Peri-menopausal period syndrome

ZhanghuiyingZhanghuiying Department Of Obstetrics & GynecologyDepartment Of Obstetrics & Gynecology

Tianjin Medical University General HospitalTianjin Medical University General Hospital

Staging of women Staging of women climclimacteric periodacteric period

adolescenceadolescence 40yrs40yrs Final periodFinal period1yrs after 1yrs after the the Final Final

periodperiod 60-6560-65yrsyrs

Life Life stopstop

Pre menopausePre menopause Post Post menopausemenopause

Peri Peri menopausemenopause

Transitional phaseTransitional phase

(( 参考参考 WHOWHO 的定义的定义 ))

climacteric period

DefinitionMenopauseMenopause the cessation of menses for a year or more. the cessation of menses for a year or more. It is caused by ovarian failure.It is caused by ovarian failure. It marks the end of a women’s reproductive lifeIt marks the end of a women’s reproductive life It occurs normally between the ages of 45– 55 years and It occurs normally between the ages of 45– 55 years and

at a mean age of 51 years.at a mean age of 51 years. It is a physiological processIt is a physiological process

Peri-menopausePeri-menopause is a period before and after the menopaus is a period before and after the menopause. Encompasses the years leading up to menopause-anywhee. Encompasses the years leading up to menopause-anywhere from 2-8 yrs-plus the first years after final periodre from 2-8 yrs-plus the first years after final period

Peri-menopausal Period SyndromePeri-menopausal Period Syndrome peri-menopperi-menopause accompanied by the symptoms of climacteric, ause accompanied by the symptoms of climacteric, including hot flashes, excessive perspiration, night including hot flashes, excessive perspiration, night sweats, depression, agitation, vaginal dryness, insosweats, depression, agitation, vaginal dryness, insomniamnia

Premature ovarian failurePremature ovarian failure ----- ----- the cessation of the cessation of menses before the age of 40 years.menses before the age of 40 years.

Artificial menopauseArtificial menopause ------ ------ the cessation of menthe cessation of menses is secondary to some causes, such as oophorectoses is secondary to some causes, such as oophorectomy, radiation therapy.my, radiation therapy.

The basic causes of the Peri-menopausal The basic causes of the Peri-menopausal syndrome are a progressive decline in ovsyndrome are a progressive decline in ovarian production on estrogens and other arian production on estrogens and other sex hormonessex hormones

Negative Feedback

Secretion of estrogens decreased (ovary)Secretion of estrogens decreased (ovary)

↓ ↓

FSH increased (40-45 years old)FSH increased (40-45 years old)

↓ ↓

FSH,LH increased(45-50 years old)FSH,LH increased(45-50 years old)

↓ ↓

FSH increased 13 times LH increased 3 times FSH increased 13 times LH increased 3 times

(the first year menopause(the first year menopause))

↓ ↓

FSH, LH gradually decline (3 years after menopause)FSH, LH gradually decline (3 years after menopause)

Symptoms and signs

1. 1. Early Symptoms and signsEarly Symptoms and signs

  

1) 1) menstruation disorder menstruation disorder Oligomenorrhea--- intervals greater than 35 days.Oligomenorrhea--- intervals greater than 35 days. Polymenorrhea---- intervals less than 21 daysPolymenorrhea---- intervals less than 21 days hypermenorrhea hypermenorrhea amenorrheaamenorrhea menopausemenopause

2) 2) vasomotor symptomsvasomotor symptoms( hot flashes, sweat( hot flashes, sweat

s)s) estrogen depletion result in instability in the veestrogen depletion result in instability in the ve

ssels of the skin.ssels of the skin.

The hot flashes begins on the chest and spreads The hot flashes begins on the chest and spreads

quickly over the neck, face and upper limbs whquickly over the neck, face and upper limbs wh

ich lasts only seconds but may recur many timeich lasts only seconds but may recur many time

s one day. Sweat often follows hot flashes.s one day. Sweat often follows hot flashes.

3) mood changes and sleep disturbances3) mood changes and sleep disturbances insomnia, headache, backache, depression, hateinsomnia, headache, backache, depression, hate having difficulty falling asleep and waking up soon having difficulty falling asleep and waking up soon

after going to sleepafter going to sleep

4)urinary tract problem4)urinary tract problem atrophic change in the urinary epitheliumatrophic change in the urinary epithelium decreased elastic of reproductive and urinary tract decreased elastic of reproductive and urinary tract

supporting structuressupporting structures

5)5) vaginal dryness and genital tract atrophvaginal dryness and genital tract atrophyy

atropic vaginitis, dyspareuniaatropic vaginitis, dyspareunia the vaginal skin become thin and loses its the vaginal skin become thin and loses its

rugose appearancerugose appearance small red spots appear on the vaginasmall red spots appear on the vagina

2. Late symptoms and problems2. Late symptoms and problems

6)osteoporosis6)osteoporosis Accelerated bone loss in women is clearly reAccelerated bone loss in women is clearly re

lated to the loss of ovarian function.lated to the loss of ovarian function.

Studies show that a rapid decrease in bone Studies show that a rapid decrease in bone mass occurs within 2 months of ovariotomymass occurs within 2 months of ovariotomy

There is now general agreement that postmenopausThere is now general agreement that postmenopausal osteoporosis is related to estrogen deficiencyal osteoporosis is related to estrogen deficiency

Estrogen reduce bone resorption more than they reEstrogen reduce bone resorption more than they reduce bone formationduce bone formation

Other factorsOther factors

lack of exerciselack of exercise

Malabsorption of calciumMalabsorption of calcium

7) cardiovascular lipid changes7) cardiovascular lipid changes

perimenopaual women have a lower incidence of coperimenopaual women have a lower incidence of coronary heart disease than men of same age.ronary heart disease than men of same age.

