Menopause

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The evening of a well spent life brings its lamp with it…………JOUBERT


Dr Wulf Utian is the executive director of the North American Menopause society and was first to start a Menopuse clinic.

”Menopasue” is derived from greek literature , means…… ”cessation of the monthly period.”

Menopause management

  • Detailed history is to be taken—History of hysterectomy or the natural cessation of the periods, age of menopause , symptoms like hot flushes , lack of sleep , vagianl dryness, palpitations, depression etc.
  • Physical examination is to be done—-
  • Pulse , BP , heart , lungs , height , weight , waist circumference , BMI , breast examination and pelvic examination.

Risk factors are

Family history of fractures and breast carcinoma , premature menopause , hypertension , diabetes mellitus, sedentary life style , obesity , dyslipidemia and family history of clotting .
Assessment of physical activity , diet , vision , hearing , sexual health , urinary incontinence history is to be taken.

Laboratory tests


  • Complete haemogram
  • Fasting blood glucose
  • Lipid profile
  • Pap’s smear
  • Transvaginal usg
  • Mammogram
  • Thyroid function tests
  • BMD

Management


Lifestyle modification

Diet containing high fiber and sufficient water , phytoestrogens…carrot , beetroots, pumpkin , garlic , oats , barley , pomegranate , wheat , soya , dates , cherries , papaya , par boiled rice , saunf , yam  etc.
fermented foods like idli’s , dhokla etc enhance the nutritive value.
Flaxseeds , primrose oil , ginseng , vitamin E are also useful.

HRT ( hormone replacement therapy )

  • ET– estrogen therapy
  • EPT— estrogen progesterone therapy
  • AT— androgen therapy
  • Tibolone
HRT
Micronized estradiol (estrace ) 0.5 to 2 mgm per pill is the drug of choice.
Ethinyl estradiol is also given.
Estraderm patches
Vivelle-Dot —-.estradiol is fat soluble , gets easily absorbed from the skin. There are dots in between the patch resulting in smaller overall patch.
Esta spray
Estradiol transdermal spray has a metered dose—-Technology which releases low and flexible doses.
Vaginal preparations

Indications of HRT

Women with premature menopuse before 40 yrs of the age are at a risk of osteoporosis and cardiovascular diseases and is usually started for vasomotor and urogenital symptoms

Contraindications of HRT

  • Active endometrial hormone dependant cancers
  • Active breast cancer
  • Undiagnosed vaginal bleeding
  • Abnormal LFT
  • Venous thrombosis

Relative contraindications

Migraine
family history of cancer breast
Utrine fibroids
Endometriosis
Gall stones

When to start HRT and when to stop

In case of premature menopuse as soon as it startes and to be continued till the age of natural menopause.Moderate to severe symptoms require HRT. Minimal dose upto 2 yrs is sufficient in 75% of women,.2-3 months gap is required to see whether to continue HRT or not ?
Women having hot flushes and vaginal dryness may require restarting of the therapy.

Withdrawal symptoms of HRT

  • Pain
  • Stiffness
  • Hot flushes
  • Depression
  • Vaginal dryness
  • Weight gain
  • Bloating or gas.
Reassurance , adequate diet , lots of water , physical activity usually controls the symptoms in 75% of women.25% require restarting of the therapy provided there are no risk factors to restart it again.
Progestogens are also an integral part of HRT..
IUS-LNG and natural progesterone in women having uterus protect against endometrial hyperplasia which occurs with unopposed estrogen.
Tibolone ( gonadomimmetic ) 2.5mg daily orally may be a choice for surgically induced menopause.
Plasma estriol levels witth ET therapy need to be maintained at 250pmol/l for symptom control and bone protection.
Testosterone may be added who do not get relief from lethargy , loss of libido and headache inspite of the adequate ET dose.
If BSO is done at a younger age , HRT should be strated till the age of natural menopause.
Transdermal patches are prefered and should be strated just after the operation when patient is in the hospital
Ref
  1. Dr Rashmi S Shah , Jt sect, IMS ,
  2. Dr Sharad kumar, Jt Sec, IMS , Lucknow
  3. Dr Meeta singh, Founder Secretary IMS.
  4. Dr Duru shah , President of IMS
  5. Dr Atul Praful Munshi, Sr Prof. obgyn, Ahmedabad
  1. Vivelle-dot, an estrogen patch.

    Image via Wikipedia

Estradiol

Image via Wikipedia

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