MENOPAUSE

‫ ٭‬Permanent cessation of menstruation

due to loss of ovarian follicular function
‫ ٭‬Lack of ovarian hormones
‫ ٭‬Diagnosed retrospectively after 12
months of amenorrhoea
‫ ٭‬Average age of menopause in India
ranges from 43.5 to 48.5 yrs
‫ ٭‬One third of life in menopausal state
spsk
 PROBLEM IN INDIA
‫ ٭‬Life expectancy - 61 yrs
‫ ٭‬Women in menopausal age (50-59 yrs)
- 36 millions
‫ ٭‬Regional variation
– by age 40
• In Kerala - 8.2% menopausal
• In AP - 37.6% menopausal
– by age 50
• In Kerala - 53% menopausal
• In AP - 83% menopausal

spsk
 REACTION TO MENOPAUSE
‫ ٭‬A welcome change -
– No bleeding and no risk of pregnancy
– Relatively clean state and hence can attend
religious and social functions
– Less psychological symptoms - joint family support
– Low-fat, high calorie diet
– Diet rich in soya products, milk products
– Adequate exercise

Ignorance is a bliss
spsk
 DEFINITIONS
‫ ٭‬Premenopause - Two yrs before cessation
of periods
‫ ٭‬Perimenopause - 5 yrs before and 1 yr
after menopause
‫ ٭‬Postmenopause - dates from final
menstrual period
‫ ٭‬Induced menopause - chemotherapy,
radiotherapy or surgery
‫ ٭‬Climacteric - 2 yrs before and 5 yrs after
menopause

spsk
 VASOMOTOR SYMPTOMS
‫٭‬ Experienced by 50-75% women
‫٭‬ Only 25% suffer physical distress
‫٭‬ Hot flushes & night sweats
‫٭‬ Sudden, transient sensation ranging from
warmth to intense heat that spreads over the
body, particularly on chest, face, and head.
Accompanied by flushing and perspiration,
followed by a chill
‫ ٭‬Lasts for 3-6 mins
‫ ٭‬Disturbed sleep-irritability-depression

spsk
 ENDOCRINOLOGY OF
VASOMOTOR SYMPTOMS

‫ ٭‬Estrogen influences thermoregulatory,

neural and vascular function
‫ ٭‬No association with LH surge, episodic
GnRH release.
‫ ٭‬Sudden decrease in estrogen levels
‫ ٭‬More marked in surgical menopause

spsk
 Anatomical Changes
‫ ٭‬Atrophy of genital organs
– ovary,
– fallopian tubes,
– Uterus,
– Cervix,
– vagina,
– labia

spsk
 GENITAL SYMPTOMS
‫٭‬ Dryness of vagina
‫٭‬ Vaginal irritation
‫٭‬ Vaginal discharge
‫٭‬ Recurrent infections
‫٭‬ Vulvovaginal pruritis
‫٭‬ Dyspareunia
‫٭‬ Post-coital bleeding
‫٭‬ Genital prolapse
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 URINARY SYMPTOMS
(Urethral Syndrome)

‫٭‬ Frequency
‫٭‬ Urgency
‫٭‬ Nocturia
‫٭‬ SUI
‫٭‬ Urge incontinence
‫٭‬ Recurrent UTI

spsk
 PSYCHOLOGICAL SYMPTOMS
‫٭‬ Sustained change of mood
‫٭‬ Inability to enjoy oneself
‫٭‬ Presence of depressive thought process
‫٭‬ Sexual dysfunction
‫٭‬ Increased irritability
‫٭‬ Reduced memory

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 BONE AND OSTEOPOROSIS

‫ ٭‬Postmenopausal osteoporosis - low

bone mass & micro architectural
deterioration of bone tissue due to
increased bone resorption - increased
fracture risk
‫ ٭‬Indians have poor skeletal health
‫ ٭‬High prevalence of osteoporosis

spsk
 EVALUATION FOR
POSTMENOPAUSAL OSTEOPOROSIS
‫ ٭‬All women over 65 yrs of age
‫ ٭‬Younger postmenopausal patients with
high risk factors
– Prior fracture
– Tobacco use
– Weight loss
– Low body weight
– Patients on long term glucocorticoid therapy
– Suspicion of osteoporosis on plain X-Ray
spsk
 Pathophysiology

