Week 8

• Perimenopause


  • At the start, menstrual cycles will become increasingly irregular, the volume of vaginal fluid production will gradually decrease and menstrual bleeding may change
  • This is due to the gradual decline in estrogen production
  • Towards the end, 'menopause like' symptoms will start to emerge, more menstrual changes will occur and females may experience very late periods, or miss cycles entirely
  • Perimenopause can last up to 10 years before the start of menopause and is generally a time of waning fertility
• Menopause


  • Begins after the last period a women ever has
  • The average age at which females undergo menopause is approximately 51 years, however this may occur during her 40's or even 60's
  • Generally, age at which menopause starts is maternally linked - if a women's mother started menopause when she was 45 years of age, there is a good chance she will experience menopause at 45 as well
  • She may experience occasional bleeding beyond this point, but this is not a menstrual cycle per se
  • At this point, menopause symptoms increases in intensity and number
  • Typically, menopause symptoms last for 5 to 8 years and can be particularly bothersome for many women
• Postmenopause


  The period beginning 12 months after the last period, and signals the start of additional effects on the body, including an increased risk of osteoporosis, cardiovascular disease, UTI, breast cancer, incontinence, depression
• Menopause


  • Leads to a drastic reduction in the production of estrogen and progesterone since follicles, the major source of female reproductive hormones, fail to be recruited and matured to produce these hormones
  • This does not mean that females stop producing these hormones completely, since they will continue to be made by the adrenal gland, however this is in much lower amounts than the developing follicle
  • Since there are estrogen and progesterone receptors located in many cells of the body, and these hormones affect cell function and growth, cells start to lose normal functionality causing a wide array of menopause symptoms
• Goals of treatment of menopause

  To alleviate symptoms and reduce the risk of osteoporosis
• Options for treatment of menopause

  • Hormonal therapy
  • Non-hormonal therapy
• Hormonal therapy for menopause symptoms


  • To effectively 'replace' endogenous estrogen and/or progesterone using 'exogenous' hormones
  • These may be given orally, as a subdermal patch, as an implant, a vaginal gel, or via several other systemic or topical applications
• Principles guiding systemic hormonal treatment in menopause

  • Is systemic therapy preferred and warranted
  • Do they have any contraindications
  • Do they require contraception
  • Do they have an intact uterus
  • If they are taking combined MHT, is it continuous or cyclical?
• Main categories of medicine for menopausal symptoms

  • Estrogen only
  • Combined estrogen and progestogen
  • Tibolone
• Other treatments for menopause

  • Intravaginal estrogen therapy
  • Non-hormonal therapy
• Other treatments for menopause do not reduce the risk of osteoporosis
• Male anatomy


  • Vas deferens
  • Prostate gland
  • Seminal vesicles
  • Urethra
  • Penis
  • Epididymis
  • Testicles (testes)
  • Scrotum
• Vas deferens


  • Long, muscular tube that travels from the epididymis into pelvic cavity, to just behind bladder
  • Transports mature sperm to urethra in preparation for ejaculation
• Prostate gland


  • Walnut-sized structure located below urinary bladder in front of rectum, which contributes additional fluid to the ejaculate
  • Prostate fluids help nourish sperm
  • The urethra, which carries ejaculate to be expelled during orgasm, runs through centre of prostate gland
• Seminal vesicles


  • Sac-like pouches that attach to vas deferens near base of bladder
  • Make a sugar-rich fluid (fructose) that provides sperm with a source of energy and helps the sperms' motility
  • This fluid makes up most of the volume of ejaculatory fluid (ejaculate)
• Urethra


  • The tube that transports both semen and urine out of the body is located at the tip of the glans penis, which also contains nerve endings
  • Semen, which contains sperm, is expelled (ejaculated) through the end of the penis when a man reaches sexual climax
  • When the penis is erect, the flow of urine is blocked from the urethra, allowing only semen to be ejaculated at orgasm
• Penis


  The male organ for sexual intercourse which has three parts: Root, Body/Shaft, Glans
• Epididymis