After the menopause a woman’s risk increase progrAfter the menopause a woman’s risk increase progressively until age 70 when it become equal to that of essively until age 70 when it become equal to that of menmen

HDLHDL （（ high density lipoprotein ） ,LDL,LDL, total , total cholesterol cholesterol

This observation led to the supposition that estrogeThis observation led to the supposition that estrogen might be a key factor.n might be a key factor.

Estrogen has protection against heart disease Estrogen has protection against heart disease

Diagnosis

1)1) HistoryHistory menstrual abnormalitymenstrual abnormality

2)2) Symptoms:Symptoms: vasomotor symptoms, vaginal vasomotor symptoms, vaginal dryness, urinary frequency, insomnia, irritdryness, urinary frequency, insomnia, irritability, anxiety, skin change, breast changeability, anxiety, skin change, breast changes, urinary tract problem, pelvic floor chans, urinary tract problem, pelvic floor change( cystocele. Rectocele. Prolapse), skeletal ge( cystocele. Rectocele. Prolapse), skeletal change(backache, ) and so on.change(backache, ) and so on.

3)Physical examination:

The clinical findings vary greatly depending on the tiThe clinical findings vary greatly depending on the time elapsed since menopause and the severity of the eme elapsed since menopause and the severity of the estrogen deficiencystrogen deficiency

Skin: thin ,drySkin: thin ,dry Breast loss turgorBreast loss turgor The labia are smallThe labia are small The uterus becomes much smallerThe uterus becomes much smaller The muscles of the pelvic floor are looser and thinerThe muscles of the pelvic floor are looser and thiner Prolapse may be presentProlapse may be present

4) 4) Laboratory diagnosisLaboratory diagnosis

Cytologic smear from the vaginal wallCytologic smear from the vaginal wall E2, FSH, LH determinationE2, FSH, LH determination

Treatment 1)   education, understanding, reassurance

Every woman with climacteric symptoms dEvery woman with climacteric symptoms deserves an adequate explanation of physioloeserves an adequate explanation of physiologic event she is experiencing ,in order to disgic event she is experiencing ,in order to dispel her fears and minimize symptoms such apel her fears and minimize symptoms such anxiety , depression and sleep disturbance.nxiety , depression and sleep disturbance.

Reassurance should be emphasizedReassurance should be emphasized

2)   hormone replacement therapy(HRT )

Estrogen therapyEstrogen therapy The use of estrogens can relieve the menopThe use of estrogens can relieve the menop

ausal symptoms.ausal symptoms. The hot flashes , sweats and other complaiThe hot flashes , sweats and other complai

nts disappear or improve within a few days nts disappear or improve within a few days of starting estrogens therapyof starting estrogens therapy..

3) traditional medicine therapy3) traditional medicine therapy

The administration of estrogen without proThe administration of estrogen without progestogen increases the risk of gestogen increases the risk of endometrial endometrial cancercancer and and breast cancer.breast cancer.

So, correct cyclical therapy, with 10-14 daySo, correct cyclical therapy, with 10-14 days s progestogen per monthprogestogen per month , can reduces the , can reduces the incidence of cancer.incidence of cancer.

Contraindication

vascular thrombosisvascular thrombosis hypertensionhypertension diabetesdiabetes chronic liver diseasechronic liver disease myoma, endometriosis,myoma, endometriosis, breast diseasebreast disease gallbladder diseasegallbladder disease

The common hormone of HRT

EstrogenEstrogen ProgestogenProgestogen TiboloneTibolone

Estrogennatural synthetic

estradiol

estrone

estriol

Conjugated estrogen

ethinylestradiol

mestranol

Progestogen

Medroxyprogesterone acetate(MPMedroxyprogesterone acetate(MPA)A)

progesteroneprogesterone

Tibolone Tibolone is a synthetic steroid having weak esTibolone is a synthetic steroid having weak es

trogenic, progestogenic,and androgenic propetrogenic, progestogenic,and androgenic properties.rties.

it reduces endometrail hypoplasia , improves it reduces endometrail hypoplasia , improves symptoms of dryness and painful intercourse,isymptoms of dryness and painful intercourse,improves libido.mproves libido.

Can be used in those with a personal history oCan be used in those with a personal history of breast cancerf breast cancer

Routes of administration of HRT OralOral TransdermalTransdermal SubcutaneousSubcutaneous vaginalvaginal

The types of HRT

Combined sequential therapyCombined sequential therapy Continuous combined therapyContinuous combined therapy Estrogen only –hysterectomised Estrogen only –hysterectomised

womenwomen TiboloneTibolone

Combined sequential therapy

Estrogen are given continuously(30 days)

MPA 10-14 days Withdrawal bleeding

Stop

Next month

Continuous combined therapy

Estrogen continuously

MPA continuously

No Withdrawal bleeding

Side-effects of HRT

Irregular uterine bleedingIrregular uterine bleeding Breasts tendernessBreasts tenderness Progestogen-related symptoms (abdProgestogen-related symptoms (abd

ominal bloating,edema)ominal bloating,edema)

Risk of HRTBreast cancerBreast cancerEndometrial cancerEndometrial cancer Venous thromboembolismVenous thromboembolism

Do evaluation every year may find any abnormals ， reduce the incidence of the above risk

Information

Next Monday afternoon clinic learningNext Monday afternoon clinic learning 22 ：： 30 pm 30 pm Tianjin Medical University General Hospital ouTianjin Medical University General Hospital ou

tpatient department building 10tpatient department building 10 thth floor reproduc floor reproductive medicine center tive medicine center

Group II -1Group II -1 Teather : wang yanxiaTeather : wang yanxia