GYN 6

• Menopause


  Permanent cessation of menstruation at the end of reproductive life due to loss of ovarian follicular activity
• Clinical diagnosis of menopause

  Stoppage of menstruation (amenorrhea) for twelve consecutive months without any other pathology
• Menopause transition


  The period of time during which a woman passes from the reproductive to the non-reproductive stage, covering 4–7 years on either side of menopause
• Perimenopause


  The time starting few years before continuing after the period of onset of menopause
• Climacteric

  The time after the cessation of reproductive function
• Postmenopause


  The phase of life that comes after the menopause
• Age of menopause


  • Genetically predetermined, not related to age of menarche or age at last pregnancy, variably related to lactation, use of oral pill, socioeconomic condition, race, height, cigarette smoking, severe malnutrition, high altitude
  • Ranges between 45–55 years, average being 47 years
  • Late menopause seen in women with high parity or higher BMI, Earlier menopause seen in cases following chemotherapy, ovarian resection
• Due to increased life expectancy, about one-third of life span will be spent during the period of estrogen deficiency stage with long-term symptomatic and metabolic complications
• Hypothalamo-pituitary gonadal axis changes during menopausal transition and menopause

  1. Ovarian follicles become resistant to pituitary gonadotropins, diminished estradiol production

  2. Decrease in negative feedback effect on hypothalamo-pituitary axis, increase in FSH

  3. Increase in LH

  4. Decrease in inhibin, anti-Müllerian hormone (AMH)

  5. Disturbed folliculogenesis leading to anovulation, oligoovulation, premature corpus luteum or corpus luteal insufficiency

  6. Shorter menstrual cycles due to shortening of follicular phase

  7. Accelerated rate of follicular depletion, no more follicles available, estradiol production drops to 20 pg/mL, no endometrial growth, absence of menstruation
• Estrogens after menopause


  Predominant estrogen is estrone, to a lesser extent estradiol, derived from peripheral conversion of androgens, biologically less potent than estradiol
• Androgens after menopause


  Main androgens are androstenedione and testosterone, secreted by ovarian stromal cells, peripheral levels reduced due to conversion to estrone in adipose tissue, decreased estrogen:androgen ratio
• Progesterone after menopause


  Trace amount, probably adrenal in origin
• Gonadotropins after menopause


  Secretions of both FSH and LH are increased, FSH rises 10-20 fold, LH rises 3-fold, due to absent negative feedback effect of estradiol and inhibin
• Prolactin and inhibin levels fall during menopause
• GnRH, FSH, LH and estrogens decline with physiologic aging
• Organ changes during menopause

  • Ovaries shrink, fallopian tubes show atrophy, uterus becomes smaller, endometrium becomes thin and atrophic, vagina becomes narrower, vulva shows atrophy, breasts show atrophy, bladder and urethra undergo atrophic changes, pelvic relaxation and uterine descent
• Bone metabolism changes after menopause

  Bone loss of 3-5% per year due to estrogen deficiency, osteoporosis due to reduced bone mass but normal bone mineral to matrix ratio, estrogen prevents osteoporosis by inhibiting osteoclastic activity, increasing calcium absorption, stimulating calcitonin and 1,25-dihydroxyvitamin D
• Cardiovascular changes after menopause

  Increased risk of cardiovascular disease due to estrogen deficiency, estrogen prevents cardiovascular disease by increasing HDL, decreasing LDL and total cholesterol, inhibiting platelet and macrophage aggregation, stimulating nitric oxide and prostacyclin release
• Menstrual patterns prior to menopause

  • Abrupt cessation (rare)
  • Gradual decrease in amount and duration
  • Irregular with or without excessive bleeding
• Menopausal symptoms


  • Vasomotor symptoms
  • Urogenital atrophy
  • Osteoporosis and fracture
  • Cardiovascular disease
  • Cerebrovascular diseases
  • Psychological changes
  • Skin and hair changes
  • Sexual dysfunction
  • Dementia and cognitive decline
• Risk factors for vasomotor symptoms

  • Early menopause
  • Surgical menopause
  • Smoking
  • Use of SERMs
  • Sedentary lifestyle
  • White women
• Hot flashes


  Sudden feeling of heat followed by profuse sweating, due to low estrogen level, coinciding with GnRH pulse secretion and increased LH, involving thermoregulatory center and neurotransmitters
• Genital and urinary changes

  Estrogen deficiency causes atrophic epithelial changes in vagina, urethra, bladder, leading to dyspareunia, vaginal infections, urinary symptoms
• Sexual dysfunction


  Estrogen deficiency associated with decreased sexual desire, due to both psychological and atrophic genital changes
• Skin and hair changes

  Thinning, loss of elasticity and wrinkling of skin, loss of pubic and axillary hair, balding, due to low estrogen with normal testosterone
• Symptoms of menopausal transition

  • Menstrual changes
  • Vasomotor symptoms
  • Psychological changes
  • Sexual dysfunction
  • Urinary changes
  • Other symptoms (back aches, joint aches, weight gain, palpitations)
• Collagen content and thickness


  Decrease by 1–2% per year
• Characteristics of menopAusAl trAnsition

  • 'Purse string' wrinkling around the mouth and 'crow feet' around the eyes
• Symptoms of menopAusAl trAnsition

  • Menstrual changes
  • Vasomotor symptoms
  • Psychological
  • Others
• Menstrual changes


  • Shorter cycles (common)
  • Irregular bleeding
  • Vaginal dryness
  • Dyspareunia
  • Decreased libido
• Vasomotor symptoms


  • Hot flashes
  • Upper body sweating
  • Anxiety, lack of sleep
  • Incontinence
  • Urgency
  • Dysuria
• Psychological


  • Irritability
  • Mood swings
  • Poor memory
  • Depression
• Others


  • Back aches
  • Joint aches
  • Weight gain
  • Palpitations
• Estrogen receptors are present in the facial skin and maximum are present in the facial skin
• Estrogen replacement can prevent this skin loss during menopause
• After menopause, there is some loss of pubic and axillary hair and slight balding
• This may be due to low level of estrogen with normal level of testosterone
• Psychological changes


  Increased frequency of anxiety, headache, insomnia, irritability, dysphasia and depression
• Estrogen


  Increases opioid (neurotransmitter) activity in the brain and is known to be important for memory
• Dementia


  Estrogen improves cerebral perfusion and cognition