MENOPAUSE

INTRODUCTION

Menopause is commonly defined by the state of the uterus and the absence of menstrual flow
or "periods", but it can instead be more accurately defined as the permanent cessation of the
primary functions of the ovaries. What ceases is the ripening and release of ova and the
release of hormones that cause both the build-up of the uterine lining and the subsequent
shedding of the uterine lining (the menses or period).

The transition from a potentially reproductive to a non-reproductive state is normally not

sudden or abrupt, occurs over a number of years, and is a consequence of biological aging.
For some women, during the transition years the accompanying signs and effects (including
lack of energy, hot flashes, and mood changes) can be powerful enough to significantly
disrupt their daily activities and sense of well-being. In those cases various different
treatments can be tried.

DEFINITION

Menopause means permanent cessation of menstruation at the end of reproductive life due to
loss of ovarian follicular activity. It is the point of view when last and final menstruation
occurs.

The clinical diagnosis is confirmed following stoppage of menstruation foe twelve

consecutive months without any other pathology.

Premenopause refers to the period prior to menopause , postmenopause to the period after
menopause and perimenopause to the period around menopause (40 – 55 years )

AGE OF MENOPAUSE

The age of menopause is not related to the age of menarche or age at last pregnancy,
lactation, socio economic condition , race , height or weght. Cigarette smoking and severe
malnutrition may cause early menopause. The age of menopause ranges between 45- 55
years, average being 50 years.

HORMONAL CHANGES

Bone loss due to menopause occurs due to changes in a woman's hormone levels.

The stages of the menopause transition have been classified according to a woman's bleeding
pattern, supported by changes in the pituitary follicle-stimulating hormone (FSH) levels

In younger women, during a normal menstrual cycle the ovaries produce estradiol,
testosterone and progesterone in a cyclical pattern under the control of FSH and luteinising
hormone (LH) which are both produced by the pituitary gland. Blood estradiol levels remain
relatively unchanged, or may increase approaching the menopause, but are usually well
preserved until the late perimenopause. This is presumed to be in response to elevated FSH
levels. However, the menopause transition is characterized by marked, and often dramatic,
variations in FSH and estradiol levels, and because of this, measurements of these hormones
are not considered to be reliable guides to a woman's exact menopausal status.

Menopause occurs because of the natural or surgical cessation of estradiol and progesterone
production by the ovaries, which are a part of the body's endocrine system of hormone
production, in this case the hormones which make reproduction possible and influence sexual
behaviour. After menopause, estrogen continues to be produced in other tissues, notably the
ovaries, but also in bone, blood vessels and even in the brain. However the dramatic fall in
circulating estradiol levels at menopause impacts many tissues, from brain to skin.

In contrast to the sudden fall in estradiol during menopause, the levels of total and free
testosterone, as well as dehydroepiandrosterone sulfate (DHEAS) and androstenedione
appear to decline more or less steadily with age. An effect of natural menopause on
circulating androgen levels has not been observed. Thus specific tissue effects of natural
menopause cannot be attributed to loss of androgenic hormone production.

Natural or physiological menopause occurs as a part of a woman's normal aging process. It is

the result of the eventual depletion of almost all of the oocytes and ovarian follicles in the
ovaries. This causes an increase in circulating follicle stimulating hormone (FSH) and
luteinizing hormone (LH) levels because there are a decreased number of oocytes and
follicles responding to these hormones and producing estrogen. This decrease in the
production of estrogen leads to the perimenopausal symptoms of hot flashes, insomnia and
mood changes. Long term effects may include osteoporosis and vaginal atrophy.

