MENOPAUSE
? 1.The cessation of menses is
menopause.The climacteric and
perimcnopausal are the periods of waning
ovarian function,
Age of menopause
Age of menopause and female life expectancy,
2.Female life expectancy
1850 1900 1950 2000
40
50
60
70
80
90 90
80
70
60
50
40
3.SYMPTOMS AND SIGNS
OF OVARIAN FAILURE
(1) Menstrual Cycle Alterations Soon after an adolescentwoman has her first
menstrual cycle,regular,predictable menstrual
cycles are established that continue until
approximately 40 years of age,Around 40 years,
the number of ovarian follicles becomes
substantially depleted and subtle changes occur
in the frequency and length of menstrual cycles,
? A woman may note shortening or
lengthening of her cycles,The luteal phase
of the cycle remains constant at 13 to 14
days,whereas the variation of cycle length
is related to a change in the follicular phase,
Women in their 20s and 30s ovulate 13 to
14 times per year,Several years in advance
of menopause,the frequency of ovulation
decreases to 11 to 12times per year and,
with advancing reproductive age,may
decrease to 3 to 4 times per year,
? With the change in reproductive cycle
length and frequency,there are
concomitant changes in the plasma
concentration of FSH and LH, More
FSH is required to stimulate follicular
maturation,Beginning in the late 30s
and early 40s,the concentration of
FSH begins to increase, This is the
frist chemical evidence of ovarain
failure,
The 5- to 10-year period before
menopause is termed
perimvenopause.During the
perimenopausal years,women begin to
experience symptoms and signs of
estrogen deficiency as reproductive
function becomes increasingly
inefficient,Realative change in FSH as
a function of life are presented in
Table 38.1,
(2)Hot Flushes and Vasomotor
Instability
Coincident with the change in reproductive cycle
length and frequency,the hot flush is the first
physical manifestation of ovarian failure,
Occasional hot flushes begin several years before
actual menopause,The hot flush is the most
common symptom of impending ovarian failure,
More than 95% of perimenopausal women
experience hot flushes,
(3)Sleep Disturbances
? Ovarian failure with consequent
declining estradiol induces a change in a
woman’s sleep cycle so that restful sleep
becomes difficult and for some,
impossible,The latent phase of
sleep(I.e,the time required to fall asleep)
is lengthened; the actual period of sleep
is shortened,
? Therefore,perimenopausal and
postmenopausal women complain of
having difficulty falling asleep and of
waking up soon after going to sleep,This
is one of the most disabling and least
appreciated adverse effects of menopause,
The sleep cycle is restored to the
premenopausal state by the
administration of replacement estrogens,
(4)Vaginal Dryness and Genital
Tract Atrophy
? The vaginal mucosa,cervix,endocervix,
endometrium,myometrium,and uroepithelium
are estrogen-dependent tissues,With decreasing
estrogen production,these tissues become
atrophic,resulting in various symptoms,The
vaginal epithelium becomes thin and cervical
secretions diminish,
? Women experience vaginal dryness while
attempting or having sexual intercourse,leading
to diminished sexual enjoyment and dyspareunia,
Atrophic vaginitis also may present with itching
and burning,The thinned epithelium is also more
susceptible to becoming infected by local flora,
? Therapy with replacement estrogens restores the
integrity of the vaginal epithelium,relieving
symptoms of vaginal dryness and
dyspareunia.Sexual pleasure is often restored,
(5)Mood Changes
? Perimenopausal and postmenopausal women
often complain of volatility of affect,Some
women experience depression,apathy,and
“crying spells.” These may be caused directly by
estrogen deficiency,by estrogen-deficiency
associated sleep disturbance,or by both,Not
only are these emotional symptoms disturbing to
a woman but also her inability to control these
feeling is equally of concern,
The physician should provide counseling and
emotional support as well as medical therapy,
The role of estrogons in central nervous system
function is unknown,However,it is well
established that sex steroid hormone receptors
are present in the central nervous system,
Estrogen replacement in perimenopausal and
postmenopausal women often diminishes these
mood swings,
(6)Skin,Hair,and Nail Changes
? Estrogen influences skin thickness,With
declining estrogen production,skin tends to
become thin,less elastic,and eventually
more susceptible to abrasion and trauma,
Estrogen replacement helps restore the
thickness and elasticity of skin,Estrogen
therapy also helps to slow the formation of