‫ ٭‬Balance between osteoblastic and

osteoclastic activity

‫ ٭‬Accelerated bone loss after menopause

due to lack of estrogen

spsk
 Bone Formation & Bone resorption

- BAD CELLS - GOOD CELLS

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Normal Osteoporosis
 EVALUATION FOR
POSTMENOPAUSAL OSTEOPOROSIS
‫ ٭‬DEXA Scan for Bone Mineral Density
– Dual energy X-Ray absorptiometry of the hip and
spine
‫ ٭‬For every 1-SD decrease in age-adjusted
BMD, the RR of fracture increases by 2
fold
‫ ٭‬Consider pharmacotherapy for patients
with low BMD

spsk
 LONG TERM GENITAL EFECTS

‫٭‬ Genital atrophy

‫٭‬ Senile vulvovaginitis
‫٭‬ UV prolapse
‫٭‬ Dyspareunia
‫٭‬ Recurrent infections

spsk
 EFFECT ON
CARDIOVASCULAR SYSTEM
‫٭‬ Cardioprotective role of estrogens
‫٭‬ Estrogen favourably affects lipid profile
‫٭‬ It lowers LDL and raises HDL
‫٭‬ Estrogen deficiency may lead to
atherosclerosis,IHD,MI

spsk
 EFFECT ON
CARDIOVASCULAR SYSTEM
‫ ٭‬Epidemiological and Observational
studies have shown 35.5% reduction of
cardiovascular events in
postmenopausal women on traditional
HRT

spsk
 MISCELLANEOUS LONG TERM
EFFECTS

‫ ٭‬Age related Lens opacities

‫ ٭‬Menopausal gingivostomatitis
‫ ٭‬The reduction of collagen causes
thinning of skin and wrinkling
‫ ٭‬The incidence of thinning of skin and
wrinkling reduces by 30% in women on
traditional HRT
‫ ٭‬Alzheimer disease
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 WHY TREAT ?
‫ ٭‬MEDICALIZATION OF NORMAL
PHYSIOLOGICAL PROCESS
– CHANGE OF LIFESTYLE
– DIETARY CHANGES
– EXERCISE
– REASSURANCE
– MEDITATION
‫ ٭‬TREATMENT IMPROVES QUALITY OF
LIFE
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 THE IDEAL HRT
‫ ٭‬TREATS MENOPAUSAL SYMPTOMS
‫ ٭‬BENEFICIAL EFFECT ON CARDIOVASCULAR
SYSTEM
‫ ٭‬LOW INCIDENCE OF BREAST TENDERNESS,
NO INCREASE OF CA BREAST
‫ ٭‬NO ENDOMETRIAL PROLIFERATION
‫ ٭‬TREATS VAGINAL ATROPHY
‫ ٭‬PREVENTS MENOPAUSAL BONE LOSS

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PRE TREATMENT EVALUATION

‫ ٭‬Routine Physical Examination

– Height
– Weight
– BP
– Breast Examination
– Pelvic Examination

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 PRE TREATMENT EVALUATION

‫ ٭‬Routine Screening Examination

– Mammography
– TVS
– Lipid Profile
– LFT
– Pap Smear

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 Management of Menopause
‫ ٭‬Counseling-Pregnancy and cancer
phobia
‫ ٭‬Thorough clinical examination
‫ ٭‬Contraceptive advice
‫ ٭‬Diet
‫ ٭‬Exercises

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 Hormone Replacement therapy

‫ ٭‬Estrogen
‫ ٭‬Progesterone
‫ ٭‬Androgens

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 ESTROGENS
‫٭‬ Premarin, Conjugated estrogens 0.625 mg tab
‫٭‬ Premarin cream (conjugated estrogen)
‫٭‬ Evalon cream (Estriol succinate) 1 mg/g
‫٭‬ Progynova (Estradiol Valerate) 1
mg, 2 mg tab
‫ ٭‬Estraderm skin patch, self adhesive
transdermal. 0.75, 1.5, 3 mg
‫ ٭‬E 2 gel (estradiol 0.06% w/w)
‫ ٭‬Sandrena gel (estradiol 1 mg / satchet)

