MENOPAUSE

DEFINITION:-
Menopause meaens permanent cessation of menstruation at the end of
reproductive life due to permanent cessation of overian function.
• Natural menopause is recognized after 12 consecutive months without menstrual
periods that are not associated with a physiologic( e.g., lactation) or pathologic cause.
• The word "menopause" literally means the "end of monthly cycles" from the greek
word “pausis” (cessation) and the root men- (month), because the word "menopause"
was created to describe this change in human females, where the end of fertility is
traditionally indicated by the permanent stopping of monthly menstruation or menses.
However, menopause also exists in some other animals, many of which do not have
monthly menstruation; in this case, the term is synonymous with "end of fertility".

TERMINOLOGIES:-
1. CLIMACTERIC:- It is the phase of aging process during which a women passes from
the reproductive to the non-reproductive stages. This phase covers 5-10 years on
either side of the menopause.
2. PREMENOPAUSE:- It is a part of the climacteric before menopause, when the
menstruation cycle is likely to be irregular.
3. MENOPAUSAL TRANSITION:- The time from the late trproductive stage and entry
into postmenopause.
4. POSTMENOPAUSE:- It is the phase of life that comes after the menopause.
5. PREMATURE MENOPAUSE:- The occurance of menopause before the age of 40
years.

AGE OF MENOPAUSE:-
• It has been estimated that the onset of menopause usually begins between the ages of
45 and 55 years, with a worldwide average of about 51 years.
 • According to the National Family Health Survey conducted in 1988 and 1999, the
mean age of onset of menopause in Indian women is about 44.3 years. With the
average lifespan of a women increasing in the recent years, women will lead one-
third of their life in the postmenopausal stage.
• These fact necsssitate a need to understand and address the concerns of the
postmenopausal women in a better and sophisticated way to help such women lead a
healthy and happy life.
• The age of menopause occurs is genetically predetermined and is not related to the
following factors:
 number of prior ovulations;
 duration of lactation amenorrhea;
 failure to ovulate spontaneously;
 race;
 socioeconomic conditions;
 education;
 height or weight;
 use of oral pills;
 age at menarche; and
 age at the last pregnancy.
However, cigarette smoking and severe malnutrition may cause
early menopause.

ENDOCRINE REGULATION:-
• The timing of menopause correlates with time of exhaustion of the overian follicular
reserve which steadily depletes as a women ages. Usually at menopause, there are no
follicles in the ovaries and also there is a decrease in the oestrogen and progesterone
levels.
• The decreasing follicles cause a resultant decrease in the inhibin levels that are
produced by the granulosa cells during the follicular phase of the menstrual cycle.
Inhibin forms a closed-loop feedback system along with FSH and the levels of both
are connected inversely.
 • A decrease in the inhibin levels stimulates FSH increase and vice versa. During
menopause, the inhibin levels begin to fall as the number of ovarian follicles begins
to decline, this initiates FSH production that is known to increase estrogen
production.
• However, due to the decrease in the number of follicles FSH fails to stimulate
sufficient oestradeol secretion and oestradeol levels steadily declines, eventually
resulting in the failure of endomatrial development and absence of uterine bleeding.
This phenomena is clinicaly observed as the menopause.
Neumorous studis have concluded that estrogens are not only
reproductive hormones but are also pleiotropic hormones that have certain roles in a wide
variety of nonreproductive functions such as bone and mineral metabolism, memory and
cognition, cardiovascular function and the immune system. There by the withdrawal of
estrogen may account for most of the signs and symptoms attributed to menopause.

SIGNS AND SYMPTOMS:-

Symptoms are divided into physiological, psychological and social.

• PHYSIOLOGICAL ASPECT:-
◦ VASOMOTAR SYMPTOMS:
▪ The characteristic symptom of menopause is “hot flush”. Hot flush is
characterised by sudden feeling of heat followed
by profuse sweating. It affects the chest area and
spreads upward to the facial skin, and generally
last for less than a minute.
▪ Palpitation, fatigue, weakness
▪ Perspiration and cutaneous vasodilation.
▪ The vasomotar symptoms have been attributed to the instability of the
thermoregulatory centre in the hypothalamus due to the deficiency of
oestrogen.