wrinkles,
(7)Osteoporosis
? Bone demineralization is a natural consequence of
aging,Diminishing bone density occurs in both men
and women,However,the onset of bone
demineralization occurs 15 to 20 years earlier in
women than in men by virtue of acceleration after
ovarian function ceases,Bone demineralization not
only occurs with natural menopause but also has
been reported in association with decreased estrogen
production in certain groups of young women,
(8)Cardiovascular Lipid Changes
? With approaching ovarian failure,
changes occur in the cardiovascular
lipid profile,Total cholesterol
increases,high-density lipoprotein
(HDL) cholesterol decreases and low-
density lipoprotein (LDL) cholesterol
increases,
4.Management of Menopause
All of the signs and symptoms,and adverse
effects,of menopause result from declining
estradiol-17B production by the ovarian
follicles,Exogenous estrogen adminstration
to the perimenopausal and postmenopausal
woman obviates most of these changes,
Estradiol-17B and its metabolic byproducts,
estrone and estriol,are used for replacement,
5.Cautions in Estrogen
Replacement
? Patients with unexplained abnormal vaginal
bleeding should not receive estrogen-
replacement therapy untile the cause of the
bleeding is ascertained and treated
appropriately,In addition,patients with active
liver disease or chronically impaired liver
function should generally not receive
estrogen replacement,
(1)Carcinoma of the Breast
? Carcinoma of the breast has been a
contraindication to estrogen replacement,In
light of the benefits of estrogen-replacement
therapy in regard to osteoporosis and
cardiovascular disease,selected patients may
not be considered inappropriate for estrogen-
replacement therapy,
(2)Thromboembolic disease
? Oral estrogens stimulate the production
of clotting factors,but estradiol
administered by the transdermal route has
no effect on clotting,Therefore,women
with a history of thromboembolic disease
can safely receive transdermal estradiol
therapy,
(3)Endometrial Carcinoma
? There is litter evidence to suggest that
estrogens should be withheld from
women with a history of carcinoma of the
endometrium if the tumor was limited to
the endometrium and myometrium,
Women with metastatic endometrial
carcinoma should not receive exogenous
estrogens,
? 1.The cessation of menses is
menopause.The climacteric and
perimcnopausal are the periods of waning
ovarian function,
Age of menopause
Age of menopause and female life expectancy,
2.Female life expectancy
1850 1900 1950 2000
40
50
60
70
80
90 90
80
70
60
50
40
3.SYMPTOMS AND SIGNS
OF OVARIAN FAILURE
(1) Menstrual Cycle Alterations Soon after an adolescentwoman has her first
menstrual cycle,regular,predictable menstrual
cycles are established that continue until
approximately 40 years of age,Around 40 years,
the number of ovarian follicles becomes
substantially depleted and subtle changes occur
in the frequency and length of menstrual cycles,
? A woman may note shortening or
lengthening of her cycles,The luteal phase
of the cycle remains constant at 13 to 14
days,whereas the variation of cycle length
is related to a change in the follicular phase,
Women in their 20s and 30s ovulate 13 to
14 times per year,Several years in advance
of menopause,the frequency of ovulation
decreases to 11 to 12times per year and,
with advancing reproductive age,may
decrease to 3 to 4 times per year,
? With the change in reproductive cycle
length and frequency,there are
concomitant changes in the plasma
concentration of FSH and LH, More
FSH is required to stimulate follicular
maturation,Beginning in the late 30s
and early 40s,the concentration of
FSH begins to increase, This is the
frist chemical evidence of ovarain
failure,
The 5- to 10-year period before
menopause is termed
perimvenopause.During the
perimenopausal years,women begin to
experience symptoms and signs of
estrogen deficiency as reproductive
function becomes increasingly
inefficient,Realative change in FSH as
a function of life are presented in
Table 38.1,
(2)Hot Flushes and Vasomotor
Instability
Coincident with the change in reproductive cycle
length and frequency,the hot flush is the first
physical manifestation of ovarian failure,
Occasional hot flushes begin several years before
actual menopause,The hot flush is the most
common symptom of impending ovarian failure,
More than 95% of perimenopausal women
experience hot flushes,
(3)Sleep Disturbances
? Ovarian failure with consequent
declining estradiol induces a change in a
woman’s sleep cycle so that restful sleep
becomes difficult and for some,
impossible,The latent phase of