spsk
 PROGESTERONES
‫ ٭‬Deviry (medroxy progesterone acetate)
2.5 mg, 10 mg tab
‫ ٭‬Regesterone ( Norethindrone acetate)
1 mg, 5 mg tab
‫ ٭‬Microgest, Puregest (Micronised natural
progesterone) 100 mg, 200 mg, 400 mg
tab

spsk
 TRADITIONAL HRT
‫ ٭‬Absence of uterus - continuos estrogen
replacement therapy (ERT)
‫ ٭‬In presence of uterus (EPRT)
– addition of progesterones for 12-14 days each
month
• Cyclic (estrogen D 1-25, progesterone D 12-25)
• continuos (estrogen continuos, progesterone
D 12-25)

spsk
 CONTRA-INDICATIONS
‫ ٭‬Active endometrial and gynaecological hormone
dependant cancers
‫ ٭‬Active breast cancer and estrogen progestogen
receptor positive cancers
‫ ٭‬Known or suspected pregnancy
‫ ٭‬Undiagnosed, abnormal vaginal bleeding
‫ ٭‬Severe active liver disease with impaired/abnormal
liver function
‫ ٭‬Acute vascular thrombosis
‫ ٭‬Estrogen dependent venous thrombosis
‫ ٭‬Inherent increased risk of thromboembolism

spsk
 CONTRA-INDICATIONS

‫٭‬ Migraine headaches,

‫٭‬ Superficial thrombophlebitis
‫٭‬ Strong family history of breast cancer
‫٭‬ Uterine fibroids
‫٭‬ Endometriosis
‫٭‬ Gallbladder disease

spsk
 SIDE EFFECTS - ESTROGENS
‫٭‬ Leg pain
‫٭‬ Breast tenderness
‫٭‬ Headache
‫٭‬ Bloating
‫٭‬ Nausea
‫٭‬ Dyspepsia
‫٭‬ Vaginal discharge

spsk
 SIDE EFFECTS
PROGESTOGENS - PHYSICAL
‫٭‬ Acne
‫٭‬ Bloating
‫٭‬ Backache
‫٭‬ Breast tenderness
‫٭‬ Headache
‫٭‬ Dizziness
‫٭‬ Greasy skin
‫٭‬ Fatigue
‫٭‬ Weight gain
spsk
 SIDE EFFECTS
PROGESTOGENS - PSYCHOLOGICAL
‫٭‬ Anxiety
‫٭‬ Confusion
‫٭‬ Depression
‫٭‬ Forgetfulness
‫٭‬ Irritability
‫٭‬ Panic attacks
‫٭‬ Poor concentration
‫٭‬ Restlessness
‫٭‬ Poor sleep
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 ANDROGENS
‫ ٭‬Tab Testosterone undecanoate 40
mg/day
‫ ٭‬Oral Micronised Testosterone 2.5
mg/day
‫ ٭‬Gels, creams, transdermal matrix
patches

spsk
 ANDROGENS- INDICATIONS
‫ ٭‬Premenopausally oophorectomized
women, who continue to suffer from
decreased libido or reduced energy
levels despite full dose ERT
‫ ٭‬Women who have not experienced relief
of vasomotor symptoms despite
maximally tolerated estrogen dose
‫ ٭‬Natural menopause with unsatisfactory
sexual function, especially loss of libido
spsk
 ANDROGENS

‫ ٭‬Maximum duration 6-9 mths

‫ ٭‬No long term studies
‫ ٭‬Tibolone can be an alternative

spsk
 Other Drugs
‫ ٭‬SERMS
– RALOXIFENE
– ORMILOXIFENE
‫ ٭‬19 nortestosterone derivative
– TIBOLONE
‫ ٭‬PHYTO-ESTROGENS
– ISOFLAVONES
– LIGNANS

spsk
 Other Drugs
‫ ٭‬Biphosphonates

‫ ٭‬Herbs

‫ ٭‬Micronutrients and antioxidants

spsk
 RALOXIFENE
‫ ٭‬Dose - 60 mg/day
‫ ٭‬Does not improve the vasomotor symptoms
of menopause, as well as the symptoms of
urogenital atrophy
‫ ٭‬Important in Osteoporosis prevention
– Approved by USFDA for prevention and treatment of
osteoporosis in menopausal women
– MORE trial (Multiple Outcomes of Raloxifene)
– Increases bone mineral density
– Reduced incidence of fracture

