Novak 29 Menopause

-1- 백병원 산부인과

2003-11-04R2 길 민 경

≥ 30% of female population of U.S.A. : postmenopausal, increasing

each woman’s response to menopause : may be different → management must be individualized to each woman’s needs

Menopause : permanent cessation of menses for 1 years, physiologically correlated with decline in estrogen secretion resulting from loss of follicular function

Perimenopausal period encompasses the time before, during, and after menopause usually begins in the mid- to late 40s often insidious & uneventful but may be abrupt and sympto

matic – Sx that begin with the menopausal transition usually continue into the postmenopausal period

Perimenopausal Phases

period surrounding the menopause – before, during, and after

length : varies, usually considered to last approximately 7 years

Menopausal Transition varying degree of somatic changes that reflect alterat

ions in the normal functioning of the ovary early recognition of the Sx and use of appropriate scr

eening tests : minimize the impact of this potentially disruptive period

In some women, menstrual irregularity : most significant Sx of the menopausal transition

Ut bleeding associated with this transition period : 2’ to normal physiologic estrogen fluctuations rather than underlying pathology and may be treated medically

Menopause Cessation of menses resulting from the loss of ovarian function :

natural event, a part of the normal process of aging. Resulting from loss of ovarian follicular function, should be characterized as an event rather than a period of time

Time of menopause is determined genetically and occurs at a median age of 51 years, related neither to race nor nutritional satatus

Menopause occurs earlier in nulliparous women, in those who smoke tobacco

Modern laboratory testing, menopause may now be more precisely defined as amenorrhea, with signs of hypoestrogenemia, and an elevated serum FSH level of greater than 40 IU/L

Postmenopausal Period

This period comprise more than one-third of the average woman’s life

Hormone replacement therapy : one of primary concerns of many postmenopausal women’s health care

Premature Ovarian Failure(1)

Loss of ovarian function is usually a gradual process that occurs over a number of years

Ovarian function is lost earlier and more suddenly than expected in some women as a result of natural causes, chemoTx, or surgery

Defined as menopause occurring spontaneously before 40 years of age

Both psychological and hormonal support may be necessary, possibility of associated endocrine abnormalities should also be considered

Premature Ovarian Failure(2) More than 40% of women who have hysterectomies, both ovaries

are removed : relatively young age of these women and the abrupt onset of associated Sx create special problems

Most obvious problem with surgical menopause is the acute onset of hot flashes → after several months, followed by signs of vaginal atrophy, long-term surgical menopause has been associated with significantly higher risk for both osteoporosis and cardiovascular disease than has natural menopause

Relative risks and benefits of oophorectomy in conjunction with estrogen replacement therapy : should be thoroughly discussed with any woman considering bilat oophorectomy at the time of hysterectomy

Hormonal Changes

Menopausal Transition

Ovarian follicle become increasingly resistant to FSH stimulation even though levels of estradiol remain relatively constant

Progesterone : produced almost exclusively by granulose cells and is highest in the med luteal phase, During menopausal transition, ovulation becomes less frequent, with a decrease in overall progesterone production

Menopause(1)

Hormones most affected are those produced by the ovaries and include estrogen, progesterone, and androgens

Menopause(2) Estrogen1. Even though the amount of estrogen secreted by the postmenopa

usal ovary is negligible, postmenopausal women continue to have measurable amounts of both estrone and estradiol

2. Androstenedione is produced by the adrenal and ovary and is aromatized to estrogen primarily by muscle and adipose tissue

3. Obese women : increased level of circulating estrogens, unopposed estrogen places them at an increased risk for endometrial cancer, not appear to protect them form acute menopausal Sx : however, higher levels do provide some skeletal protection

4. Thin women : decreased level of circulating estrogens, increased risk for developing osteoporosis

Menopause(3)

Progesterone1. After menopause, progesterone production ceases2. Associated with the absence of premenstrual Sx3. Decreased progesterone levels affect organs that are responsiv

e to gonadal hormones, such as endometrium and breast → higher risk of endometrial hyperplasia and cancer, development of breast cancer

Menopause(4) Androgens1. Third class of steroids produced by the ovaries, most notably test

osterone and androstenedione2. Prior to menopause, ovaries produce approximately 50% of the cir

culating androstenedione and 25% of the testosterone produced by a woman’s body

3. After menopauses, total androgen production decreases, mainly because ovarian production decreases but also because adrenal production decreases ovaries are responsible for 20% of the androstenedione and 40% of the

testosterone as a result of continued gonadotropin stimulation of ovarian stromal cell

oophorectomy also results in a marked reduction in androgen production, significance of these decreases will remain uncertain until the physiologic role of these hormones becomes more fully elucidated

Patient Concerns about Menopause(1)

the loss of fertility and menstrual function may have an impact on a woman’s sense of well-being → physician should be sensitive to the potentially significant emotional distress faced by women entering menopause and be prepared to offer psychological support

Patient Concerns about Menopause(2) Loss of Childbearing Capacity

loss of fertility may cause great distress Loss of Youth

the degree to which this may affect a woman may be related to the value she places on personal appearance

aging may not be important to many women, but the possibility that this may cause anxiety or depression should be considered

Skin Changes estrogen therapy may help to maintain skin thickness estrogen therapy cannot completely prevent the effects

of aging in skin, nor can it counteract the effects of environmental stresses on skin, such as sun exposure and cigarette smoking