MENSTRUATION PATTERN PRIOR TO MENOPAUSE

Any of the following patterns are observed :

 Abrupt cessation of menstruation

 Gradual decrease in both amount and duration. It may be spotting or delayed and
ultimately lead to cessation
 Irregular with or without excessive bleding

MENOPAUSAL SYMPTOMS

 Vasomotor Symptoms
 Urogenital Atrophy
 Osteoporosis And Fracture
 Cardiovascular Disease
 Cerebrovascular Disease
 Psychological Changes
 Skin And Hair
 Sexual Dysfunction
 Dementia And cognitive Decline
Vasomotor symptoms
Hot flush
Palpitation
Fatigue
 Weakness
Sleep disturbance

Genital and urinary system

Dyspareunia
Dysuria
Recurrent urinary tract infection
Stress incontinence

Vagina

Vaginal bleeding
Dyspareunia
Vaginal infections
Dryness
Pruritis
Leucorrhoea

Sexual dysfunction

Decreased sexual desire

Skin and hair

Thining , loss of elasticity and wrinkling of the skin

Purse string wrinkling around the mouth
Crow feet around the eyes
Loss of pubic and axillary hair and slight balding

Psychological changes

Anxiety
Headache
Insomnia
Irritability
Dysphasia
Depression
Dementia , mood swing and inability to concentrate

Osteoporosis and fracture

Osteoporosis may lead to back pain , loss of height and kyphosis

Fracture may involve the vertebral body ,femoral neck or distal forearm.

Cardiovascular and cerebrovascular effects

Vascular endothelial injury

Cell death and smooth muscle proliferation
 Risk of ischaemic heart disease , coronary artery disease and strokes are increased

Diagnosis of menopause

Cessation of menstruation for consecutive 12 months during climacteric

Appearance of menopausal symptoms hot flush and night sweats
Vaginal cytology
Serum oestradiol
Serum FSH and LH

MANAGEMENT

Prevention

Spontaneous menopause is unavoidable . However artificial menopause induced by surgery

or radiation during reproductive period can to some extend be prevented or delayed.

Counselling

Every woman with postmenopausal symptoms should be adequately explained about the
physiologic events. This will remove her fears and minimise or dispel the symptoms of
anxiety , depression and insomnia.

TREATMENT

NON – HORMONAL TREATMENT

Life style modification : physical activity , reducing high coffee intake , smoking and
eccessive alcohol.
Nutritious diet : balanced with calcium and protein helpful
Supplementary calcium : daily intake of 1- 1.5 gm can reduce osteoporosis and
fracture
Exercise : weight bearing exercises , walking , jogging
Vitamin D : supplementation of vitamin D3 along with can reduce osteoporosis and
fractures
Cessation of smoking and alcohol
Biphoshonate prevents osteoclastic bone resorption . It improves bone density and
prevents fracture. Drug should be stopped when there is severe pain at the site.
Commonly used drugs are etidronate and alendronate. Side effects include gastric and
oesophageal ulceration , osteomyelitis and osteonecrosis of the jaw.
Fluoride prevents osteoporosis and increases bone matrix . It is given at a dose of 1
mg / kg for short term only . Calcium supplementation should be continued. Long
term therapy induces side effects ( brittle bones ).
Calcitonin inhibits bone resorption . Simultaneous therapy with calcium and vitamin
D should be given . It is given either bt nasal spray or by injection .
Selective oestrogen receptor modulators are tissue specific in action . Raloxifene
increase bone mineral density , reduce serum LDL and to raise HDL2 level.It inhibits
 the oestrogen receptors at the breast and endometrial tissues. Risks of breast cancer
and endometrial cancer are therefore reduced. Risks of venous thrombo embolism is
increased.
Clonidine , an alpha adrenergic agonist may be used to reduce the severity and
duration of hot flushes.
Thiazides reduce urinary calcium excretion . It increases bone density specially
when combined with oestrogen.
Paroxetine , a selective serotonin reuptake inhibitor , is effective to reduce hot flushes
Gabapentine is an analogue of gamma amino butyric acid . It is effective to control
hot flushes
Phytoestrogens lower the incidence of vasomotor symptoms , osteoporosis and
cardiovascular disease. It reduces the risk of breast and endometrial cancer.
Soy protein is found effective to reduce vasomotor symptoms.