◦ CNS SYMPTOMS:-
 ▪ Oestrogens are known to regulate the synthesis and the rate of release of many
neurotransmitters, particularly the noradrenergic transmission in the medulla
oblongata and the hypothalamus.
▪ A deficiency of oestrogen reduces serotonin synthesis in the brain and this has
been the factor proposed to be the responsible for the development of insomnia
during menopause.
▪ It has been proposed that along with normal aging, oestrogen plays a role in the
decline of the cognitive functions in the women. Dementia and mainly
Alzheimer disease are more common.

◦ REPRODUCTIVE TRACT SYMPTOMS

▪ The anatomical changes in the genitourinary tract have been attributed directly
to the reduction in the oestrogen levels in the body. Decreased levels of the
oetsrogen leads to thinning of the vaginal epithelium and reduction in the
 vaginal transudates, which causes vaginal dryness and dyspareunia.
▪ The vaginal dryness may further be accentuated by the decrease in the cervical
mucus production. The amount of supporting collagen tissues also begin to
decline gradually. The decline in the collagen content of the structures that
support the uteres (cardinal and uterosacral ligaments) causes them to lose their
tonicity and uterine descensus may occur.
▪ The development of a cytocele, rectocele and/or enterocele may also occur
owing to the decreased collagen content in the endopelvic fascial tissue. Inside
the pelvis, the uterus becomes smaller and fibroids, if present, become less
symptomatic. Endometriosis and adenomyosis are usually alleviated with the
onset of menopause, and many patient with pelvic pain finally achieve
permanent pain relief.
▪ The cervix begins to shrink and the vaginal fornices disappear gradually. As
the vaginal orifice narrows, it leads to dyspareunia.

◦ URINARY SYMPTOMS:
▪ The cells lining the trigone of the bladder and the urethra are generally
stimulated by oestrogen, and oestrogen deficiency can lead to atrophy of the
cells making this areas more sensitive to the irrititating effect of urine, causing
urgency, frequency, and dysuria.
▪ The incidence of the urethral caruncle is also increased and urinary tract

infection may also ensue. The tonicity of the internal urinary sphincter
decreases as a result of poor vascularity resulting in stress incontinence. These
urinary symptoms are collectively reffered to as the urethral syndrome.

◦ HEART DISORDERS:
▪ Oxidation of LDL and foam cell formation cause vascular endothelial injury,
ell death and smooth muscle proliferation. All these lead to vascular
atherosclerotic changes, vasoconstriction and thrombus formation.
▪ Risks of ischemic heart disease, coronary artery disease and strokes are
increased.
 ◦ OESTEOPOROSIS AND FRACTURE:
▪ Following menopause there is decline in collagenous bone matrix resulting in
oesteoporotic changes. Bone mass loss and microarchitectural deterioration of
bone tissue occurs primarily in trebecular bone (vertebra, distal radius) and in
cortical bones.
▪ Bone loss increases to 5% per years during menopause. Osteoporosis may be
primary (Type 1) due to oestrogen lose, age, deficient nutrition (calcium, vit.
D) or hereditary. It may be secondary (Type 2) to endocrine abnormalities
(parathyroid, diabetes) or medication.
▪ Oesteoporosis may lead to back pain, loss of height and kyphosis. Fracture
may involve the vertebral body, femoral neck, or distal forearm.

◦ SKIN AND HAIR:

▪ There is thinning, loss of elasticity and wrinkling of the skin. Skin collagen
content and thickness decrease by 1-2 per cent per year.
▪ “Purce String” wrinkling around the month and “Crow feet” around the eyes

are the characteristics. Oestrogen receptors are present in the skin and
maximum are present in the facial skin.
▪ Oestrogen replacement can prevent this skin loss during menopause. After
menopause, there is some loss of pubic and axillary hair and slight balding.
This may be due to low level of oestrogen with normal level of testosterone.

