Menopause and Climacteric
Definition. Menopause refers to final cessation of menstruation while climacteric signifies the period at which the woman gradually adjustments from the reproductive life into a single of senescence. Meno¬pause is also referred by the laity as 'the change of life'. Then again both the terms are generally synonymously made use of, menopause getting the favorite term applied. These are physiological processes due to cessa¬tion of ovarian follicular function.
Aetiology. Menopause occurs as result of exhaustion of eggs from ovarian follicles and Consequent oestrogen deprivation.
Physiological Changes in Climacteric or Menopause and Post menopausal age.
Genital. Progressive atrophy of genital organs occurs with extra and far more deposition of fibrous tissue in them.
Ovary. They go smaller (5 gm. each), fibrotic with furrowed surface, Follicles get exhausted. Ovarian Vessels develop into sclerosed. Cortical stromal hyperplasia is a frequent discovering due to high LH level in women aged 40¬46 years. Ovarian stroma becomes a source of small amount of androgens.
Fallopian tubes shrink with diminished mortility.
Uterus becomes modest and fibrotic due to atrophy of muscle. Endometrium becomes thin and atrophic (senile). In some girls, endometrial. hyperplasia may possibly happen after menopause as a result of continuous oestrone stimulation. Cervix atrophies and flushes with the vaginal vault. Cervical secretion becomes scant, thick and later 4isappears. The vaginal epithelium atrophies with loss of rugosity. Vaginal smear shows atrophic modifications. Vagina contracts with shallowness of the fornices. Vulva gradually atrophies with narrowing of the introitus : pelvic cellular tissue becomes gradually lax.
Secondary sex characteristics. Breasts show gradual atrophy of the glandular tissue resulting in flabbynes. These grow to be pendulous due to deposition of fat about. Pubic and axillary hair becomes sparse.
Physical. Body weight decreases immediately after 65 years. There is reduce in cell mass of organs. Skin wrinkles, becomes much less elastic with hair appearing on face. Subcutaneous fat deposition. happens on the hip and thighs. Height diminishes postraenopausally just after 65 years. Kyphosis could develop due to spinal osteoporosis.
Metabolic. Osteoporosis occurs as a result of oestrogen deprivation. Reduction in trabecular bone (collagen matrix) (Osteoblasts) and Calcium leads to oestrogen deprived Osteoporosis. Premenopausally woman is protected against ischaernic heart disease due to high HDL and low LDL cholesterol. The latter rises postmenopause, thus incidence of ischaernic heart illness also rises. Premature menopause organic or by oophorectomy suffers from improved risk of cardiovascular diseases (cardiac and cerebral stroke) and osteoporosis.
Digestive. Hypochlorhydria develops. Motor activity of whole alimentary tract diminishes resulting in dyspepsia and constipation in postmenopausal females. Bladder and urethral epithelia atrophy.
Psychosexual. Emotional upsets are common. At menopause sex urge can raise. Following 60 years, sex urge wanes as an aging course of action.
Endocrinal. There is gonadal failure at menopause. Plasma Oestradiol level falls, oestrone remains usual, ovarian stroma having said that, produces andostenedione. Extraglandular conversion of androstenedione to oestrone occurs in fatty tissue. Postmenopausally, adrenal cortex becomes the source of oestrone derived from androstenedione. Oestrone becomes the predominating oestrogen soon after menopause. Postmenopausal day-to-day oestrone formation has been estimated as 15 100 gg/day (Mac Donald et al, 1973) and serum level at 30 70 pg/ml. Progesterone secretion ceases from the ovary due to failure of ovulation. Total urinary oestrogen level falls to about 6 Pg1 24 hours at the postmenopausal period. Androstenedione level mostly from adrenal cortex, small . from ovary comes to one particular half that observed prior to menopause. Testosterone level does not appreciably fall simply because postmenopause ovary secretes far more testosterone.
Pituitary gonadotrophins. FHS and LH are secreted in escalating amount due to the absence of negative feed back manage by the ovarian steroids. LH ovulatory surge disappears, the mean basal serum menopausal gonadotrophin levels are in the range of 50 150 rn LU/ml FSH and 50 100 m IU/ml LH. FSH level is 15 instances higher than premenopausal level by three five years after menopause although LH level is improved three fold. Prolactin level falls.
Timing. The procedure of climacteric could possibly gradually start off two three years prior to menopause but may well continue two five years right after it. The age at which menopause happens varies widely from 40 to 55 years with mean age of about 47 years. Genetic makeup, race and climate influence age of menopause. Women of tropics get earlier menopause than those in colder climate. Some think that the early the menarche starts, the later would be the menopause even though late coming of the menarche is related with early menopause. Early or delayed menopause is deemed when menopause takes place ahead of 35 years or immediately after 55 years respectively. Early menopause might be due to ovarian failure, oophorectomy or ovarian irradiation.
Delayed menopause is commonly due to some pelvic pathology like uterine fibroid or in association with disease e.g., diabetes mellitus.
