Menopause

& HRT
Hamza Fadel 1845552
Supervised by:– Dr. Mohammed_Malak

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Objectives

Define Menopause Care of menopausal women

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Physiological changes withDescribe the WHI trial
menopause

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 Define
Menopause

refers to the last menstrual period, Permanent

Cessation of menses

The exact time of menopause is usually determined in

retrospect; that is, 1 year without menses

In most women, menopause occurs between the ages

of 50 and 55 years, with an average age of 51.5 years.

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 Define
Menopause

Menopause Premature Menopause Premature Ovarian

failure

Age >40 30-40 <30

Causes • Depletion of ovarian • Idiopathic • Autoimmune

follicles • Radiation therapy disease

• Surgical removal • Galactosemia

• Fragile X syndrome

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 Physiology of
Menopause

• Women are born with between 1.5 and 2 million oocytes and
reach menarche with about 400,000.

• Most women ovulate about 400 times between menarche and

menopause

• When the oocytes either have all ovulated or become atretic,

the ovary becomes minimally responsive to pituitary
gonadotropins, the ovarian production of estrogen and
progesterone ends, and ovarian androgen production is
reduced.

• These hormonal alterations often result in unpleasant and

even harmful physical, psychological, and sexual changes in
postmenopausal women

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Physiology of
Menopause

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 Physiology of
Menopause
years before menopause, the ovary begins to show signs of
impending failure.  Perimenopausal years

• Anovulation becomes common, with resulting unopposed pro

duction of estrogen and irregular menstrual cycles.
• Heavy Menses
• Endometrial hyperplasia
• Mood and emotional changes
• Hot Flashes

These perimenopausal symptoms may occur 3 to 5 years before

there is complete loss of menses

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Hormonal Changes
Estrogen estradiol (E2) values decline, but estrone levels may increase.
Estrone (E1) can be produced by peripheral conversion of androstenedione
from the ovary and the adrenal gland.

Progesterone Progesterone is Decreased

Androgens Androgen, Testosterone, androstenedione, All are decreased

Postmenopausal women are more sensitive to androgen Because of lost
opposition of estrogen.
Gonadotrophins GnRH is increased  due to low level of estrogen.
FSH and LH are increased.

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 Clinical
manifestations
General symptoms:-
• Hot Flashes, dizziness, and palpitations, Confusion, memory
loss, mild depression

Urogenital symptoms:-
• Atrophic vaginitis, Severe dyspareunia, frequency, urgency,
Urinary incontinence.

Cardiovascular diseases

Osteoporosis

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Osteoporosis

Remodeling of bone continues throughout life, but with estrogen

deprivation, osteoclastic activity far exceeds the osteoblasts’
ability to lay down bone.

Leads to osteoporosis which is decrease in bone density.

An early clinical sign of osteoporosis is a loss of height greater

than 1.5 inches because of vertebral compression fracture,
Other signs:– Wrist / hip fracture

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Osteoporosis

The American College of Obstetricians and Gynecologists

(ACOG) recommends bone mineral density screening for
osteoporosis
Women with risk factors <65 years
Women without risk factors >65 years

Screening by Dual-energy x-ray absorptiometry (DEXA)

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 Treatment and
prevention of
osteoporosis

Pharmacological Non-Pharmacological

Vitamin D and Calcium Weight- bearing exercise

supplementation

Estrogen replacement therapy w/w Smoking Cessation

progestin

selective estrogen receptor Alcohol Cessation

modulators ( raloxifene )

Bisphosphonate (alendronate ) --

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Menopausal Care

Screening:–
• Hormones screening ( FSH / LH / Estrogen /
Progesterone )
• Lipid profile to prevent atherosclerosis
• DEXA screening
• Endometrium ultrasound for endometrial cancer
• Mammogram for breast-cancer
• Pap-smear for cervical cancer

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 Hormonal
Replacement
therapy
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Hormonal replacement
therapy

Hormonal replacement therapy:- is the use of estrogen alone or estrogen +

progesterone.

Hormonal therapy was provided for the treatment of hot flashes and the
symptoms of genitourinary atrophy.
Later, increasing evidence revealed that prevention of osteoporosis was a
specific benefit of ovarian hormonal therapy.

Women with uterus  combined

Women without uterus  estrogen alone
Vaginal dryness  Local estrogen

Severe continuous bleeding or intermittent bleeding after more than 4

months of hormonal therapy should prompt a search for uterine pathology

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Hormonal replacement
therapy

Indications:-
• Moderate to severe hot flashes or other menopausal
symptoms
• Loss of bone mass
• Stopped having period before age of 50
• Lost normal function of ovaries before age 40

Contraindications:-
• History of breast cancer or endometrial cancer
• Liver disease
• History of DVT or Stroke

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Hormonal replacement
therapy

Other treatment Options:-

• Healthy Diet
• Calcium and Vit-D
• Selective estrogen receptor modulator ( tamoxifen,
Raloxifine) raloxifene doesn’t stimulate endometrial or breast
duct epithelial proliferation. Additionally, it reduce osteoclastic
activity and prevent osteoporosis, and it worsen vasomotor
symptoms.
• SSRI ( alleviate menopausal symptoms, Preserve bone
mineral density, Depression )
• Exercise
• Cessation of smoking and alcohol

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 WHI Trial

The Women’s Health Initiative (WHI) study of the National

Institutes of Health (NIH) was undertaken with a goal of sorting
out the benefits of ovarian hormonal therapy.

The study included 17,000 women who past the age of

menopause ( average age is 63 )

The two arms of the study are:–

• Combined preparation of conjugated estrogen and
medroxyprogesterone acetate
• Estrogen Only

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 WHI Trial

In All Arms:-

• Previously reported protection from osteoporotic fracture was

confirmed.
• 37% reduction of colorectal cancer was found

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 WHI Trial

After 5 years of follow-up, the combined ovarian hormonal arm

was halted in July of 2002:-

Risks:-
• Breast cancer
• Stroke
• Thrombosis
• Heart disease

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 WHI Trial

In February 2004, the estrogen-only arm of the WHI was halted:-

• significantly increased risk of stroke

• protective effect against hip fracture
• The risk of breast cancer was not increased

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WHI Trial

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 WHI Trial

The WHI study has been widely criticized for examining women
who, for the most part, were well past the age of menopause
when they were entered into the study (average age 63).

The general consensus now is that combined ovarian hormonal

therapy is indicated primarily for the relief of significant
menopausal symptoms such as frequent hot flashes,
genitourinary discomfort, and other quality of life issues.
The length of treatment should be minimized.

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Quiz

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 Quiz

Regarding Osteoporosis, which is correct:-

A- Cannot be prevented by estrogen
B- Calcium and Exercise are important in prevention and
management
C- is not a serious disease
D- Osteoblast activity exceeds Osteoclast

What is the most common complain of women with menopause

A- Depression
B- Dyspareunia
C- Urinary incontinence
D- Hot flashes

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REFERENCES

● Hacker & Moore’s Essential of Obstetrics and

Gynecology 6th edition
● Kaplan USMLE Step 2 Lecture notes 2020 Obstetrics &
Gynecology
● Uptodate

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Thank you
Hamza Fadel 1845552
Supervised by:– Dr. Mohammed_Malak

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