• PSYCHOLOGICAL ASPECT:
▪ Psychological symptoms such as anxiety, depression and irritability tend to
increase after menopause. The role of oestrogen in releiving these symptoms
has been constantly reviewed to identify its role as a
direct mechanism or indirect. The depressive
symptoms may be related directly to the altered
hormonal levels or may be due to the disturbed sleep
cycles or vasomotor disturbances.
▪ Headache, insomnia, dysphasia, mood swing and
inability to concentrare are also associated with this.
 • SOCIAL ASPECT:
▪ Loanliness
▪ Social isolation
▪ Lack of intrest in family, friends and society

DIAGNOSTIC TESTS:-
• History- presence of typical symptoms along with amenorrhoea for more than 12
months.
• physical examination
• Serum FSH level- excess of 30 IU/L confirms the diagnosis
• Pelvic examination
• Pap smear
• Lipid profile
• Blood sugar
• Bone density studies

HORMONE REPLACEMENT THERAPY:

The HRT is indicated in menopausal women to overcome the short-term and long-term
consequences of oestrogen deficiency.

• INDICATION OF HRT:-
◦ Hormone replacement therapy (HRT) is generally advised for women who are
symptomatic and are at high risk of developing cardiovascular disorders,
oesteoporosis, Alzheimer disorder or colonic cancer,
◦ for prevention of osteoporosis and
◦ to maintain the quality of life in menopausal years.

• CONTRAINDICATIONS OF HRT:-
◦ It include the presence of breast or endometrial cancer,
 ◦ active thrombophlebitis and
◦ undiagnosed abnormal uterine bleeding.
◦ Women with active liver disease should not be advised oral oestrogen therapy.

• BENEFITS OF HORMONE REPLACEMENT THERAPY:-

◦ Improvement of vasomotar symptoms (70-80%)
◦ Improvement of urogenital atrophy
◦ Increase in bone mineral density (2-5%)
◦ Decreased risk in vertebral and hip fractures (25-50%)
◦ Reduction in colorectal cancer (20%)
◦ Possibly cardio protection.

• TREATMENT REGIMEN FOR OSTEOPOROSIS:

(1) HRT
• Oestrogen: daily dose- 0.625 mg conjugated oestrogen; minimum bone
sparing dose
• Progestins (in women with an intact uterus)
Sequential: 5 mg medroxyprogesterone acetate (MDPA) for 2 weeks every month
Continuous combined regimen: 2.5 mg MDPA
• Oestrogen may be administered orally, subdermal implants, vaginal cream,
percutaneous gel or by transdermal patch.
(2) OTHER DRUGS
• Calcitonin 200 IU/day- inhibits bone resorption
• Fluoride 1 mg/kg- increases bone matrix
• Tibolone 1.25 mg/day
• Raloxifene- increases bone mineral density, reduce serum LDL and to raise
HDL level so risk of breast and endometrial cancer is redused.
• Clonidine- reduce the severity and duration of hot flushes.
• Biphosphonates- Alendronate 5 mg/day for prevention; 10 mg/day
prevents osteoclastic bone resorption.
(3)ADDITIONAL MEASURES
• Weight bearing exercises
• Adequate ultraviolet exposure
• Vitamin D >400 IU/day
• Calcium supplementation-1000 mg/day
• Stop smoking and alcohol consumption
• Avoid excessive caffeine
 • MONITORING PRIOR TO AND DURING HRT:-
A base level parameter of the folowing and their subsequent check up (at least annually) are
mandatory.
◦ Physical examination including pelvic examination
◦ Blood pressure recording
◦ Breast examination and memography
◦ Cervical cytology
◦ Pelvic ultrasonography (TVS) to measure endometrial thickness.
Any irregular bleeding should be investigated throughly.

• RISKS OF HORMONE REPLACEMENT THERAPY:-

◦ Endometrial cancer
◦ Breast cancer
◦ Venous Thromboembolic disease
◦ Coronary Heart Disease
◦ Lipid metabolism
◦ Dementia, Alzheimer disease

SURGICAL MENOPAUSE:
While most women go through natural menopause about 50 years of
age, there are some who undergo menopause in their 40s and even as early as 20s and 30s.
Approximately 600,000 women in the US have a hysterectomy which is the second most
common major surgery among women. About 55% of women who have had hysterectomies
also undergo bilateral oophorectomy. This means they experience surgical menopause as
well.