spsk
 RALOXIFENE

‫ ٭‬Effect on CVS
– Favourable effect on lipid profile
– Reduction in cardiovascular risk
‫ ٭‬Effect on Endometrium
– No stimulatory effect
– Does not increase risk of endometrial hyperplasia

spsk
 RALOXIFENE
‫ ٭‬Effect on breast
– Does not increase frequency of breast pain and
tenderness
– Reduces incidence of ER-positive breast tumours
– Long term effects on breast not known
Side Effects-Hot Flushes
Contraindications-Venous thrombosis,hepatic
dysfunction

spsk
 TIBOLONE
‫ ٭‬Dose - 2.5 mg/day
‫ ٭‬Estrogenic, progestogenic and
androgenic activity
‫ ٭‬Tissue specific pharmacologic effects
‫ ٭‬Metabolites
– Δ-4 tibolone
– 3α-OH tibolone
– 3β-OH tibolone

spsk
 TIBOLONE - clinical use
‫ ٭‬Treatment of menopausal symptoms,
both vasomotor and psychological
‫ ٭‬Beneficial effect on vaginal epithelium

‫ ٭‬Reversal of atrophic vaginitis, reduction

of vaginal dryness
‫ ٭‬Improvement of libido
‫ ٭‬Reduction of dyspareunia

spsk
 TIBOLONE - clinical use
‫ ٭‬Effect on Bone
– Exerts estrogenic effects on bone
– Effective in prevention and treatment of osteoporosis
– Increases bone mass
– Prevents bone loss
– Reduces the incidence of fractures
‫ ٭‬Effect on breast
– anti-estrogenic
– ? increase incidence of cancer breast
– No long term trials

spsk
 TIBOLONE - clinical use
‫ ٭‬Effect on Endometrium
– No endometrial hyperplasia
– No effect on endometriosis
– Does not increase fibroid size
‫ ٭‬No adverse effect on liver and renal
function
‫ ٭‬No adverse effect on coagulation

spsk
 TIBOLONE - SIDE EFFECTS
‫٭‬ Vaginal bleeding
‫٭‬ Breast pain
‫٭‬ Headache
‫٭‬ Weight gain
‫٭‬ Edema
‫٭‬ Rash
‫٭‬ Depression

spsk
 PHYTOESTROGENS
‫ ٭‬Isoflavones - Soya
– Dietary source
• Soy
• Lentils
• Beans
• Legumes
‫ ٭‬Lignans - Flaxseed
– Dietary source
• Cereals
• Fruits
• Plant cell wall
• Flaxseed oil

spsk
 PHYTOESTROGENS

‫ ٭‬Coumestans - Red Clover

– Dietary source
• Bean sprouts
• Sunflower seeds
• Red clover
‫ ٭‬Weak estrogens. ER binding less than
1% of estradiol
‫ ٭‬300 plants possess estrogenic activity
spsk
 PHYTOESTROGENS
‫ ٭‬Use of phytoestrogens associated with a
lower incidence of breast, endometrial,
and colorectal cancer
‫ ٭‬Inhibitory effect on human cancer cell line
‫ ٭‬Decrease the intensity and frequency of
vasomotor symptoms
‫ ٭‬Placebo controlled trial suggest that daily
intake of 60 gm/day soy protein is useful
in alleviating vasomotor symptoms

spsk
 PHYTOESTROGENS
‫ ٭‬Does not alter the psychological
symptoms of menopause
‫ ٭‬Does not reduce symptoms of vaginal
atrophy
‫ ٭‬Clinical trials have shown that the
incidence of cardiovascular disease is
reduced
‫ ٭‬Favourable effect on lipid profile

spsk
 PHYTOESTROGENS
‫ ٭‬Prevention of osteoporosis is
controversial. Data lacking
‫ ٭‬Dose - 40 mg isoflavone daily
‫ ٭‬Side effects:-
– acidity
– abdominal cramping
– constipation
– allergic reaction

spsk
 HERBS
‫٭‬ Turmeric
‫٭‬ Cumin (jeera)
‫٭‬ Saunf
‫٭‬ Methi
‫٭‬ Cardamom
‫٭‬ Cinnamon
‫٭‬ Saffron
‫٭‬ Ginger
‫٭‬ Ginseng

spsk
 BISPHOPHONATES
‫ ٭‬Antiresorptive drugs
– Suppress bone resorption
– improve bone mass
– reduce fracture risk
‫ ٭‬Alendronate
– For prevention 5 mg/day or 35 mg/week
– For treatment 10 mg/day or 70 mg/week
– Double blind randomised, placebo controlled trials
have shown efficacy in increasing bone mass and
reducing fracture incidence
spsk
 BISPHOPHONATES

