Menopause

MENOPAUSE

Definition

          Menopause is defined as the permanent physiological cessation of menstruation at the end of reproductive life due to loss of ovarian follicular activity.

          It’s the point of time when the last and final menstruation occurs.

Climacteric

          Climacteric is the phase of aging process during which a woman passes from the reproductive to the nonreproductive stage.

          This phase covers 5-10 years on either side of menopause.

Premenopausal

          It’s the part of the climacteric before menopause. When the menstrual cycle is liked to be irregular.

          Postmenopause is the phase that comes after the menopause.

Age of menopause

 

Ø  Age of menopause is genetically predetermined.

Ø The age of menopause ranges between 45 to 55 years average being 50 years.

Ø Cigar ate smoking and severe malnutrition may cause early menopause.

Endocrinology of climacteric and menopause

1.     Depletion of the ovarian follicle in the prior stage of menopause.

·        Resulting in increasing FSH level.

·        The serum level of estradiol from 50-300pg/ml before menopause to 10 to 20pg/ml after menopause.

2.     The diminished folliculogenesis result in anovulation olio goes ovulation and corpus luteum insufficiency.

3.     Shorting of the follicular phase leads shorter menstrual cycle.

4.     There is a fall in the level of prolactin and inhibition.

Organ changes

                 

Organ changes

                                          I.            Genitourinary system

a)     Ovaries – shrink in size.

b)    Wrinkled and white.

1.     Fallopian tube

a)     Atrophy

b)    Muscle coal become thinner. become less prominent.

c)     Plicate become less prominent.

2.     Uterus

a)     Smaller

b)    Endometrium become thin and atrophic

c)     Cervical secretion becomes scandy.

3.     The vagina

a)     Atrophy

b)    Labia become flattened

c)     Pubic hair become scantier resulting in a narrow introit.

4.     Breast

a)     Gland become atrophy

b)    Nipple decrease in size

                   The breast becomes flat and pendulous.

               II.            Skeletal system

Loss of bone mass by about 3% - 5% per year due to deficiency of estrogen leading to osteoporosis.

           III.            Cardiovascular system

Deficiency of estrogen increases the risk of cardiovascular disease of its function of decreasing high-density lipoprotein cholesterol and antioxidant property.

v  Menstruation pattern prior to menstruation

Ø Abrupt cessation of menstruation.

Ø Gradual decrease in both amount and duration.

Ø Irregular with or without excessive bleeding.

v Symptoms of menopause

A.   Menstrual changes

Ø Shorter cycle

Ø Irregular bleeding

B.   Vasomotor symptoms

Ø Hot flashes

Ø Night sweat

Ø Sleep disturbances

C.   Psychological changes

Ø Irritability

Ø Mood swings

Ø Poor memory

Ø Depression

D.   Sexual dysfunction

Ø Vaginal dryness

Ø Dyspareunia

E.   Urinary changes

Ø Incontinence

Ø Urgency

Ø Dysuria

F.    Others

Ø Backaches

Ø Joint aches

Diagnosis of menopause

Ø Cessation of menstruation for consecutive 12 months during climacteric.

Ø Average age of menopause 50 years.

Ø Appearance of menopausal symptoms, hot flashes and night sweat.

Ø Vaginal cytology – low estrogen.

Ø Serum estradiol - < 20 pg/ml.

Ø Serum FSH and LH - > 40 mool/ml

v Management

1.     Prevention

Ø Spontaneous menopause is unavoidable.

Ø Artificial menopause induced by surgery ( bilateral oophorectomy ) or radiation or chemotherapy during the reproductive period can to some extent be prevented or delayed.

2.     Counseling

Ø Every woman with postmenopausal symptoms should be adequately explained about the physiological events.

v Treatment 

1.     Non-hormonal therapy

2.     Hormonal therapy

1. Non-hormonal therapy

A.   Lifestyle modification

Ø Increase physical activity

Ø Reducing high coffee intake

Ø Stop smoking alcohol

B.   Nutrition diet

Ø Balanced with calcium and protein.

C.   Supplementary calcium

Ø Daily intake of 1 – 1.5 q can reduce.

v Hormonal therapy

Ø Replacement of estrogen and progesterone are prescribed for women with premature ovarian failure.

v Benefits of hormonal therapy

Ø Improvement of vasomotor symptoms.

Ø Improvement of urogenital atrophy.

Ø Decreased risk of vertebral and hip fracture.

Ø Reduction in colorectal cancer.

Ø Possibility cardioprotection.

v Contraindication hormonal therapy

Ø History of breast cancer.

Ø Liver disease.

Ø Jaundice

Ø Gall bladder disease.

Ø Endometritis.

v Abnormal menopause

Ø Premature menopause – below age 40 years.

Ø Delayed menopause – above 55 years.

Ø Artificial menopause – surgical removal ovary.

Ø Surgical menopause – bilateral oophorectomy.

Ø Radiation menopause – gamma radiation leads to menopause below          40 years.

