
Parabasal & Intermediate - Progesterone
Superficial Estrogen
100/0/0: Menopausic (Shift to the Left)
0/80/20: Pregnant or in the Secretory Phase

Work ups
Breast: Mammography
TVS: Uterus
Check for Endometrial thickness
IF thick: Do not give E
DX:
1. CHMI
2. Gonadotropin FSH followed by LH
3. E (measured form: Estradiol)
4. Inhibin B - More sensitive test:
It inhibits the secretion of GnRH & eventually
the gonadotropin so with Inhibin, it will lead
to continuous FSH
TX:
E + P (HRT)
1. Used in patient has intact uterus because E alone
may result to a hyperplastic endometrium
2. Risk for Endometrial CA

ET because even in Local E, some of it may be

CASE 10
systemically absorbed.
52 year old G3P3 (3003) complains of pain during sexual contact for the past 4 mos. She also notes night sweats & difficulty
sleeping. LMP March 2012, PPE: Breasts: Symmetrical, no mass, no tenderness; Speculum examination: Vaginal mucosa is
pale pink, smooth; Cervix pale pink, smooth, no discharge. IE: cervix is firm, short, flushed to the vaginal walls; Uterus is small;
Adnexa no mass nor tenderness

CASE:
TX: Estrogen Oral/ Topical/ Patch
Bear in mind all the effects of E on the body, not just to
offset the symptoms of menopause.
If you are going to give E, it will be termed as ET:
Estrogen Therapy. (Past: ERT Estrogen Replacement
Therapy)

Before start of HT for menopause, make sure there are


no risk factors that may complicate use of hormones
1. NO breast conditions - do mammography,
2. NO liver pathology (metabolize by the liver)
3. NO varicosities (Look at the legs), risk for
thromboembolism

After starting HT when do you stop?


Perhaps after 1 year try to withdraw, & if she is
asymptomatic: Discontinue

Oral - CEE Conjugated Equine E: 0.3/ 0.625/ 1.25 mg


Principle: Start with the lowest dose 0.3 mg qd.
Transdermal Patch Pure E or E+P

What can be the problem in giving E ONLY?


Remember: The effect of E is proliferating the
endometrial glands but that proliferation will be counter
affected by P.
But if you have caused proliferative
endometrium & you keep receiving E, eventually that
endometrium will become HYPERPLASTIC which is a
precursor of Endometrial CA.
Incidence of Endometrial Hyperplasia & Cancer

Do NOT give HT to prevent osteoporosis


Risk for osteoporosis:
Skinny Slim
Cigarette smoker
Coffee Drinker
Sedentary Lifestyle

For patients with intact uterus - give E + P to prevent


Endometrial hyperplasia & malignancy (Do Hormone
therapy: Combination of E & P)

In Menopause: Definitely AT RISK for osteoporosis


Fill the bone mass: Give Calcium & do weight
bearing exercise (your body should carry your
weight) by brisk walking, boxing & ZUMBA.

For patient with NO uterus give E ONLY


If patient age 35 had TAH then stops menstruating,
the patient is NOT menopausic:
Why? Because ovaries were not taken out at the
time of hysterectomy. Menopause is simply
depletion of ovarian function.
At Age 52 patient will start manifesting menopausal
symptoms because of level of FSH that woman
will just require ET. (No more uterus)

How to give it:


Still want to have menstruation - Give cyclic HT
Do not want to have menstruation & TX the
menopausal symptoms Give continuous HT
(because the moment you stop the hormones will
fall & reflected as menstruation)
Main Problem for the Case:
Painful contact due to vaginal atropy
Initial TX: Pure Local Estrogen Tx (local E tablets
placed in the vagina or local E cream but
supplement with oral P to counteract effects of E)
If from local E. still complains with systemic symptoms,
(night sweats or insomnia): Shift Local E to Oral HT, NOT

TX Osteopenia or Osteoporosis:
Alendronate, Biphosphanate, NOT HT

Before menopause, the incidence of CAD is higher


among men than women, but after menopause they are
equal.
The beneficial effect of E will LDL but without
E or after E treatment, after menopause, the incidence
of CAD is practically the same.
WHI: Asymptomatic were given E produced incidence
of stroke & ischemic heart disease.
Again: SYMPTOMATIC patients should be the only 1 to
receive TX.