‫ ٭‬The effect lasts for 2 years after

stopping the drug
‫ ٭‬Can be used safely for 7 years
‫ ٭‬Can be combined with HRT
‫ ٭‬Given along with calcium and Vit D

spsk
 CALCITONIN
‫ ٭‬Not enough evidence
‫ ٭‬Trials have shown some increase in
bone density
‫ ٭‬Available as inj 100 U s/c per day or
Nasal spray 200 U/day

spsk
 MICRONUTRIENTS &
ANTIOXIDANTS
‫ ٭‬Micronutrients & antioxidants have
definite beneficial effect on oxidative
stress of menopausal women
‫ ٭‬Existing evidence supports increased
requirement for Vitamins E, A, C and
selenium. Recent evidence for increase
requirement of B1 and B6 is also
accumulating

spsk
 MICRONUTRIENTS &
ANTIOXIDANTS

‫ ٭‬A balanced diet with 5–9 servings of

fruits & vegetables can provide all the
micronutrients & antioxidants

spsk
 ‫ ٭‬Menopause is ……….
not a pause,
…..It’s beginning of new
Life…………

spsk
 To be
continued

spsk
 “ You do not heal old age
You protect it;
You promote it;
You extend it.”

Sir James Ross

spsk
spsk
 Heart and Estrogen/Progestin
Replacement Study (HERS I)
(JAMA 1998)
 Secondary prevention of coronary heart disease
 Included only women with a prior history of
CVD
 Average age - 67 years
 Duration of the follow-up was 4.1 years among
2763 women
 Randomized to 0.625 mg of CEE plus 2.5 mg of
MPA, to placebo
 Evaluate effects of HRT on fatal & nonfatal CAD

spsk
 Mean Change in LDL, HDL and Triglyceride
Levels by One Year
HERS
% change from baseline
to year one
15
10
5

0
-5
-10 oestrogen-progestin
placebo
-15
-20
LDL-C HDL-C Triglycerides
JAMA 1998: 280: 605-613
spsk
 Incidence of Non Fatal MI and CHD Death
HERS
Incidence (%)
15
oestrogen-progestin
placebo
10

0
0 1 2 3 4 5
Follow-up (years)
JAMA 1998: 280: 605-613
spsk
 Despite improving the lipid
profile in women with CHD,
HRT did not improve their
survival

spsk
 HERS II RESULTS
(2002)
‫ ٭‬The HERS II study reconfirms the absence of
secondary cardioprotection. However it
demonstrates no overall increased cardiac risk
with long term use.
‫ ٭‬Extension of HERS I study
‫ ٭‬Follow up of 6.8 yrs

spsk
 HRT & CA BREAST
‫ ٭‬Meta-analysis published in Lancet 1997
‫ ٭‬52,705 patients of breast cancer and
108,411 women without breast cancer
were evaluated retrospectively
‫ ٭‬Ever users for > 5 yrs had a relative risk
of 1.35 and risk increased with increasing
duration of use

Collaborative Group on Hormonal Factors in Breast Cancer. Lancet; 1997; 350: 1047

spsk
spsk
 What was the “ WHI (The
Women’s Health Initiative
Study)” all about?

JAMA, July 17, 2002 -- Vol 288, No. 3

spsk
Objective
Assess the major health benefits and risks of the most commonly used
ombined hormone
Design
First randomized placebo controlled primary prevention trial with oral
strogen- progestin
atient Population
16,608 post- menopausal women with intact uterus aged from 50 -79
nterventions
0. 625mg Premarin & 2.5mg Provera (PremPro)
Main Outcomes
Coronary heart disease (nonfatal myocardial infarction and CHD death)
Invasive breast cancer
lanned Duration
8. 5 years, however, stopped at 5.2 years on 31 Mar 2002
spsk JAMA, July 17, 2002 -- Vol 288, No.
 WHI TRIAL