                                    

Gynecological Disorder

GYNECOLOGICAL DISORDER

1. Uterine prolapse

 

Normal Uterus

INTRODUCTION

          Uterine prolapse occurs when pelvic weaken providing muscles and ligaments stretch and weaken providing inadequate support for the uterus. The uterus then descends into the vaginal canal. Uterine prolapse usually happens in women who have had one or more vaginal births. Congenital or nulliparous prolapse seen in young women.

DEFINITION

          Prolapse of uterus refers to a collapse descend or change in the position of the uterus in relation to surrounding structures in the pelvis.

CONTENTS

1. Associate Conditions

     A. Cystocele

     B. Urethrocele

     C. Enterocele

     D. Rectocele

     E.Relaxec Perineum

 2. Degree of Prolapse

     a. First Degree

     b. Second Degree

     c. Thrid Degree

3. Causes

4. Symptons

5. Examination & Diagnosis

6. Conservation & Complications

ASSOCIATED CONDITION 

Other conditions associated with prolapse uterus occurs due to the weakness of muscle that holds the uterus in place.

1.    Cystocele

 

cystocele

It’s a herniation or bulging of the upper two-thirds of the anterior vaginal wall, where a part of the bladder bulges, into the vagina. This leads to urinary frequency, urgency, retention, and incontinence.

2.    Urethrocele

There is herniation of the anterior vaginal wall. This may appear independently or long with cystocele and is called urethrocytocele.

3.    Enterocele

Enterocele

There is herniation of the upper posterior vaginal wall, where a portion of small bowel bulges into the vagina. Standing leads to a pulling sensation and backache and this is relived on lying down.

4.    Rectocele

Rectocele

There is herniation of the middle third of the posterior vaginal wall where the rectum bulges into the vagina. This makes bowel movement difficult to the point that the women may need to push on the inside of the vagina to empty the bowel.

5.    Relaxed perineum

There is gaping of the introits produced by turn perineal body with bulge of the lower part of the posterior vaginal wall.

Degree of prolapse

Prolapse of the uterus may be one of three types depending on severity.

A)  First degree

The uterus sags downwards from the normal anatomic position into the upper vagina. The external as remains inside the vagina.

B)  Second degree

The cervix is at or outside the vaginal introits, but the uterine body remains inside the vagina.

C)  Third degree

This type is also referred to as a complete prolapse or precedential. The entire uterus descends to lie outside inroitous.

CAUSES

Ø Stretching of the pelvic support system. Longer and difficult childbirth or multiple childbirth.

Ø Pelvic relaxation that happens during pregnancy as the weight of the gravid uterus continuously bears down upon the pelvic diaphragm.

Ø Chronic increase in intra abdominal pressure such as may be associated with obesity abdominal or pelvic tumors, ascites, constipation, chronic cough.

Ø Normal aging and lack of estrogen hormone after menopause.

SYMPTOMS  

1.  A feeling of something down per vagina especially while moving out.

2.    Backache or dragging pain in the pelvis which may be relived on lying down.

3.    Dyspareunia

4.    Urinary symptoms

a.     Difficulty in passing urine.

b.    Incomplete emptying of the bladder, causing frequent desire to pass urine.

c.     Urgency and frequency of micturition.

d.    Stress incontinence usually due to associated retrocele.

e.     Retention of urine may really occur.

5.    Bowel symptoms.

a.     Difficulty in passing stool.

b.    Excessive white or blood stained discharge. Per vaginal due to associated vaginitis or ulceration.

EXAMINATION AND DIAGNOSIS

1.    Inspection and palpation- vaginal, rectal rectovaginal examination.

2.    Examination in squatting position, if re-confirmation is required.

3.    Examination of pelvic in a dorsal and standing position.

4.    Examination under anesthesia, if difficult to arrive at conclusion.

MANAGEMENT OF UTERINE PROLAPSE

Preventive:

1. Adequate antenatal and intranasal care to avoid injury to the supporting structures during virginal delivery either.

2. Adequate postnatal care.

Ambulation and pelvis to encourage early floor exercise during puparium.

3. General Measures:

   4. To avoid strenuous activities cough, constipation, and heavy weight lifting.

5.    Limiting and spacing pregnancies health avoid pelvic relaxation.

CONSERVATION:

Ø Estrogen replacement therapy may improve minor degree prolapse in postmenopausal women.

Ø In might case, exercises to straining pelvic floor muscle may help.

Ø Obeys patients may be interacted to reduce weight in order to reduce pressure on a pelvic organ.

Ø To avoid wearing constrictive clothing.

COMPLICATION

A: Immediate

          Hemorrhage within 24hours following surgery.

Ø Retention of urine.

Ø Infection to bleeding to cystitis.

Ø Wound sepsis.

Ø Vault cellulitis.

B: Late

Ø Dyspareunia.

Ø Recurrence of prolapse.

Ø Vasico vaginal fistula following bladder injury.

Ø Rectovaginal fistula following rectal injury.

Ø Cervical stenosis hematoma.

Ø Infertility.

Ø Cervical incompetency.