Obstetrics and Gynecology Department Faculty of Medicine of Andalas University Definitions Menopause: a point in time that follow 1 year after the cessation of menstruatioin Postmenopause: those years following this point. The average age of FMP (final menstruation periode): 51.1 yrs the cessation of mensis due ovarian failure may occur at any age. Premature ovarian failure: cessation of menses before age 40 and is associated with an elevated FSH level. Perimenopause or climacteric: the time period in the late reproductive years, usually late 40s to early 50s characteristically: it begins with menstrual cycle irregularity and extends to 1 year after permanent cessation of menses. The more correct terminology: menaopausal transition typically develops over a span 4 to 7 yrs, and the average age at its onset is 47 yrs. Influential factors Environmental, genetic, surgical influences may alter ovarian aging Smoking: advances the age of menopause Chemotherapy, pelvic radiation, ovarian surgery: lead to earlier age of menopause Hypothalamus-PituitaryOvarian Axis Changes
Ovarian failure ovarian steroid release
ceases, and negative feedeback is opened GnRH is released at maximal frequency and amplitude FSH and LH levels rise up (4x). Ovarian Changes The process of atresia of the non dominant cohort of follicles, largely independent of menstrual cyclicity, is the prime event that leads to the eventual loss of ovarian activity and menopause Bone Metabolism and Structural Changes
Normal bone: dynamic, living tissue that is in a
continuous process of destruction and rebuilding (remodelling) This remodelling (or bone turnover): allows adaptation to mechanical changes in weigh bearing and other physical activities Process of remodelling involves: a constant resorption of bone (by osteoclasts) and a concurrent process of bone formation (by osteoblasts) During menopause: the rate of bone mass decline increases to 2 5 % per year for the first 5 10 year Osteopenia and Osteoporosis Bone disorders: characterized by a progressive reduction in bone mass (typically: trabecular bone) and predispose to fractures in the spine, hips, and other sites. Fracture: the most debilitating and costly consequence of osteoporosis associated with significant morbidity and mortality, and the risk of dying 2 x higher. Only 40 % of those who sustain a hip fracture are capable of returning to their prefracture level of independence Pathophysiology Osteoporosis: a skeletal disease in which bone strength is compromise, resulting in an increased risk for fracture A major proportion of bone strength is determined by bone mineral density (BMD) Primary osteoporosis: bone loss associated with aging and menopausal estrogen deficiency ec estrogen regulatory effect on bone resorption is losts most rapid in the early postmenopausal years. Secondary osteoporosis: caused by other diseases or medication. Pathophysiology, contd Aging and a loss of estrogen: lead to significant increase in osteoclastic activity Ca intake or impaired of Ca: serum level of ionized Ca PTH level stimulates production of vit. D serum Ca level In menopausal woman: estrogen responsiveness of bone to PTH more Ca removed from bones serum Ca level lowers PTH level and vit D level Diagnosis of Osteoporosis Standard: BMD reported as T-score T-score of -2.0 means: the BMD is 2 SDs below the average peak bone mass for a young woman Criteria for Interpretation of BMD table. Prevention The most important predictive factors: bone density in combination with age, fracture history, ethnicity, various drug treatments, weight loss, and physical fitness. The presence of a key risk factor should alert a clinician to the need for further assessment and possibly active intervention, such as calcium therapy coupled with weight-bearing exercise or pharmacologic therapy. Treatment Primary goal: fracture prevention in low BMD women the aim: to stabilize or increase BMD. Treatment: lifestyle changes or pharmacotherapy Therapeutic options: Hormonal th/ for prevention Biphosphonates and selective estrogen reseptor modulator (SERM) for prevention and treatment Calcitonin and injectable hPTH for treatment Treatment contd Nonpharmacologic therapy Calcium Vitamin D Diet : protein supplementation Physical activity: aerobic exercise Fall-Prevention Strategies Falls: responsible for >90% hip fractures Minimize falls by: reducing clutter and implementing nonslip tiles, rug with nonskid backing, night lights. Hip protector padding