WHAT IS SURGICAL MENOPAUSE?

The ovaries produce estrogen, progesterone and androgens which are
essential to the regulation of the menstrual cycle. When a hysterectomy occurs, these
hormones get suddenly interrupted and their levels fall resulting in symptoms of
menopause. This is termed surgical menopause.
• Although removal of ovaries becomes unavoidable in most hysterectomy surgeries,
every effort is made by the surgeon to leave the ovaries intact in order to avoid the
sudden absence of hormones. Surgical menopause occurs in women who have not yet
had natural menopause.
• Most often, surgical menopause is caused quite dramatically when there is surgical
interference like hysterectomy, bilateral oophorectomy, where both the ovaries are
removed. Hysterectomy with removal of ovaries is referred to as TAHBSO, total
abdominal hysterectomy and bilateral salpingo oophorectomy. This removal of
ovaries and fallopian tubes lead to surgical menopause condition.
• In the case of hysterectomy when the uterus is removed and ovaries remain,
menstrual periods stop but significantly the menopausal symptoms occur at the same
age as would naturally. Surgery is warranted in conditions such as endometriosis,
ovarian cysts, fibroids, ovarian cancer and pelvic organ prolapse.

• Planning a surgical menopause

•Surgical menopause is a difficult decision especially at a younger age. The younger the
woman, the more problems she will encounter.
•A complete hormonal check up is essential for every woman who has to undergo
hysterectomy. This way a baseline reading of the hormonal needs is obtained and one
can always try to achieve these normal levels with the right hormones again.
•Post care has to be planned and it is important for a young woman undergoing
hysterectomy to be under the care of a hormonal therapy specialist who can handle
the side effects of surgical menopause.
•Research is still at an infant stage seeking to determine the long time effects of surgical
menopause on heart disease, osteoporosis and general health especially on younger
woman.

SYMPTOMS OF SURGICAL MENOPAUSE:

• Since there is abrupt disruption of hormones after hysterectomy, the menopausal
 symptoms are more severe, more frequent and last longer when compared to natural
menopause. The symptoms are triggered by the body's sudden inability to make
certain hormones due to the removal of ovaries.
• Hot flushes and night sweats are the commonest symptoms of surgical menopause. It
is estimated that about 75 - 90% of women who have had surgical menopause
experience them. This is due to the disturbance of the central thermostat located in
the hypothalamus which is kept stable by normal circulating estrogen.
• Other symptoms of surgical menopause range from sleepless nights, vaginal dryness
and itching to decrease in sexual desire and painful intercourse.
• Depression is another common result of low estrogen level.
• Thyroid dysfunction, bladder infections, incontinence, weight gain, migraine, and
irritability are also symptoms of surgical menopause.

MANAGEMENT OF SURGICAL MENOPAUSE:-

• Estrogen is immediately given after surgery to try to prevent the intense changes
especially the hot flashes that can occur in woman undergoing hysterectomy.
Estrogen replacement therapies like EstroGel have found to relieve many women
experiencing surgical menopause. It is not usually recommended for women with
existing or high risk of cardiovascular disease.
• Estrogen gel which is relatively a new preparation is prescribed. This is quite easy to
use and it has to be applied to the upper leg or stomach daily. The gel works by
releasing a consistent dosage of estrogen into the blood stream making the Hormone
Replacement Therapy HRT option effective.
• Vaginal ring is designed for women whose womb has been removed. Vaginal creams
which can be applied directly to the vagina by an applicator give relief locally on the
lining of the vagina and are beneficial for vaginal atrophy conditions.
• HRT implants which are small pellets inserted under the skin periodically once in six
months supply hormones. These are surgically inserted into the fatty layers of the
abdomen under a local anesthetic.
• HRT patches come in various dosages and these are small plasters which can release
hormones into the blood stream transdermally. The patch needs to be changed twice
 weekly and possible side effects could be skin irritation and allergy.
• Tablets are the most common form of HRT and they are for long term usage which
needs to be carefully considered. It is imperative to consider the usage of all HRT
preparations very carefully and regularly so as to ensure maximum benefit at the
lowest possible dose with effective symptom relief and protections.
• Exercise is another form of self help which is a positive therapy. Begin with small but
regular walks and then gradually move over to weight bearing exercises which help
to release endorphins from the brain that send feel good messages to the body.

