Sunday, July 19, 2015

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Menopause - Definition, symptoms and hormone replacement therapy



 Menopause  refers to a point in time that follows 1 year after the permanent cessation of menstrual periods that occurs naturally or is induced by surgery, chemotherapy or radiation.

On average, natural menopause occurs between 50 and 51 years (range 45–59) and is part of the process of normal ageing. It has been noted that smoking advances the age of menopause by approximately 2 years.
The diagnosis can only be made retrospectively and it is usually preceded by months or years of irregular cycles, that is not associated with some other physiological or pathological causes.

If the cessation of menses occurs before the age of 40, then it is referred to as the "Premature ovarian failure".
The older terms perimenopause or climacteric generally refer to the time period in the late reproductive years, usually late 40s to early 50s. Characteristically, it begins with menstrual cycle irregularity and extends to 1 year after permanent cessation of menses. The more correct terminology for this time is menopausal transition. This transition typically develops over a span of 4 to 7 years, and the average age at its onset is 47 years

Up to 75% of women will experience adverse symptoms related to menopausal transition while the others may not have any symptoms at all. Although symptoms associated with menopause occur as a result of oestrogen deficiency, replacing it is not always the treatment of choice.
The use of HT should be made on an individual basis, after careful consideration of quality of life and personal risk factors. In addition to any pharmacological treatments considered, lifestyle modifications are essential.

Below a few of the symptoms are discussed and whether hormone replacement may be helpful:

Hot flushes are characterised by a feeling of intense warmth, often accompanied by profuse sweating, anxiety, skin reddening and palpitations. They are sometimes followed by chills.
In most cases, they will resolve in around 1 year or less without any treatment.
1/3 rd of the patients will have symptoms for up to 5 years after natural menopause and in 20% they may persist for up to 15 years or more.
Menopause induced by surgery is associated with about a 90% probability of hot flushes during the first year. In these cases, symptoms are often more abrupt and severe and can last longer than those associated with a non-surgical menopause.

Hormone therapy is the most effective (80% efficacy) treatment for vasomotor symptoms associated with menopause at any age, but benefits are more likely to outweigh risks for symptomatic women before the age of 60 years or within 10 years after menopause.
Extra care must be taken in women with a history of hormone-dependent cancer, e.g. breast cancer.


Genitourinary symptoms due to menopause can affect up to 50% of women, however it is under diagnosed and under treated. The pathology here is that there is a loss of estrogen which results in urogenital ageing. The tissues of the vaginal walls becomes thinner since the amount of collagen and elastin is reduced. The walls become pale, thin and lose their elasticity. A reduction in vaginal secretions and decreased tissue elasticity also increases the susceptibility to trauma and pain or irritation during or after intercourse.

In addition to vulvo-vaginal symptoms, the less acid pH of the estrogen-deficient vagina increases the likelihood of urinary tract infections.

Vaginal symptoms become apparent 4–5 years after the menopause. 25–50% of all postmenopausal women have some objective changes as well as subjective complaints.
Symptoms may include vaginal dryness (75%), dyspareunia (38%), vaginal itching, burning and pain (15%).
Locally administered vaginal estrogens (creams, pessaries, tablets and vaginal rings) are equally effective in the treatment of menopause-related vulval and vaginal symptoms. Local estrogen therapy will lower vaginal pH, thicken the epithelium, increase blood flow and improve vaginal lubrication.

There are no evidence to support the use of hormone replacement for the urinary symptoms.


The decline in estrogen results in a decrease in the bone mineral density and a subsequent significant increase in the prevalence of osteoporosis.

General management includes:
1) assessment of the risk of falls and their prevention,
2) maintenance of mobility and
3) correction of nutritional deficiencies, particularly of calcium, vitamin D and protein.

Pharmacological interventions include bisphosphonates, denosumab, parathyroid hormone peptides, raloxifene and strontium ranelate. All have been shown to reduce the risk of vertebral fracture and some have been shown to reduce the risk of non-vertebral fractures. However, all are associated
with side effects and many women will fail to comply.
Hormone therapy reduces the risk of spine and hip, as well as other osteoporotic fractures even in women at low risk. It would appear that half of the traditional bone conserving doses are effective in conserving bone mass and are successful means of fracture prevention. However, hormone replacement is not the first line therapy in treating post menopausal osteoporosis.


The incidence of CVD increases with age and menopause may have an adverse effect. Hormone therapy was thought to confer CVD risk reduction but some studies demonstrated an increased number of coronary heart disease events and strokes and concluded that the risks outweighed the benefits. These studies were carried out on elderly women though and probably there was already an element of atherosclerosis that influenced the outcomes. Recent studies suggest that if hormone replacement is started soon after menopause, it may actually be beneficial.


Since the sex hormones are known to be thrombogenic there is an expected increase in the risk of deep vein thrombosis and stroke when using oral replacement therapy. The risk is further increase if the patient is a smoker.



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