Session 5: Menopause

Question 1

Define menopause.

Answer 1

When there has been a permanent cessation of menstruation for 12 consecutive months. This happens whene there are no primary follicles left. When the ovaries no longer able to produce follicles, oestrogen levels start to decline.

The time when there has been no menstrual preiods for 12 consecutive months and no other biological or physiological cause can be identified.

Question 2

Menopause is a phase, but it can be divided into subphases.

Which?

Answer 2

Pre-menopause

Peri-menopause

Menopause

Post-menopause

Question 3

Explain pre-menopause.

Answer 3

Initial changes that occur to a menstrual cycle.

The menstrual cycle often shortens, ovulation is either early, or absent, and so problems with fertility can occur.

Question 4

What happens biochemically in pre-menopause.

Answer 4

Oestrogen levels fall. The negative feedback on the HPG axis is removed and therefore levels of LH and FSH rise.

FSH will rise more than LH because of the removal of inhibin on the HPG axis.

Question 5

Explain the peri-menopause.

Answer 5

The transition phase where additional physiological changes occur.

Question 6

Which are the common physiological changes that occur during peri-menopause?

Answer 6

Mood swings

Hot flushes

Insomnia

Menstrual irregularity

Psychological symptoms

Question 7

Define post-menopause.

Answer 7

Refers to women who have experienced the changes of menopause and are now deemed as post-menopausal.

Question 8

Is it still possible to become pregnant in the phases of menopause?

Answer 8

Yes it is possible to become prengant in the pre or peri-menopausal phase.

Question 9

When does menopause usually occur?

Answer 9

45-55 years

50 yrs of age is the average.

Question 10

Define early menopause.

Answer 10

Menopause that occurs well below the average of natural menopause under age of 45.

Question 11

Define premature menopause.

Answer 11

Cessation of menstruation due to depletion of ovarian follicles before age of 40. Also called premature ovarian failure.

Question 12

When is it ocnsidered no longer possible for a woman to conceive?

Answer 12

After 12 consecutive months of no menstruation (menopause).

Question 13

Explain the hormonal changes in menopause.

Answer 13

Since a 45+ yr old will only have a few primordial follicles left to be stimulated by FSH and become a Graafian follicle. As the granulosa cells and theca interna develop.

The theca interna will then in response to LH to produce androgens. The FSH will stimulate the granulosa cells to convert androgens to oestrogens by aromatase. FSH stimulation of the granulosa cells also cause secretion of inhibin. Inhibin inhibits FSH.

This means that if there are little to no follicles left the production of oestrogen by the ovaries will decrease. At one point the oestrogen levels will fall so low that oestrogen can no longer inhibit production of LH and FSH.

FSH rises more than LH.

Question 14

Why does FSH rise more than LH during menopause?

Answer 14

Because there are no more follicles to produce granulosa cells. The granulosa cells produce inhibin which inhibits FSH.

Without this inhibition FSH will rise greatly.

Question 15

Which hormone is measured to diagnose physiological menopause?

Answer 15

FSH

Question 16

Explain hot flushes of the menopause.

Answer 16

Due to vascular changes and vasomotor tone. The oestrogen is important to maintain vasomotor tone (smooth muscle). Absence of oestrogen leads to vasodilation and transient rises in skin temperature, flushing and sweating.

Question 17

Duration of hot flushes.

Answer 17

Few seconds to several minutes

Question 18

Frequency of hot flushes

Answer 18

Rare to recurrent every few minutes.

Question 19

Symptoms of hot flushes.

Answer 19

Chills

Nausea

Anxiety

Feelings of suffocation

Inability to concentrate

Question 20

Explain dysfunctional uterine bleeding.

Answer 20

Lower oestrogen levels leads to ovulation becoming irregular. Progesterone is not produced if ovulation doesn’t occur so periods become irregular and can lead to heavy bleeding. Also intermenstrual bleedings.

Question 21

What is important to note with low progesterone levels?

Answer 21

That the oestrogen that is left can be unopposed.

Question 22

Why is unopposed oestrogen a problem?

Answer 22

Because oestrogen causes the endometrium to thicken and proliferate.

Progesterone is anti-mitotic of endometrial tissue and also enhances the inhibitory effect of oestrogen on GnRH and LH/FSH. It also inhibits the positive feedback that oestrogen has on GnRH and LH/FSH in high levels.