  • Long, coiled tube at the back of each testicle which carries and stores sperm cells created in testes
  • Brings sperm to maturity
  • During sexual arousal, contractions force sperm into the vas deferens
• Testicles (testes)


  • Oval organs that lie in the scrotum, secured at either end by spermatic cord, responsible for testosterone and sperm production
  • Within the testes are coiled masses of tubes (seminiferous tubules) responsible for spermatogenesis (producing sperm cells)
• Scrotum


  • Loose pouch-like sac that hangs behind penis, holding testicles, nerves and blood vessels
  • Protects testes and regulates temperature; sperm development requires testes at a cooler temp
  • Muscles in wall of scrotum allow contractions and relaxation, moving testicles closer to body for warmth and protection or farther for cold
• Male reproductive hormones


  • Follicle stimulating hormone (FSH)
  • Luteinising hormone (LH)
  • Testosterone
• Follicle stimulating hormone (FSH)


  Necessary for sperm production (spermatogenesis)
• Luteinising hormone (LH)


  Stimulates the production of testosterone, which is necessary to continue the process of spermatogenesis
• Testosterone


  Important in the development of male characteristics, including muscle mass and strength, fat distribution, bone mass and sex drive
• Erectile dysfunction (ED)


  A medical condition that prevents a man from achieving an erection or maintaining one through sexual intercourse
• Erectile dysfunction is common, affecting 1 in 5 men over 40 and 50% of men older than 70
• Erectile dysfunction can be caused by ageing, medical conditions, use of some drugs, or lifelong chronic smoking
• Normal penile anatomy and erection physiology

  • Corpus cavernosum
  • Tunica albuginea
  • Corpus spongiosum
  • Deep central artery
• Erection process


  1. Flaccid state: Sympathetic nervous system keeps smooth muscle contracted, allowing bidirectional blood flow

  2. Erect state: Sexual stimulation releases neurotransmitters, smooth muscle relaxes, blood flow increases, veins compressed so blood can't escape, erection results
• Mechanism of erection


  1. Central stimulation activates NANC nerves, releasing nitric oxide which stimulates guanylate cyclase, leading to decreased intracellular Ca2+ and smooth muscle relaxation

  2. Cholinergic nerves can also cause endothelial cells to release NO

  3. Adrenergic nerves release noradrenaline, causing smooth muscle contraction and flaccid state

  4. Prostaglandin E receptors also cause smooth muscle relaxation and increased blood flow
• Classification of ED


  • Primary ED
  • Secondary ED
• Primary ED


  • Relates to maldevelopment of the corpora or the blood and nerve supply
  • May also be due to primary psychological dysfunction or endocrine abnormalities
• Secondary ED


  Due to some other exogenous cause, including iatrogenic causes such as medication side-effects, toxins, or medical injury
• Vascular ED (vasculogenic)


  • ED and cardiovascular disease share the same risk factors
  • Endothelial dysfunction is the pathophysiologic mechanism, possibly also involving chronic inflammation and oxidative stress
• Hormone deficiency or hypogonadism ED (endocrinologic)

  • Low testosterone, as well as other hormones involved in testosterone metabolism, can impact erectile function
  • Relationship between testosterone and ED is complex due to lack of standardised measurement and cyclic nature of release and consumption
• Diabetes and ED


  • There is a causal link between diabetes and ED
  • T2DM may cause ED through psychological, central nervous system, or peripheral nerve effects
• Stepwise approach to managing ED

  1. Initiates the discussion: Enquire on sexual health with open-ended questions

  2. Define the sexual problem: Differentiate between different types of dysfunction

  3. History: Evaluate risk factors
• Diabetes and ED


  There is good epidemiological evidence of a causal link between diabetes and ED
• Prevalence of ED in diabetic men

  • 3 times higher than non-diabetic men (28% vs 9.6%)
  • Occurs at an earlier age
  • Increases with disease duration, being approximately 15% at age 30 rising to 55% at 60 years
• T2DM may cause ED through

  Pathophysiological changes affecting psychological function, central nervous system function or peripheral nerve activity