RISKS OF SURGICAL MENOPAUSE:

•Women with surgical menopause are seven times more prone to cardiovascular disease
risks.
•They run the risk of osteoporosis as estrogen plays a vital role in bone formation and
without estrogen calcium is lost from the bones which when not replaced breaks
easily.
•It is found that after surgical menopause in particular, bones lose roughly 3% of their
mass per year for the first five years and then 1- 2% a year thereafter. Increased bone
loss associated with oophorectomy results in fracture risk as well.
•Some studies have found that reduced levels of testosterone in women are predictive of
height loss which may occur as a result of reduced bone density.
•Gum tissues are affected and regular dental check ups are advised to tide over this
problem.
•Women younger than 45 years of age and who have had their ovaries removed face a
mortality risk 170% higher than women who have retained their ovaries after
oophorectomy. Hormone therapy is commonly advised as it is believed by many
doctors to mitigate the mortality risks.
•There is a definite lowering of sexual desire in women who have undergone surgical
menopause. This reduction is greater than that seen in women undergoing natural
menopause.
Surgical menopause is definitely difficult and different when compared
to the natural way. But it is important to stay positive. One can also join a local or Internet
menopause support group, take breaks throughout the day, relax mentally and keep fit
physically by exercising and eating a healthy diet.

COUNSELLING AND GUIDANCE:

• Women at the menopausal stage need to be supported emotionally; they may need
counselling to be educated about the condition and explanation about the normal
physiologic changes that they are undergoing
• This may also help them to overcome the symptoms of anxiety and depression.
• Certain life style modification is necessary to prevent the occurrence or minimise the
effects of the associated condition.
• The life style modification is advised include:
◦ Diet
◦ Smoking cessation
◦ Decreased alcohol intake
◦ Relaxation
◦ Stress reduction.

ROLE OF MIDWIFE:
Midwives provide health care and counseling through the peri-menopausal years and
beyond, including:
•Preventive measures for conditions that are increasingly common as a woman ages,
particularly those (like heart disease and osteoporosis) that have an increased risk
with the reduced estrogen levels found in a woman’s body after menopause.
•The advantages and disadvantages of hormone replacement therapy and self-help
measures.
•The importance of a healthy diet (low in fat, high in calcium) and exercise — aerobic
for the cardiovascular system and weight-bearing for the bones.
•The role of herbal therapies.
•Signs and symptoms that might signal a serious health problem (such as bleeding
between periods).
•She gives following advice to reduce menopausal symptoms.
1. To reduce hot flushes and hot flashes : Not too warm, Lower heat, Use cotton

clothes, Use the fan, Replace coffee, tea, cola beverages by natural juices, No
smoking, Learn to relax, Exercise on a regular basis helps to reduce anxiety, Take
plenty of fluids.
2. To reduce vaginal dryness : In sexual relations while devoting more time loving

(necking) as this will increase vaginal lubrication naturally. Using specific

lubricants that are sold in pharmacies, Vaseline or oil.
3. To control urinary incontinence : Exercises to strengthen pelvic muscles: When

the bladder is empty, try to cut the flow of urine for a few seconds (the muscles
are contracted) and then relax. Perform this exercise several times a day.
4. To prevent osteoporosis : Physical exercise moderately and regularly, where all

the joints work and thus hinders the process of decalcification of bone. A diet rich
in calcium, by increasing the intake of dairy products (especially for skimmed not
gain weight), some Ca-rich fish such as sardines, anchovies, anchovy, tuna.
Healthy diet low in fat and rich in fruits and vegetables. Sun to create enough
vitamin D, which is required for proper calcium absorption. Avoid snuff, alcohol
and stimulant beverages (coffee, tea and cola drinks) and that interfere with
calcium metabolism.
5. Preventing psychological disorders : Keep a positive attitude in life. Teach a

relaxation technique to reduce stress and anxiety. Using their own chores to relax.
Have more time for the couple. Teach him how to overcome the losses (fertility,
loss of roles, leaving the house by the children, lost parents, relatives and friends,
etc … The promotion of social relationships (friends, women’s groups,
associations), to avoid isolation and loneliness. Mental health referral if you look
at some pathology such as anxiety, stress, etc …
6. To prevent the Gynecologic Cancer : Autoexploraciones perform breast. Annual

clinical examination, mammography every two years. Exfoliative cervicovaginal

cytology.
7. cardiovascular disorders : Fat diet rich in olive oil helps regulate cholesterol.