spsk
 WHI TRIAL
• Monitored outcomes
– Coronary Heart Disease (CHD)
– Invasive Breast Cancer
– Stroke
– Pulmonary Embolism (PE)
– Endometrial Cancer
– Colorectal Cancer
– Hip Fracture
– Death due to other causes
Risk ratio
calculated for
spsk each condition
spsk
 KAPLAN MEIER ESTIMATES

spsk
 CHD EVENTS
‫٭‬ Relative risk - 1.29
‫٭‬ Additional cases per 10,000 women/yr-7
‫٭‬ Higher in the first year
‫٭‬ With another peak at year 5
‫٭‬ Beneficial effect seen in year 6

spsk
 STROKE
‫ ٭‬Relative risk - 1.41
‫ ٭‬Additional cases per 10,000 women/yr-8
‫ ٭‬Risk appeared during the 2nd year and persisted
through to 5th year
‫ ٭‬Beneficial effect seen in the 6th year

spsk
 BREAST CANCER
‫ ٭‬Relative risk -
‫ ٭‬Additional cases per 10,000 women/yr-8
‫ ٭‬Significant risk after first 4 years.
‫ ٭‬Highest in the 5th year .
‫ ٭‬Risk seemed to decline in the 6th year.
‫ ٭‬Higher in women with prior use of hormones
‫ ٭‬No increase in in-situ form of breast cancer
‫ ٭‬Probably hastened detection of small existing cancers

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 PULMONARY EMBOLISM
‫٭‬ Relative risk - 2.11
‫٭‬ Additional cases per 10,000 women/yr-8
‫٭‬ Greatest in first 2 years
‫٭‬ With a second peak at year 5
‫٭‬ Beneficial effect seen in year 6.

spsk
 COLORECTAL CANCER

‫ ٭‬Relative risk - 0.63

‫ ٭‬Less cases per 10,000 women/yr - 6
‫ ٭‬Beneficial effect seen in year 6.

spsk
 HIP FRACTURES

‫ ٭‬Relative risk - 0.66

‫ ٭‬Less cases per 10,000 women/yr - 5

spsk
 ALL CAUSE MORTALITY

NOT INCREASED

spsk
 WHY DID THE TRIAL STOP ?
ESTROGEN - PROGESTIN ARM
crossed global index of 19/10,000

RISKS
BENEFITS
CHD > 7
COLORECTAL CA < 6
STROKES > 8
HIP FRACTURES < 5
BREAST CANCER > 8
PE > 8

RISK - BENEFIT ANALYSIS

spsk ~ 19 additional risks per 10,000 patient years

 ESTROGEN ONLY ARM

DID NOT REACH A RISK -

BENEFIT LEVEL OF CONCERN

HENCE CONTINUING

STUDY CONCLUDES ON 31 MAR 2005

spsk
 LIMITATIONS OF WHI TRIAL
‫ ٭‬The trial tested only one drug regimen and in
one fixed dose only
‫ ٭‬The findings should not be extrapolated to
other forms of therapy like tibolone, SERMs,
phytoestrogens etc
‫ ٭‬The trial did not differentiate between the
effects of estrogen and the MPA
‫ ٭‬The results of this trial do not necessarily apply
to other routes of administration
spsk
 LIMITATIONS OF WHI TRIAL
‫ ٭‬The long term effects have not really been
assessed because of stopping the trial early
‫ ٭‬Some of the women participating in the trial
had either been past or current HRT users
with a family history of breast cancer
‫ ٭‬The mean age of women in this trial was 63.3
years. This is an older age group than the
one which usually seeks HRT for symptom
relief
spsk
 HRT & CA OVARY
‫ ٭‬Short term Estrogen-Progestin only replacement
therapy does not increase risk of ovarian cancer in
women.
‫ ٭‬Women on Estrogen –only (unopposed estrogen)
therapy, particularly for 10 years or more were at
significant risk of ovarian cancer. 
Menopausal Hormone Replacement Therapy and Risk of Ovarian Cancer.

