MENOPAUSE PART 1 Pathophysiology and Assessment Flashcards
Stages of Menopause
Diagnosed retrospectively
If an indiv has not had period for up to 1 yr, that is menopause
End of periods
Perimenopause, changes in normal mesntrual cycles, symptoms
Can occur 8-10 yrs before final mesntrual period
35-45 perimenopause
Stages of Reproductive Aging (STRAW)
Staging Model
Menopause transition: time you are starting to see changes aka perimenopause
Peri includes the menopause transition and up to 1 yr
Late menopause trnasition will see more cycle changes
Transition can last up to 10 years
Early postmenopause is up to 5 yrs after the last period
Definitions
§ Natural menopause:
§ Induced menopause:
§ Early menopause:
§ Premature menopause
§ Natural menopause:
* 12 months of amenorrhea with no known pathologic
cause
§ Induced menopause:
* Menopause following surgical removal or iatrogenic
ablation of the ovaries (e.g. chemotherapy, radiation)
§ Early menopause: before the age of 45 years
§ Premature menopause: before the age of 40 years
What happens during the menopause transition…
§ Ovarian function:
* Decreased number and function of follicles
* Reduced response to FSH and LH.
§ Menstrual cycles:
* Anovulatory cycles - result in menstrual irregularity
§ Hormones:
* Altered feedback regulation - Increase in FSH/LH levels
* Fluctuating and decline of ovarian hormone production –
estrogen and progesterone
3 types found estrogen found in bod
strone (E1):
*1/3 potency of estradiol
*Conversion in liver, androstenedione in peripheral tissue
Estradiol (E2):
*Most potent
*Main endogenous hormone
*Produced in ovaries
Estriol (E3):
*Least potent
*Metabolite from estradiol and estrone
*Highest levels in pregnancy as also produced by placenta
Ratio converrts will see more estrone than estradiol after menopause
Estrogen Production After MenopauseWhat happens to estrogen and progesterone
during the menopause transition?
Perimenopause:
* Higher and fluctuating estrogen
levels, lower progesterone
levels
Postmenopause:
* Low estrogen and
progesterone levels
Testosterone
§ 25% ovaries, 25% adrenals, 50% peripheral conversion from
androstenedione
§ Helps maintain libido and general well-being.
§ Testosterone levels decline gradually as women age; not as
drastic as estrogen, still produce it
* Decline is due to aging rather than menopause
§ Surgical menopause will result in drop of testosterone by 50%
Diagnosis
Menopause:
§ Cessation of periods x 12 months
§ Elevated Follicle Stimulating Hormone (FSH) levels (>30
mIU/ml)
Perimenopause:
§ Symptoms
§ +/- menstrual cycle changes
§ Not diagnosed with FSH (FSH can fluctuate)
Symptoms
Duration of symptoms longer than previously thought:
n Duration of 7 - 8 years for VMS
* Median duration after last menstrual period ~4.5 years
n For third of patients can be longer than 10 years
n 20 -25% severe enough to negatively effect QOL
Many symptoms start during perimenopause – especially
vasomotor symptoms (VMS), mood symptoms (ie irritability,
PMS), and insomnia.
note: that pregnancy is still possible during the perimenopause
Menopausal Symptoms
Vasomotor: Hot Flashes, Night sweats
Sleep: Fragmented sleep
Difficulty falling asleep
Mood symptoms: Anxiety, irritability, depressive symptoms,
PMS/mood swings*Fatigue
Concentration: Memory issues, Decreased concentration, brain fog
Urogenital ageing: Vaginal dryness, dyspareunia, frequent UTI’s etc (note: now referred to as GSM
*though all of the menopausal symptoms can happen in perimenopause as well as postmenopause, the symptoms
indicated with * may be more common in perimenopause
Other Symptoms
Muscle or joint
aches/pains/back aches
Breast tenderness*
Headaches/migraines*
Heart palpitations
Low libido
Dry skin or eyes
Hair changes
Vasomotor Symptoms
§ Estrogen levels alone not predictive of severity
§ Occurs in ~75% of women
§ Hot flash:
§ Night sweats – occur at night
§ Symptoms peak in early evening, corresponds to when core body temp is also peaking
Heat in upper body: face, neck, chest
May see perspiration, clamminess, anxiety
and increased heart rate/palpitations
Vasomotor Symptoms: Proposed Mechanisms
loss of estrogens decrease endorphin
concentrations in hypothalamus
Increased norepinephrine levels and
decreased serotonin levels
Narrow thermoregulatory zone in
hypothalamus
Vasomotor Symptoms: A new mechanism
§ KNDy neurons in hypothalamus -
control of thermoregulatory centres
§ Stimulated by neurokinin B, inhibited
by estrogen
§ Low estrogen levels leads to
hypertrophy of KNDy neurons –> overactivity of KNDy neurons lead to hto flashes
§ Target of new treatment approaches
for VMS (neurokinin-3 receptor
antagonists)
Genitourinary Syndrome of Menopause
(GSM)
§ Degeneration/loss of connective tissue:
* Collagen, elastin, smooth muscle
* Vaginal shortening and narrowing
§ Reduced vaginal blood flow and secretions
§ Glycogen production decreases change in vaginal pH from
acidic to alkaline (increases vaginal pH)
Increased UTIs
Thinning Mucosa
Decreased blood flow =
decreased secretions
Symptoms of GSM
Vaginal Atrophy
Vaginal dryness
Vaginal irritation/itching
Dyspareunia
Post-coital spotting
Lower urinary tract
Recurrent UTI
LUTS (urgency, frequency, dysuria)
Sexual Function
Low libido/desire
These sympotms dont get better, they get worse
