Menopause Flashcards
What is the Menopausal transition?
Menopausal transition: Period of time from changes in menstrual pattern to menopause
What is Menopause?
Menopause: The permanent cessation of menstruation due to loss of ovarian follicular function (amenorrhoea for 12 months)
What is Perimenopause and premature ovarian failure?
Perimenopause: No consistent definition. A period of changing ovarian function which precedes the menopause by 2-8 years
Premature ovarian failure: menopause <40
What does Menopause mean for women?
WHO defines natural menopause as at least 12 consecutive
months of amenorrhea not due to physiological/pathological causes.
Natural event reached upon exhaustion of primordial follicles
The global age at menopause is on average 51 years (range 40-
60 years) suggesting a distinct genetic control; strong correlation
exists between mothers and daughters
Menopausal health aspects include bone density, breast, the
cardiovascular system, mood/cognitive function and sexual well
being
Common symptoms include:
* Hot flushes, night sweats, vaginal dryness and discomfort during sex,
difficulty sleeping, low mood/anxiety, reduced libido
* Physical and emotional changes strongly affect women
* 1:10 women experience suicidal thoughts due to the perimenopause
Effective health care support should be individually tailored to
all aspects of the menopause when women feel particularly
vulnerable
What is fertility determined by?
Fertility is determined by ovarian reserve. The ovarian reserve will determine the rate of decline
of NGF & age of the menopause
Estimated that
for 95% of
women by 30yrs
only 12% of
max. pre-birth
NGF population
is present and
by 40yrs only
3% remains.
Life of eggs
Changes in the number of germ cells in the
human ovary during fetal development and
throughout postnatal life.
Perimenopausal period:
The ovarian reserve will determine the onset of
subfertility to sterility and to complete loss of menstrual
cycles – the menopause
Factors affecting ovarian reserve:
Nutrition (uw/ow)
In utero environment
Genetic abnormalities, some medications, injury
androgens/pcos
ethnicity/geography
autoimmunity
genetics
SMOKING: IF MOTHER SMOKES SHE CAN AFFECT OVARIAN RESERVE OF BABY GIRL
Factors affecting ovarian reserve:
Nutrition (uw/ow)
In utero environment
Genetic abnormalities, some medications, injury
androgens/pcos
ethnicity/geography
autoimmunity
genetics
SMOKING: IF MOTHER SMOKES SHE CAN AFFECT OVARIAN RESERVE OF BABY GIRL
AMH & Ovarian reserve
The levels of AMH in the human circulation vary during the life cycle, with a sexually
dimorphic pattern. Females produce virtually no AMH in utero
Levels of AMH decreases in boys and men as they age
IN women, AMH is detect in post-menopause women, declines with age becuase of a decline in follicles
AMH come from?
Small preantral to antral follicle
- produced from granulosa cells
> 45pmol/L: PCOS
<15pmol/L: low ovarian reserve
Declining levels of AMH with age. AMH secretion from
growing follicles. What happens to levels of Inhibin B and FSH as
approach peri-menopause? Link between AFC, AMH, Inhibin B and FSH.
Rise in FSH (due to loss of negative feedback)
Decline in Inhibin B (inhibin is produced by growing follicles/ grnaulosa cells, follicles decrease so inhibin B also decreases)
Can AMH predict ovarian
reserve?
Women with higher AMH, menopause at an older age than women with low AMH
Are AMH levels are becoming the gold-standard biomarker to evaluate
ovarian reserve and predict ovarian response to hormonal stimulation?
Measurements of AMH and AFC are used to diagnosed premature ovarian failure/insufficiency
used in IVF to predict ovarian response to hormonal stimulation
Homronal changes during menopause
Ovarian senescence begins near 35 years, ends with menopause ~51 years
Decline in ovarian oestrogen largely related to
number of primordial follicles, number of recruitable
follicles in each ovarian cycle and proportion of
follicles that reach adequate maturity
Rise in FSH – loss of negative feed back
Decline in inhibin B and AMH
Decline in androgen synthesis in adrenal glands and
ovaries (substrate is lost)
Marked decline in fertility after age of 35 although
this depends on ovarian reserve
Age vs Hormonal Levels
Approximate average serum concentrations
of estradiol, estrone, FSH, LH, and total
testosterone during the menopausal
transition and post-menopause.
Drop in ____
Dynamics of Perimenopause
Ovary reserve depleted <1000 follicles
Begin Menopause
Menopausal symptoms and their onset
Steep oestrogen decrease causes:
Climateric complaints
Vaginal wall atrophy
Urge incontinence
skin atrophy
Stress incontinence
Osteoporosis
Atherosclerosis
Complaint manifest
Latent Period
Estimated prevalence of menopausal symptoms: Pre-Menopause, Peri-menopause and post menopause
Hot flashes and night sweats: 14 – 51% 35 – 50% 30 – 80%
Vaginal dryness: 4 – 22% 7 – 39% 17 – 30%
Sleep disturbance:16 – 42% 39 – 47% 35 – 60%
Mood symptoms: 8 – 37% 11 – 21% 8 – 38%
Urinary symptoms: 10 – 36% 11 – 21% 8 – 38%
Hot flushes and night sweats
Experienced by approximately 80% menopausal women, can
last up to 5-13 years though number of episodes decrease with
time
Measuring frequency most objective way of assessing severity
of menopausal symptoms
Typically occurs on the face but can occur in other body
areas such as arms and the torso
Aetiology unknown but oestrogen interacts with the
noradrenergic system in the brain which plays a major
role in thermogenesis. Other neural systems have also
been implicated such as the endorphin pathways
Wet’ flushing occurs through inappropriate vasodilation
and activation of sweat glands through both central and
peripheral mechanisms. Hormone withdrawal and emotions
are both causes
Dry’ flushing (no sweat!) can be caused by several drugs, the carcinoid syndrome, phaeochromocytomas (rare cancer of adrenal medulla) & mastocytosis (accumulation of mast cells in tissues including the skin)
Osteoporosis in Menopause
Women can lose up to 20% of their bone density in
the 5 to 7 years after the menopause (www.nhs.uk).
The drop in bone density is caused by falling levels
oestrogen, which impairs the normal cycle of bone
remodelling
i.e. increases amount of bone resorbed (osteoclastic activity)
over the amount deposited (osteoblastic activity), leading to
net loss of bone
Although bone density decreases at the menopause,
the risk of osteoporosis and fractures stays relatively
low until women get much older, because bone density
is only one of the things that affects bone strength.
Treatment option include the use of bisphosphonate
compounds, maintaining calcium and Vit.D levels, weight
bearing exercises
Genitourinary Syndrome of Menopause (GSM)
GSM – relatively new term for the condition.
Previously known as vulvovaginal atrophy,
atrophic vaginitis or urogenital atrophy.
Chronic, progressive, vulvovaginal, sexual and
lower urinary tract condition characterised by
a broad spectrum of signs and symptoms
GSM more accurately describes the post-
menopausal hypoestrogenic state of the
genitourinary tract.
Can have a significant impact on quality of life
Treatment aimed at symptomatic relief.
GSM for BSSM
POI
Premature ovarian failure
(POF)/insufficiency (POI)
Defined as cessation of ovarian function
before 40 years
Affects 1:100 women before 40 years of age and
1:1000 women before 30 years of age