JAMA, July 17, 2002 –Vol288, No3, 334-431  

spsk
spsk
 ASYMPTOMATIC
MENOPAUSAL WOMEN

NO TREATMENT

spsk
 SYMPTOMATIC MENOPAUSAL
WOMEN
‫ ٭‬VASOMOTOR SYMPTOMS - TREAT
‫ ٭‬ONLY PSYCHOLOGICAL SYMPTOMS
- DO NOT TREAT
– CHANGE OF LIFE STYLE
– DIETARY CHANGES
– EXERCISE
– MEDITATION

spsk
 SYMPTOMATIC MENOPAUSAL
WOMEN
‫ ٭‬HYSTERECTOMIZED PATIENT
– ONLY ESTROGEN (ERT) 0.625 mg PREMARIN
DAILY
‫ ٭‬INTACT UTERUS
– COMBINED ESTROGEN-PROGESTERONE
REPLACEMENT THERAPY
– 0.625 mg PREMARIN + 2.5 mg DEVIRY DAILY
– 0.625 mg PREMARIN DAILY + 10 mg DEVIRY FOR
12 DAYS IN A MONTH

spsk
 HOW LONG ?
‫ ٭‬ERT - Results awaited (Mar 2005)
– More than 10 yrs - RR of Ca Ovary 2.0
‫ ٭‬EPRT
– 2 Years
– Definitely not more than 4 years
– Taper off over 4 weeks ( every alternate day)
– Stop during winter months
– The increase in cardiac events in the first year in the WHI
trial could well be because the trial was dealing with a mean
age group of women who were 63.3 years of age. Hence this
data need not necessarily apply to women in their 50s.

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 HOW LONG ?
‫ ٭‬EPRT
– In the WHI trial the risk of pulmonary embolism is
greatest in the first 2 years and the risk of stroke
appears in the 2nd year. The women considering HRT
would need to be counseled regarding these issues
– If symptoms persist after withdrawal, consider:
• Change of life style
• Tibolone
• Phytoestrogens
• Herbal treatment

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 DO NOT START ERT/EPRT IN
THE SIXTH DECADE OF LIFE
ONWARDS

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 DO NOT GIVE HRT FOR
‫ ٭‬PRIMARY OR SECONDARY
CARDIOPREVENTION
‫ ٭‬OSTEOPREVENTION
‫ ٭‬TREATMENT OF OSTEOPOROSIS

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 PATIENT HESITANT FOR
ERT/EPRT
‫ ٭‬TIBOLONE
– Effective in alleviating symptoms
– Androgenic effects
– No need for adding progestogens
– Vaginal bleeding, depression
– Costly
– Long term randomised studies lacking

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 PATIENT HESITANT FOR
ERT/EPRT
‫ ٭‬PHYTOESTROGENS
– Till further evidence is available, the use of
extracted phytoestrogen preparations cannot be
propagated. However consumption of natural
whole food with high content of phytoestrogens is
a good alternative until more scientific data is
available
– Do not alleviate psychological symptoms
– Do not improve urogenital symptoms

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 POSTMEONOPAUSAL
OSTEOPOROSIS
‫ ٭‬PHARMACOTHERAPY FOR:-
– TREATMENT OF OSTEOPOROSIS
– PREVENTION OF OSTEOPOROSIS
• BMD WITH T-SCORE < 2.0
• BMD WITH T-SCORE < 1.0 WITH RISK
FACTORS OF OSTEOPOROSIS

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 POSTMEONOPAUSAL
OSTEOPOROSIS
‫ ٭‬TAB ALENDRONATE
– For prevention - 5 mg/day or 35 mg/week
– For treatment - 10 mg/day or 70 mg/week
– For 7-9 years
‫ ٭‬TAB RALOXIFENE
– Dose 60 mg/day
– Suitable in patients interested in breast cancer risk
reduction
– Does not alleviate menopausal symptoms
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 POSTMEONOPAUSAL
OSTEOPOROSIS
‫ ٭‬TIBOLONE
– Dose 2.5 mg/day
– If patient has associated menopausal symptoms

‫ ٭‬ALL PATIENTS WITH LOW BMD GIVE:-

– TAB CALCIUM 1200 mg - 1500 mg DAILY
– TAB VIT D 400 IU - 800 IU DAILY

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 ONGOING IMPORTANT
TRIALS
‫ ٭‬WHI - ESTROGEN ONLY ARM
‫ ٭‬WISDOM - Women International Study
of Long Duration Estrogen after
Menopause
‫ ٭‬RUTH - Raloxifene use for the Heart
‫ ٭‬MORE - Multiple outcomes of Raloxifene
evaluation

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