sleep(I.e,the time required to fall asleep)
is lengthened; the actual period of sleep
is shortened,
? Therefore,perimenopausal and
postmenopausal women complain of
having difficulty falling asleep and of
waking up soon after going to sleep,This
is one of the most disabling and least
appreciated adverse effects of menopause,
The sleep cycle is restored to the
premenopausal state by the
administration of replacement estrogens,
(4)Vaginal Dryness and Genital
Tract Atrophy
? The vaginal mucosa,cervix,endocervix,
endometrium,myometrium,and uroepithelium
are estrogen-dependent tissues,With decreasing
estrogen production,these tissues become
atrophic,resulting in various symptoms,The
vaginal epithelium becomes thin and cervical
secretions diminish,
? Women experience vaginal dryness while
attempting or having sexual intercourse,leading
to diminished sexual enjoyment and dyspareunia,
Atrophic vaginitis also may present with itching
and burning,The thinned epithelium is also more
susceptible to becoming infected by local flora,
? Therapy with replacement estrogens restores the
integrity of the vaginal epithelium,relieving
symptoms of vaginal dryness and
dyspareunia.Sexual pleasure is often restored,
(5)Mood Changes
? Perimenopausal and postmenopausal women
often complain of volatility of affect,Some
women experience depression,apathy,and
“crying spells.” These may be caused directly by
estrogen deficiency,by estrogen-deficiency
associated sleep disturbance,or by both,Not
only are these emotional symptoms disturbing to
a woman but also her inability to control these
feeling is equally of concern,
The physician should provide counseling and
emotional support as well as medical therapy,
The role of estrogons in central nervous system
function is unknown,However,it is well
established that sex steroid hormone receptors
are present in the central nervous system,
Estrogen replacement in perimenopausal and
postmenopausal women often diminishes these
mood swings,
(6)Skin,Hair,and Nail Changes
? Estrogen influences skin thickness,With
declining estrogen production,skin tends to
become thin,less elastic,and eventually
more susceptible to abrasion and trauma,
Estrogen replacement helps restore the
thickness and elasticity of skin,Estrogen
therapy also helps to slow the formation of
wrinkles,
(7)Osteoporosis
? Bone demineralization is a natural consequence of
aging,Diminishing bone density occurs in both men
and women,However,the onset of bone
demineralization occurs 15 to 20 years earlier in
women than in men by virtue of acceleration after
ovarian function ceases,Bone demineralization not
only occurs with natural menopause but also has
been reported in association with decreased estrogen
production in certain groups of young women,
(8)Cardiovascular Lipid Changes
? With approaching ovarian failure,
changes occur in the cardiovascular
lipid profile,Total cholesterol
increases,high-density lipoprotein
(HDL) cholesterol decreases and low-
density lipoprotein (LDL) cholesterol
increases,
4.Management of Menopause
All of the signs and symptoms,and adverse
effects,of menopause result from declining
estradiol-17B production by the ovarian
follicles,Exogenous estrogen adminstration
to the perimenopausal and postmenopausal
woman obviates most of these changes,
Estradiol-17B and its metabolic byproducts,
estrone and estriol,are used for replacement,
5.Cautions in Estrogen
Replacement
? Patients with unexplained abnormal vaginal
bleeding should not receive estrogen-
replacement therapy untile the cause of the
bleeding is ascertained and treated
appropriately,In addition,patients with active
liver disease or chronically impaired liver
function should generally not receive
estrogen replacement,
(1)Carcinoma of the Breast
? Carcinoma of the breast has been a
contraindication to estrogen replacement,In
light of the benefits of estrogen-replacement
therapy in regard to osteoporosis and
cardiovascular disease,selected patients may
not be considered inappropriate for estrogen-
replacement therapy,
(2)Thromboembolic disease
? Oral estrogens stimulate the production
of clotting factors,but estradiol
administered by the transdermal route has
no effect on clotting,Therefore,women
with a history of thromboembolic disease
can safely receive transdermal estradiol
therapy,
(3)Endometrial Carcinoma
? There is litter evidence to suggest that
estrogens should be withheld from
women with a history of carcinoma of the
endometrium if the tumor was limited to
the endometrium and myometrium,
Women with metastatic endometrial
carcinoma should not receive exogenous
estrogens,