Question 23

What are complications of unopposed oestrogen?

Answer 23

No ovulation -> no progesterone -> endometrial proliferation.

Endometrial proliferation can lead to an increased risk of carcinoma.

Question 24

Explain the changes of the ovaries in menopause.

Answer 24

The ovaries become smaller as they atrophy.

This is because the oestrogen production is going down.

After the menopause the substantially increased gonadotropin levels maintain ovarian androgen secretion despite the substantial oestrogen demise.

Aromatase can convert this androgen to oestrogen in ovaries and adipose tissue.

Question 25

Changes in general appearance during menopause.

Answer 25

The skin loses its elasticity. Due to loss of elastin and collagen.

Weight increase. Most likely due to mood swing. However there is more deposition of fat around hips, waist and buttocks.

The hair becomes dry and coarse as well as thin.

The voice can become deeper due to thickening of the vocal cords.

Question 26

Explain the effects digestive and urinary system due to menopause.

Answer 26

Since oestrogen is involved in vasomotor tone of smooth muscle it will have an effect on digestive and urinary tracts.

Constipation can occur and bloating.

Loss of pelvic tone can lead to urinary incontinence and increased tendency of UTIs.

Question 27

What are the early post-menopausal consequences?

Answer 27

Vaginal atrophy

Dyspareunia

Skin atrophy

Urge-stress incontinence

Question 28

Explain the changes in the genital organs (internal).

Answer 28

The uterus can become small and fibrotic due to atrophy of the muscles after the menopause as the endometrium regress and so does the myometrium.

The cervix will become smaller and appear to flush with the vagina.

There is thinning of the cervix and vaginal rugae is lost.

Question 29

Explain the changes in the external genital organs.

Answer 29

The fat in the labia majory and the mons pubis decreases and pubic hair become spare.

The breast in thin women become flat and shrivelled

The breast in heavy built women remain flabby and pendulous

Question 30

What cancer can be a differential for post-menopausal women, and why?

Answer 30

Ovarian cancer can present with symptoms as vague as bloating which also can happen in post-menopausal women.

There has also been a link with HRT for symptomatic treatment of menopause and ovarian cancer.

Question 31

State the late consequences of post-menopausal women.

Answer 31

Osteoporosis

Atherosclerosis

Coronary heart disease

Cardiovascular disease

Alzheimer’s disease

Question 32

Explain why osteoporosis happens in post-menopausal women.

Answer 32

Oestrogen normally inhibits osteoclasts. But as oestrogen levels fall osteoclast activity will increase. This means that more bone is absorbed and increased calcium loss from bone.

This leads to osteoporosis.

Can cause pathological fractures such as #NOF.

Also causes reduced height due to reduced bone mass

Question 33

Explain cardiovascular effects of post-menopausal women.

Answer 33

Low levels of oestrogen and progesterone cause changes in the lipid profile in postmenopausal women.

This leads to increasing circulating lipid levels and increased risk of atherosclerosis. Increased cholesterol levels and hyperlipidaemia.

This can lead to embolic events such as MI and stroke.

(This might because less androgens are produced which are produced from cholesterol. If cholesterol doesn’t go down that pathway it will accumulate somewhere else)

Also blood pressure increases and insulin resistance increases as well which can lead to diabetes.

Question 34

Treatments of menopause.

Answer 34

Hormonal or non-hormonal

Question 35

Explain non-hormonal management of menopause.

Answer 35

Dietary advice

Avoid caffeine, alcohol and spicy foods to alleviate hot flushes

Question 36

Hormonal management of menopause.

Answer 36

HRT (Hormonal replacement therapy)

The main purpose is to manage symptoms related to low levels of oestrogen to improve well-being and limit osteoporosis.

Question 37

What types of HRT are there?

Answer 37

In pill form where you get both oestrogen and progesterone.

Vaginal cream with oestrogen.

Transdermally in patch form.

Question 38

Why is HRT not given for cardioprotection?

Answer 38

The reason why it isn’t working for cardiovascular protection is not known.

It might be that giving exogenous oestrogen does not help with that maybe cholesterol accumulate due to it not going down the pathway to be converted into androgens.

This is entirely speculations.