Clinical Functions of Menopause and climacteric
Menstrual Symptoms. This occurs in types of (a) progressive scanty menstrual loss followed by cessation of menses, (b) menses at prolonged intervals lastly ceasing, (c) sudden cessation of menses. Prior to menopause menstrual cycles turn out to be anovulatory. Any excessive menstrual loss or irregular haemorrhage is not menopausal as in generally believed by lay public but is due to some pelvic pathology.
Other symptoms. Most women stay asymptomatic. They adapt nicely the physiological alterations of menopause. Some may have mild symptoms of placing on weight, joint pains, improve of sex want followed by its gradual lower.
Signs. The following signs appear gradually in a normal woman in the menopausal period and thereafter.
1. General signs. Increase in weight, deposition of fat on the hip, buttocks, around breasts. Breasts are examined.
two. Genital signs.
Vulva. Progressive atrophy with scanty hair with narrowing of the vaginal introitus.
Vagina. This becomes narrow with 'tenting' of vaginal vault,, thinning of mucous membrane and 18ss of rugae.
Cervix. Portio vaginalis atrophies and gets flushed with vaginal vault.
Uterus. Body is felt compact and hard.
Adnexae. Ovaries turn out to be impalpable.
Diagnosis. This can be made from clinical capabilities aided by atrophic vaginal smear and elevated serum FSH level of 50 mIU/ml and above. Elevated plasma LH level is much less useful. Urinary or serum oestrogen level shows value similar to follicular phase and therefore much less reputable for diagnosis.
Differential Diagnosis. Stoppage of menses due to menopause can be simulated by that due to pseudocyesis or pregnancy.
Treatment. Psychotherapy. Explanations for the condition and reassurances are to be given to the woman passing via climacteric when searching for advice for cessation of menses. Improvement of well being by dietetic adjustment, adequate rest and physical exercise and standard evacuation of bowel are to be ensured. For sleep disturbance, diazepam (Valium) five mg. or Lorazepam 1 or two mg. is taken orally at bed time.
Menopausal or Climacteric Syndrome
Menopausal Syndrome refers to group of symptoms that are seasoned by some females through climacteric. Hot flushes (vasomotor instability symptom) that final for 1 year in 80% are characteristic of menopausal syndrome. It diminishes of its own by three 4 years. The lead to of hot flush is unclear but follows oestrogen withdrawal in girls with poor vascular manage. Rise of hypothalamic endorphin is implicated. It is knowledgeable by, 25% ladies with psychological background, specifically following oophorectomy or ovarian irradiation at younger age.
Flush depends on rate of oestrogen loss and extragonadal oestrone formation. The body gradually adjusts itself to all-natural decline of oestrogen and flushes gradually pass off.
Symptoms. These appear as follows: vasomotor and other symptoms normally stick to but even precede cessation of menses.
1. Menstrual. Menses quit as currently described below menopause. A proportion of premenopausal women come with emotional symptoms, loss of libido and dry vagina during intercourse, Hot flushes and sweats are complained with scanty and delayed menses by some ladies.
two. Vasomotor. 'Hot flushes' (feeling of warmth) due to cutaneous vasodilatation are frequently skilled by these, girls on the face and neck spreading all more than the body this feeling of heat can be followed by sweating. They could possibly come once a day but occasionally each and every hour they come particularly at night. These are characteristic manifestations of menopausal syndrome.
3. Emotional. This is manifested by headache, irritability, sleeplessness, giddiness, fatigue, depression, palpitation. There could possibly be sensations of 'pins and needles' in the sole and palm. Disturbed sleep can be due to hot flushes and sweats.
4. Sexual. These are decreased libido and dyspareunia due to atrophic vaginitis and lack of vaginal lubrication during intercourse.
5. Musculoskeletal. These appear as backache, pain in joints due to laxity of ligaments and muscles.
Signs. These are exact same as described beneath menopause.
Diagnosis. This has been already described below menopause.
Differential Diagnosis. Pseudocyesis of spurious pregnancy may be mistaken by the patient for menopausal syndrome. In the former, amenorrhoea, enlargement of breasts and abdomen due to deposition of fat like that in pregnancy happen there is also the false feeling of foetal movements due to flatulent dyspepsia. The patient need to be assured that her symptoms are menopausal. In all these instances, pregnancy can also happen and should certainly be meticulously excluded by thorough examination, immunological urinary pregnancy test and pelvic ultrasound.
Premature Menopause
Definition. Menopause coming on a patient below 35 years is named premature menopause. Result in. Poor stock of ovarian follicles gets exhausted. Clinical Attributes, Symptoms, Secondary amenorrhoea for a lot more than 6 months. In some hot flushes, mood instability, disturbed sleep, loss of libido, (menopausal syndrome). draying of hair. Signs. Atrophic vaginal epithelism, usual or small sized uterus. Investigations. Raised serum FSH above 50 mIU/ml. ovarian biopsy showing no ovarian follicles is not performed. Therapy Assurance, diazepam for poor sleep. Oestrogen therapy for menopausal syndrome are given. Menstruation can not be brought on hormone therapy.
Male Climacteric. About ten per cent men encounter climacteric symptoms at a later age than ladies due to androgen deprivation. The rest 90 per cent gradually adapt themselves devoid of symptoms.