Healthy diet rich in fruits and vegetables. Control of blood pressure to rule out
hypertension. Exercise. Hormone replacement therapy.
NAME OF THE TOPIC: GUIDE: MRS. VASUDHA PRAJAPATI MAM
MENOPAUSE PRESENTER:- MS. KARISHMA SHROFF
UNIT: VIII TOTAL HOURS:- 2 HOURS
SUBJECT: OBSTETRIC AND DATE: 28 /09/2010
GYNECOLOGICAL NURSING

SR CONTENT PAGE NO
N
O.
1 DEFINITION
2 TERMINOLOGIES
3 AGE OF MENOPAUSE
4 ENDOCRINE REGULATION
5 SIGNS AND SYMPTOMS
6 DIAGNOSTIC TEST
7 HORMONE REPLACEMENT THERAPY
8 SURGICAL MENOPAUSE
9 COUNSELLING AND GUIDANCE
10 ROLE OF MIDWIFE
GENERAL OBJECTIVE:
At the end of the class student have indepth knowledge regarding
menopause, its signs and symptoms and management.

SPECIFIC OBJECTIVE:-
At the end of the class the student will able to:
• Define menopause
• Explain terminologies regarding menopause
• Recognise age of menopause
• Describe endocrine regulation
• Assess signs and symptoms of menopause
• Identify diagnostic tests of menopause
• Explaine surgical menopause
• Perform counselling and guidance
• Plan care for patient as a midwife
TEACHING METHOD:-
LECTURE CUM DISCUSSION

A.V. AIDS:-
• CHALK AND BOARD
• LCD
• HAND OUTS
CONCLUSION:
Today u have learn MENOPAUSE, its signs and symptoms and
management. Now hope you will able to plan care for such patient. At the end of this
teaching, I would like to thank madam for providing me this opportunity, and thank u all for
your co-operation.
BIBLIOGRAPHY:
• BOOKS:
1. C.S. Down “Textbook of Gynaecology, Contraception & Demography”, 14th edition,
Dawn books, Kolkatta, 2003, Pp53-57
2. D.C. Dutta, “Textbook of Gynaecology”, 5th edition, New Central Book agency (P)
Ltd, Kolkata, 2008, Pp55-62