HORMONE REPLACEMENT THERAPY

The HRT is indicated in menopausal women to overcome the short term and long term
consequences of oestrogen deficiency.

Indication of hormone replacement therapy

 Relief of menopausal symptoms

 Prevention of osteoporosis
 To maintain the quality of life in menopausal years

BENEFITS OF HRT

 Improvement of vasomotor symptoms

 Improvement urogenital atrophy
 Increase in bone mineral density
 Decreased risk in vertebral and hip fractures
 Reduction in colorectal cancer
 Possibly cardio protection

Risk factors for osteoporosis in a woman

 Family history
 Age – elderly
 Race – asian , white race
 Lack of oestrogen
 Body weight – low BMI
 Early menopause – surgical , radiation
 Dietary – decrease calcium , vitamin D and increase caffeine and smoking
 Sedentary habit
 Drugs – heparin , corticosteroids
 Diseases – thyroid diseases , hyperparathyroidism amlabsorption , multiple myeloma.
RISKS OF HORMONE REPLACEMENT THERAPY

 Endometrial cancer
 Breast cancer
 Venous thromboembolic disease
 Coronary heart disease
 Lipid metabolism
 Dementia , Alzheimer are increased

CONTRAINDICATIONS TO HRT

 Undiagnosed genital tract bleeding

 Oestrogen dependent neoplasm in the body
 History of venous thromboembolism
 Active liver disease
 Gall bladder disease

AVAILABLE PREPARATIONS FOR HORMONE REPLACEMENT

THERAPY

The principle hormone used in HRT is oestrogen.Commonly used oetrogens are

conjugated oestrogen or micromised oestrodiol.

Considering the risks , hormone therapy should be used with the lowest effective dose
and for a short period of time.

 Oral oestrogen regime : oestrogen conjugated equine oestrogen .3 mg is given

daily for woman who has had hysterectomy.
 Oestrogen and cyclic progestin : For a woman with intact uterus , oestrogen is
given continuosly for 25 days and progestin is added for last 12-14 days
 Continuous oestrogen and progestin therapy : Continued combined therapy can
prevent endometrial hyperplasia
 Subdermal implants : Implants are inserted subcutaneously over the anterior
abdominal wall using local anesthesia.
 Percutaneous oestrogen gel : 1 gm applicator of gel , delivering 1 mg of
oestradiol daily , is to be applied onto the skin over the anterior abdominal wall
or thighs.
 Transdermal patch : It contains 3.2 mg of 17 beta oestrdiol , releasing about 50
micro gram of oestradiol in 24 hours.
 Vaginal cream : conjugated equine vaginal oestrogen cream 1.25 mg daily is
very effective specially when used for treating atrophic vaginitis.
 Progestins : In patients with history of breast carcinoma or endometrial
carcinoma , progestins may be used.
 Tibolone : It is a steroid having weakly oestrogenic , progestogenic and
androgenic properties.
MONITORING PRIOR TO AND DURING HRT

A base level parameter of the following and their subsequent checkup are mandatory.

 Physical examination including pelvic examination

 Blood pressure recording
 Breast examination and mammography
 Cervical cytology
 Pelvic ultrasonography to measure endometrial thickness

DURATION OF HRT USE

Generally , use of HRT for a short period of 3-5 years has been advised. Menopausal

women should maintain optimum nutrition , ideal body weight and perform regular

exercise.

SURGICAL MENOPAUSE

Menopause can be surgically induced by bilateral oophorectomy (removal of ovaries), which

is often, but not always, done in conjunction with removal of the Fallopian tubes (salpingo-
oophorectomy) and uterus (hysterectomy). Cessation of menses as a result of removal of the
ovaries is called "surgical menopause". The sudden and complete drop in hormone levels
usually produces extreme withdrawal symptoms such as hot flashes, etc.

Removal of the uterus without removal of the ovaries does not directly cause menopause,
although pelvic surgery of this type can often precipitate a somewhat earlier menopause,
perhaps because of a compromised blood supply to the ovaries.