Patient Concerns about Menopause(3) Changes in Mood and Behavior

Depression common problem for women and older patients belief that depression is increased during the perimenopausal period,

studies have failed to show a relationship between clinical depression and hormonal status

many psychiatric Sx occurring during this period may be more related to psychosocial events

Anxiety and Irritability many women report an increased level of anxiety and irritability during

the perimenopausal period multiple studies, however, have found no evidence to suggest that psy

chological Sx experienced during the menopausal transition are related to estrogen changes

increased anxiety and irritability associated with the perimenopausal period are more clearly associated with psychosocial factors than with estrogen status

Patient Concerns about Menopause(4)

Decreased Libido major concern for some women is a decrease in libido

or sexual satisfaction that may occur with natural or surgical menopause

Sexual activity, however, remains relatively stable in menopausal women

Vaginal changes associated with menopause may also contribute to decreased sexual satisfaction, also lead to dyspareunia → treated easily with oral or vaginal estrogen therapy

The role androgens play in libido before and after menopause is uncertain

Menopausal Transition(1)

Beginning at the age of 40 years, routine health maintenance should include screening for problems related to hormonal changes

Menopausal Transition(2) Abnormal bleeding

Menstrual irregularity occurs in more than one-half of all women during the menopausal transition Ut bleeding can be irregular, heavy, or prolonged in most cases, this bleeding is related to anovulatory cycles disruption of normal menstrual flow has been attributed to a gradual d

ecrease in the number of normally functioning follicles and is reflected by a gradual increase in early follicular-phase FSH levels

although anovulation is one of the more common causes of abnormal Ut bleeding, pregnancy must always be considered

Malignant precursors such as complex endometrial hyperplasia become more common during the menopausal transition perimenopausal women with abnormal Ut bleeding should undergo an

endometrial Bx to exclude a malignant condition

Menopausal Transition(3)

Evaluation Goal of evaluation of abnormal Ut bleeding is to achieve the

greatest accuracy with the least risk and expense for the Pt With development of less invasive office procedures and mo

re accurate outpatient surgical approaches, Ut curettage without hysteroscopy is seldom done

Fig 29.1

Menopausal Transition(4)

Menopausal Transition(5) Vaginal Ultrasonography

Vaginal USG : established first step in the evaluation of perimenopausla bleeding

With saline injection, sonohysterography can accurately visualize polyps and other focal intrauterine lesions

Endometrial stripe < 5mm thick : associated with an extremely low risk of endometrial hyperplasia or cancer

Endometrial Sampling The importance of the endometrial Bx cannot be overemphasized

for the pre or postmenopausal woman with abnormal Ut bleeding well accepted that endometrial Bx performed in the office is just as ac

curate as D&C and certainly more economical D&C should be reserved for Pt with abnormal endometrial bx or for co

nditions that preclude performing an office bx , such as Cx stenosis

Menopausal Transition(6)

Hysteroscopy with Uterine Curettage Addition of hysteroscopy to Ut curettage : greatly improved d

iagnostic accuracy in the evaluation of focal intrauterine lesions

Treatment(1)

Hormonal or surgical, depending on the pt’s Sx and Dx

Anovulation is one of the most common cuases of abnormal Ut bleeding during menopause, hormonal therapy is the first approach after the presence of intrauterine pathology has been excluded

Treatment(2)

Hormonal Therapy

Treatment(3) Oral Contraceptives

Modern low-dose(0.35mg ethinyl estadiol) oral contraceptives offer many advantages with minimal risk : use of OCs until menopause has been found to be safe in women with no risk factors for CVD

Before starting the administration of OCs in the age group, pt should be free of the following risk factors hypertension hypercholesterolemia ciagarette smoking previous thromboembolic disorder cerebral vascular disease or coronary artery disease

because the estrogen dose in these pills is approximately 4 times the dose used after the menopause, women taking this therapy should be switched to traditional estrogen therapy by 50 years of age or sooner if Sx occur

Treatment(4)

Cyclic Progestins medroxyprogesterone 10mg daily for 10 days each month induce withdrawal bleeding and to decrease the risk of endo

metrial hyper

Treatment(5)

Surgical Therapy

Treatment(6)

Dilatation and Curettage endometrial polyps are determined to be the cause of abnor

mal Ut bleeding, curettage can be both therapeutic and diagnostic

with exception of endometrial polyps, curettage has not been shown to have any long-term benefit in the Tx of abnormal Ut bleeding

Treatment(6) Hysterecotmy

Although removal of uterus is most common and effective surgical Tx for abnomal Ut bleeding, hysterectomy is associated with a certain degree of morbidity and cost

Prior to recommending hysterectomy, an adequate preoperative evaluation must include endometrial sampling and adequate trial of hormonal therapy to control bleeding

Standard practice for postmenopausal women undergoing hysterectomy to have their ovaries removed to avoid the subsequent risk of ovarian cancer

Oophorectomy has been recommended in women older than 40 to 45 years for the same reson

Treatment(7) Endometrial Ablation

A relatively new and potentially advantageous approach to DUB during the menopausal transition : endometrial ablation

Minot surgical procedure involves destrying the functioning endometrium with electrical energy using a hysteroresectoscope

Most Pt report either decreased bleeding or amenorrhea, and both intraoperative and postoperative complications are uncommon

Risk of Ut malignancy after any type of endometrial ablation procedure remains uncertain subsequent endometrial cancer after endometrial ablation has been reported o

nly in women who had preexisting endometrial hyperplasia⇒ thorough fractional curettage should be performed prior to the procedure until long-term data become available, women considering this therapy should

be informed about the potential risk of endometrial ablation