3. Netter’s, “Obstetrics & Gynecology”, 2nd edition 2008, Philadelphia, Pp424-426

4. Kamini Arvind Rao, “Textbook of Gynaecology”, 1st edition, Elsevier India Pvt. Ltd.,
2008, Pp69-75
EVIDENCED BASED STUDIES:
(1)Postmenopausal hormone therapy and risk of cardiovascular disease by age and
years since menopause.
Rossouw JE, Prentice RL, Manson JE, Wu L, Barad D, Barnabei VM, Ko M, LaCroix AZ,
Margolis KL, Stefanick ML
Abstract
CONTEXT:
The timing of initiation of hormone therapy may influence its effect on cardiovascular
disease.
OBJECTIVE:
To explore whether the effects of hormone therapy on risk of cardiovascular disease vary by
age or years since menopause began.
DESIGN, SETTING, AND PARTICIPANTS:
Secondary analysis of the Women's Health Initiative (WHI) randomized controlled trials of
hormone therapy in which 10,739 postmenopausal women who had undergone a
hysterectomy were randomized to conjugated equine estrogens (CEE) or placebo and
16,608 postmenopausal women who had not had a hysterectomy were randomized to CEE
plus medroxyprogesterone acetate (CEE + MPA) or placebo. Women aged 50 to 79 years
were recruited to the study from 40 US clinical centers between September 1993 and
October 1998.
MAIN OUTCOME MEASURES:
Statistical test for trend of the effect of hormone therapy on coronary heart disease (CHD)
and stroke across categories of age and years since menopause in the combined trials.
RESULTS:
In the combined trials, there were 396 cases of CHD and 327 cases of stroke in the hormone
therapy group vs 370 [corrected] cases of CHD and 239 cases of stroke in the placebo
group. For women with less than 10 years since menopause began, the hazard ratio (HR) for
CHD was 0.76 (95% confidence interval [CI], 0.50-1.16); 10 to 19 years, 1.10 (95% CI,
0.84-1.45); and 20 or more years, 1.28 (95% CI, 1.03-1.58) (P for trend = .02). The
estimated absolute excess risk for CHD for women within 10 years of menopause was -6
per 10,000 person-years; for women 10 to 19 years since menopause began, 4 per 10,000
person-years; and for women 20 or more years from menopause onset, 17 per 10,000
person-years. For the age group of 50 to 59 years, the HR for CHD was 0.93 (95% CI, 0.65-
1.33) and the absolute excess risk was -2 per 10,000 person-years; 60 to 69 years, 0.98
(95% CI, 0.79-1.21) and -1 per 10,000 person-years; and 70 to 79 years, 1.26 (95% CI,
1.00-1.59) and 19 per 10,000 person-years (P for trend = .16). Hormone therapy increased
the risk of stroke (HR, 1.32; 95% CI, 1.12-1.56). Risk did not vary significantly by age or
time since menopause. There was a nonsignificant tendency for the effects of hormone
therapy on total mortality to be more favorable in younger than older women (HR of 0.70
for 50-59 years; 1.05 for 60-69 years, and 1.14 for 70-79 years; P for trend = .06).
CONCLUSIONS:
Women who initiated hormone therapy closer to menopause tended to have reduced CHD
risk compared with the increase in CHD risk among women more distant from menopause,
but this trend test did not meet our criterion for statistical significance. A similar
nonsignificant trend was observed for total mortality but the risk of stroke was elevated
regardless of years since menopause. These data should be considered in regard to the short-
term treatment of menopausal symptoms.

(2)Randomized trial of estrogen plus progestin for secondary prevention of coronary

heart disease in postmenopausal women. Heart and Estrogen/progestin Replacement
Study (HERS) Research Group.
Hulley S, Grady D, Bush T, Furberg C, Herrington D, Riggs B, Vittinghoff E.

Abstract
CONTEXT:
Observational studies have found lower rates of coronary heart disease (CHD) in
postmenopausal women who take estrogen than in women who do not, but this potential
benefit has not been confirmed in clinical trials.
OBJECTIVE:
To determine if estrogen plus progestin therapy alters the risk for CHD events in
postmenopausal women with established coronary disease.
DESIGN:
Randomized, blinded, placebo-controlled secondary prevention trial.
SETTING:
Outpatient and community settings at 20 US clinical centers.
PARTICIPANTS:
A total of 2763 women with coronary disease, younger than 80 years, and postmenopausal
with an intact uterus. Mean age was 66.7 years.
INTERVENTION:
Either 0.625 mg of conjugated equine estrogens plus 2.5 mg of medroxyprogesterone
acetate in 1 tablet daily (n = 1380) or a placebo of identical appearance (n = 1383). Follow-
up averaged 4.1 years; 82% of those assigned to hormone treatment were taking it at the end
of 1 year, and 75% at the end of 3 years.
MAIN OUTCOME MEASURES:
The primary outcome was the occurrence of nonfatal myocardial infarction (MI) or CHD
death. Secondary cardiovascular outcomes included coronary revascularization, unstable
angina, congestive heart failure, resuscitated cardiac arrest, stroke or transient ischemic
attack, and peripheral arterial disease. All-cause mortality was also considered.
RESULTS:
Overall, there were no significant differences between groups in the primary outcome or in
any of the secondary cardiovascular outcomes: 172 women in the hormone group and 176
women in the placebo group had MI or CHD death (relative hazard [RH], 0.99; 95%
confidence interval [CI], 0.80-1.22). The lack of an overall effect occurred despite a net
11% lower low-density lipoprotein cholesterol level and 10% higher high-density
lipoprotein cholesterol level in the hormone group compared with the placebo group (each
P<.001). Within the overall null effect, there was a statistically significant time trend, with
more CHD events in the hormone group than in the placebo group in year 1 and fewer in
years 4 and 5. More women in the hormone group than in the placebo group experienced
venous thromboembolic events (34 vs 12; RH, 2.89; 95% CI, 1.50-5.58) and gallbladder
disease (84 vs 62; RH, 1.38; 95% CI, 1.00-1.92). There were no significant differences in
several other end points for which power was limited, including fracture, cancer, and total
mortality (131 vs 123 deaths; RH, 1.08; 95% CI, 0.84-1.38).
CONCLUSIONS:
During an average follow-up of 4.1 years, treatment with oral conjugated equine estrogen
plus medroxyprogesterone acetate did not reduce the overall rate of CHD events in
postmenopausal women with established coronary disease. The treatment did increase the
rate of thromboembolic events and gallbladder disease. Based on the finding of no overall
cardiovascular benefit and a pattern of early increase in risk of CHD events, we do not
recommend starting this treatment for the purpose of secondary prevention of CHD.
However, given the favorable pattern of CHD events after several years of therapy, it could
be appropriate for women already receiving this treatment to continue.
 JG COLLEGE OF NURSING
AHMEDABAD

