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Menopause and Hrt


  1. Menopause is defined as the permanent cessation of menses for 1 year and is physiologically correlated with the decline in estrogen secretion resulting from the loss of follicular / ovarian function.
  2. The perimenopausal period encompasses the time before, during, and after menopause. The length of this period varies but is usually considered to last approximately 7 years, beginning with the decline in ovarian function in a woman's 40s and continuing until she has not had menses for 1 year.
  3. The time of menopause is determined genetically and occurs at the median age of 51 years in West and 47 years in India. The average age of menopause is 51 years with a normal range of 43-57 years.
  4. Menopause occurs earlier in nulliparous women, in tobacco smokers, and hysterectomized women.
  5. Premature ovarian failure is defined as menopause occurring spontaneously before 40 years of age with SFBH > 40.

Elevated FSH (≥35 lU/L) is the sine qua non of menopause


Diagnostic criteria of menopause

  1. Cessation of menopause'
  2. Apearance of menopausal symptoms 'hot flushes'
  3. Vaginal cytology 10/85/5
  4. Serum estradiol <20pg/mL
  5. Serum FSH and LH >40 mlu/mL

Mechanism of Menopause


Premature Ovarian Failure


Ovarian failure < 40 year with FSH > 40.

(Early menopause is 45 year with FSH >40)


Causes of Premature Ovarian Failure:

  1. Chromosomal etiology
  2. Iatrogenic causes
  3. Radiation
  4. Chemotherapy
  5. Surgical alteration of ovarian blood supply
  6. Savage syndrome
  7. Infections
  8. Autoimmune disorders
  9. Galactosemia
  10. Cigarette smoking
  11. Idiopathic

Menopausal Symptoms

  1. Hot flushes:
    • The classic symptom associated with estrogen deficiency is the hot flash, also known as hot flush
    • This symptom is described as "recurrent, transient periods of flushing, sweating and a sensation of heat, often accompanied by palpations, feeling of anxiety and sometimes followed by chills"
    • The entire episode usually lasts no more than 1-3 min and may recur as many as 30 times per day, although 5-10 times per day is probably more common
    • Hot flashes are experienced by at least half of all women during natural menopause and even more women after surgical menopause
    • In severe cases, hot flashes may be accompanied by fatigue, nervousness, anxiety, irritability, depression, and memory loss. These sensations, if occurring at night, are called as "night sweats" and can lead to interruption of sleep patterns
    • Physiologically, hot flashes correspond to marked, episodic increase in the frequency and intensity of gonadotropin-releasing hormone (GnRH) pulses from the hypothalamus and not due to increased GnRH secretion
  2. Vaginal dryness, dyspareunia, recurrent vulvovaginal infections, and urinary tract infections
  3. Mood swings, irritability, and depression
  4. Decreased libido
  5. Memory loss
  6. Osteoporosis

Risk factors for osteoporosis:


Modifiable risk factors:

  • Estrogen deficiency (menopause/premature menopause/prolonged amenorrhea)
  • Low BMI
  • Prolonged immobility
  • Smoking, alcohol abuse
  • Nutritional factors
  • Secondary causes: celiac disease

No modifiable risk factors:

  • Age
  • Race
  • Positive family history
  • Prior fragile fracture

Osteoporosis is defined as the reduction in the quantity of bone, leading to enhanced susceptibility to fractures.

Bones associated with postmenopausal fractures:

  1. Spinal vertebrae
  2. Radius
  3. Neck of femur.

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