Notes of Dr. Dee 2013

Cause:

Ovarian insults: Early surgical castration (ovarian drilling


PCOS)

Steroid Intake
Other Symptoms:

BMI

Collagen: Sagging of the skin, wrinkling

Libido due to androgen in the ovary

Dyspareunia

Vaginal Atropy: Dryness & redness

UTI due to anatomical changes

POP

Fats Aromatase (DHEA: Peripheral)

Osteoporosis (Chronic of E: LATE SX)


DEXA Scan

T-score: Younger age group/ Healthy adults

-2.5 (osteoporosis)

N: Osteopenia

Z score: Age
Laboratory Test

FSH

AMH

Inhibin (Early FP)


TX
Libido:

Give oral Testosterone: TIBOLONE E, A, P action


HOT FLUSHES

Estrogen (Best treatment)

Oral, cream (vaginal), patch (given to Px w/ Liver


disease & ____ 3 weeks E, 1 week P)

(-) Uterus: TAHBSO (young patient with chronic/


severe endometriosis)

E + P (several months)

Low dose E

CI: Liver problem, Breast CA/ Endometrial CA


Past Hx of Stroke

E+P

(+) Uterus

Menstruate

SSRI, gabapentin, Clomidine, Phytoestrogen (Ramifemin)


Block
VAGINAL SYMPTOMS

Local

Topical Cream
OSTEOPOROSIS

Bisphosphates (oral) NPO 30 mins,

SERMS Not given

Antagonists: Breast, Uterus

Agonist: Bone

Ca Supplements/ Vitamin D

Estrogen: Bone anti-resorptive agent

Additional Notes from Dr. Dee 2013 (KQ )


Additional Notes from Dr. Gonzalez 2012
Again please hide your notes especially if you are under PPP, she tends
to browse on your reviewer lying on your table.

Notes of Doc Gonzales 2012

Hot Flushes Oral


Genital topical
Urogenital infections: vaginitis prone to infection: vaginal
flora, PH: acidic Normal
o Menopause: Not acidic, but Basic (alkali)
What maintains the acidity?
o Lactobacillus
o Estrogen effect on Epithelium: Thickening
o Underneath the epithelium what substrate
Lactobacillus need? LACTIC ACID
o Substrate: GLYCOGEN

If patient is menopausal:

Earliest complaint: Hot flushes due to Estrogen deficiency


o Night sweats

Last complaint: BONE - osteoporosis

Thinned endometrium

Glycogen LA Lactobacillus & PH = Vaginitis

POP due to tone: ligaments & muscles

Collagen: Wrinkling of the skin TX: Botox/ Surgical


Physiological

Mood swings

Depression separated from children, death in the family,


medical probles

Loss of libido changes in the ovary, testosterone

TX: Testosterone replacement therapy (not E alone but


androgens as well)

Agents: TIBOLONE, which do not stimulate Breast &


Endometrium
Estrogenic, Progesteronic & Testosteronic
Cardiovascular

Risk: Atherosclerotic Vessels (LDL, HDL)

TX: Statin

For those prone to HPN: No estrogen (probably)


Skeletal

Osteoporosis

@ risk: Sedentary lifestyle

Long term: Steroids intake

Measurement: DEXA
o T score: young healthy adult
o Z score: compared to age group
o Normal T score: C1 neg N abn
TX:

Estrogen: Anti Bone resorptive Effects


BiPO4: Oral SE GI
Ca + Vit D
SERMS Tibolone, Raloxifen
Antagonist to breast & uterus
Agonist: Bone

Cancer:

Endometrial Empress: Estrogen Monotherapy?

Breast: 5 years than lower dose


o Giving E alone Not increase Breast Ca
o But E + P Increase Breast Ca
o Also Colorectal Ca

Contraindication receiving Estrogen


o Breast
o Uterine
o However for early stage 1
Oral: Metabolize: hepatic: make sure there are no liver
problem
Blood: Thrombosis, Problem in periphery: No E