SUBJECT: OBSTETRICS AND GYNECOLOGICAL

NURSING
TOPIC : MENOPAUSE

 PRESENTED TO:-
MRS VASUDHA PRAJAPATI
ASSOCIATE PROFESSOR
JG COLEGE OF NURSING

 PRESENTED BY:-
MS. KARISHMA SHROFF
1ST YEAR M.Sc. NURSING
JG COLLEGE OF NURSING
 NAME OF THE STUDENT TEACHER:

MS. KARISHMA SHROFF

NAME OF THE TEACHER SUPERVISOR:

MRS. VASUDHA PRAJAPATI MAM

SUBJECT : OBSTETRICS AND GYNECOLOGICAL NURSING

UNIT :
TOPIC : MENOPAUSE
GROUP : 3RD YEAR B,SC. NURSING STUDENTS
PLACE :JG COLLEGE OF NURSING
DATE : 20/10/2010
TIME : 11 TO 12 P.M

TEACHING METHOD:-LECTURE CUM DISCUSSION.

INSTRUCTIONAL AIDS:
• CHALK AND BOARD
• TRANSPERNCY SHOWING HORMONAL
REPLACEMENT THERAPY
• LCD
• PAMPHLET REGARDING SURGICAL MENOPAUSE
• BOOKLET REGARDING HEALTH EDUCATON ON
MENOPAUSE
• TREATMENT REGIMEN FOR OSTEOPOROSIS:
(1) HRT
• Oestrogen: daily dose- 0.625 mg conjugated oestrogen; minimum
bone sparing dose
• Progestins (in women with an intact uterus)
Sequential: 5 mg medroxyprogesterone acetate (MDPA) for 2 weeks
every month
Continuous combined regimen: 2.5 mg MDPA
• Oestrogen may be administered orally, subdermal implants, vaginal
cream, percutaneous gel or by transdermal patch.
(2) OTHER DRUGS
• Calcitonin 200 IU/day- inhibits bone resorption
• Fluoride 1 mg/kg- increases bone matrix
• Tibolone 1.25 mg/day
• Raloxifene- increases bone mineral density, reduce serum LDL and
to raise HDL level so risk of breast and endometrial cancer is
redused.
• Clonidine- reduce the severity and duration of hot flushes.
• Biphosphonates- Alendronate 5 mg/day for prevention; 10 mg/day
prevents osteoclastic bone resorption.
(3)ADDITIONAL MEASURES
• Weight bearing exercises
• Adequate ultraviolet exposure
• Vitamin D >400 IU/day
• Calcium supplementation-1000 mg/day
• Stop smoking and alcohol consumption
• Avoid excessive caffeine