NURSING MANAGEMENT

Advice to do the exercise for reducing menopausal symptoms

Advice about life style modification and nutritious diet
Reinforce the physicians explanation of surgical menopause and its possible effects
Allow time for questions and clarification of information provided
Explain the probable effects of the surgery on sexual functioning
Explain the rationale for ,side effects of schedule for taking and importance of taking
medications prescribed
Keep scheduled follow up appointments with health care provider while on estrogen
replacement therapy
Avoid lifting objects over 10 pounds ,sitting for long periods , stair climbing, and
strenuous physical activity for 6 – weeks post operatively
Avoid douching , using tampons and sexual intercourse for 4 – 6 weeks
postoperatively
SUMMARY

Menopause is the cessation of a woman's reproductive ability, the opposite of menarche.

Menopause is usually a natural change; it typically occurs in women in midlife, during their
late 40s or early 50s, signalling the end of the fertile phase of a woman's life.

menopause is commonly defined by the state of the uterus and the absence of menstrual flow
or "periods", but it can instead be more accurately defined as the permanent cessation of the
primary functions of the ovaries. What ceases is the ripening and release of ova and the
release of hormones that cause both the build-up of the uterine lining, and the subsequent
shedding of the uterine lining (the menses or period).

The transition from a potentially reproductive to a non-reproductive state is normally not

sudden or abrupt, occurs over a number of years, and is a consequence of biological aging.
For some women, during the transition years the accompanying signs and effects (including
lack of energy, hot flashes, and mood changes) can be powerful enough to significantly
disrupt their daily activities and sense of well-being. In those cases various different
treatments can be tried.

CONCLUSION

Medically speaking, the date of menopause (in a woman with an intact uterus) is the day after
the final episode of menstrual flow finishes. "Perimenopause" is a term for the menopause
transition years, the time both before and after the last period ever, while hormone levels are
still fluctuating erratically. "Premenopause" is a term for the years leading up to menopause.
"Postmenopause" is the part of a woman's life that occurs after the date of menopause; once a
woman with an intact uterus (who is not pregnant or lactating) has gone a year with no flow
at all she is considered to be one year into post menopause.
NURSING MANAGEMENT

Advice to do the exercise for reducing menopausal symptoms

Advice about life style modification and nutritious diet
Reinforce the physicians explanation of surgical menopause and its possible effects
Allow time for questions and clarification of information provided
Explain the probable effects of the surgery on sexual functioning
Explain the rationale for ,side effects of schedule for taking and importance of taking
medications prescribed
Keep scheduled follow up appointments with health care provider while on estrogen
replacement therapy
Avoid lifting objects over 10 pounds ,sitting for long periods , stair climbing, and
strenuous physical activity for 6 – weeks post operatively
Avoid douching , using tampons and sexual intercourse for 4 – 6 weeks
postoperatively

NURSING DIAGNOSIS

 Pain ( mild or moderate ) related to specific menopausal condition

 Grief related to mid to late life losses
 Deficient knowledge related to limited experience regarding specific menopausal
condition
 Ineffective coping related to lack of acceptance of prognosis

NURSING INTERVENTIONS

 Education regarding reduction of risk factors

 Emphasizing prevention strategies
 Explaining therapeutic interventions to ensure successful compliance
 Education to focus on health promoting nutrition , maintenance of appropriate
weight for height and exercise
BILBLIOGRAPHY

 D.C DUTTA , Text book of gynaecology , 6th edition ,new central book publishers,
page No 56-63.
 Myles Text book for Midwives ,14th edition , Churchill Livingstone Publishers ,page
No 123-126
 Annamma Jacob , A comprehensive Text Book of Midwifery and Gynaecological
nursing , 3rd edition ,page No 144-146

NET REFERENCE

 Menopause: MedlinePlus
 www.Menopause and Menopause Treatments.com
 Menopause.org