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Effects of Estrogen Deficiency

What is menopause?
• A physiological loss of ovarian hormonal
activity
• Closely allied to loss of reproductive potential
• Permanent cessation of the primary ovarian
function
Physiology
The Ovaries
• 2 functions
– Produce ova
– Secrete hormones
• Start secreting estrogen & progesterone from
puberty to menopause
• Most of the beneficial effects derive from
estrogen
Actions of Estrogen
• Formation of the secondary sex characteristics
• Develop ovaries, tubes, uterus & vagina
• HPO axis interaction
• Endometrial proliferation
• Increases fat deposition
• Maintain the skin & vessels
• Bone – increase formation & reduce
resorption
Hypothalamus-
Pituitary-
Ovarian Axis
Actions of Progesterone
• its actions are amplified in the presence of
estrogen
• Interacts with hypothalamus and pituitary to
regulate menstrual cycle
• converts endometrium to secretory stage
• makes cervical mucous & vaginal epithelium
impenetrable to sperm
• inhibits lactation during pregnancy
• makes the uterus less contractile
CLINICAL IMPLICATIONS OF
MENOPAUSE
Minor Conditions
• Urinary tract infections
• Vaginal dryness
• Vaginal infections
• Joint & Muscle pains
Symptoms Mimicking Disease
• Abnormal vaginal bleeding
– Perimenopausal
– Postmenopausal
• General pains eg. Breast
Perimenopausal abnormal bleeding
• At this age, there are many conditions that
peak
– e.g. Adenomyosis, polyps, fibroids, hormonal
• Cancers are always a concern, esp Ca Cervix
• Infections are the most common occurrence
• All these must be ruled out before a diagnosis
of perimenopausal bleeding is made
Postmenopausal Bleeding
• Consider it as always abnormal
• Always think of cancer
• Usually due to atrophy or infection
THE CONSEQUENCES OF
MENOPAUSE
Menopausal symptoms

• Menstrual symptoms
• Other symptoms
• Neurological
• Libido
• Urinary tract
• Genital

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Menopausal symptoms
• Menstrual
– 3 classic ways in which the menstrual period
ceases are as follows:
• Sudden cessation.
• Gradual diminution in the amount of blood loss with
each regular period until menstruation stops.
• Gradual increase in spacing of periods until they
cease for at least a period of one year.

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Other symptoms

• 60-70% women go
through
menopausal period
without problems
• Rest needs guidance
and treatment

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Hot Flushes

• Early and acute symptom of estrogen deficiency.


• These are waves of vasodilatation affecting the face and neck and last
for 2-5 mins each.
• Followed by severe sweating.
• Occurring at night may disturb sleep.
• Sometimes preceded by headache.
• Palpitation and anginal pain maybe felt.
• Mental depression due to lack of sleep, irritability and lack of
concentration.
• With passage of time severity of hot flushes decreases.

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Cause of hot flushes

• Caused by noradrenalin, which disturbs the


thermoregulatory system.
• Oestrogen deficiency reduces hypothalamic
endorphins, which release more
norepinephrine and serotonin.
• This leads to inappropriate heat loss
mechanism.

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Neurological

• Vasomotor symptoms and


paraesthesia take the form of
sensations of pins and needles
in the extremities.

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Psychomotor & Mental
• loss of libido
• suicidal tendencies
• marital discord
Libido

• Estrogen and androgen deficiency causes urogenital


atrophy, which affect sexual function.

• Leads to a decline in sexual interest.

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Urogenital Problems
• The symptoms which develop a little
later are :
– Urinary
• Dysuria
• Stress incontinence and urge
• Recurrent infection

Genital
Dry vagina
Dyspareunia
Loss of libido

Faecal incontinence
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Urinary tract
• Oestrogen deficiency
causes

• Urethral caruncle
• Dysuria with or without
infection
• Urge
•Stress incontinence( due to poor vascularity and loss of tone of
internal urethral sphincter).
These symptoms are clubbed together under the term

urethral syndrome.
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Genital

• Atrophic vagina reduces


the vaginal secretion, and
dry vagina cause
dyspareunia.
• Loss of libido adds to
sexual dysfunction.

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COMPLICATIONS
or
LATE SEQUELAE

Menopause is a normal developmental


process, but the decline in Estrogen can
have clinical sequelae.

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– Vasomotor symptoms.
• HTN

– Osteoporosis.
• Arthritis
• Osteoporosis of vertebral bones, upper end of hip joint,wrist
• frature

– Cardiovascular disease.
• ischaemic heart disease, MI, HTN
• Stroke
• Cardiac irregularities
• Tachycardia

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– Urogenital atrophy.
• Prolape genital tract
• Stress incontinence of urine & feces
• Ano-colonic cancer

– Cognitive decline and Alzheimer's disease.

– Cataract, glaucoma, macular degeneration

– Skin changes and Tooth decay

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Long Term Effects
• Cardiovascular
• Bone
• Cancers
• Cerebrovascular
• An incipient slowly progressing skeletal disorder:
microarchitectural detirioration of bone mass resulting in
increased fragility and predilection to frature in the absence of
sig. trauma
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Definition by WHO
OSTEOPENIA:
• As a BMD b/w 1 and 2.5 SD below the young adult mean
peak

OSTEOPOROSIS:
• As BMD which is 2.5 or more below the SD of mean young
adult values

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Pathophysiology
• Bone remodeling : at cellular level
osteoclastic and osteoblastic activity
• Metabolic : osteocytes and lining
cells
• Peak bone mass : by 35-40yrs
• Then after slow subsequent age
related loss of bone mass: 0.4%
annually for everyone
• Accelelarated rate in women: 2%
cortical bone and 5% trabecular
bone; estrogen def, Ca def, VitD def

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• Bone Ca amts at 40 yo : 1200g; when drops to 750g:
frature is liabile
• In elderly women : vertebral fraturegibbus formation,
bent spine and shortening of height
• : hip frature

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Family history of osteoporosis
Low Ca intake in diet
Smoking and excess of caffeine and alcohol intake
Early menopause
Low weight
Surgical menopause
Radiation menopause
Thyrotoxicity
Sedentery life syle
Women on GnRH, heparin, cortico steroids , danazol, clomiphene
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CARDIOVASCULAR
DISEASE

• Estrogen is cardioprotective(antioxidant
property also)
• After menopause HDL,LDL, total
cholesterol ,
• Estrogen deficiencyatherosclerosis, ischemic
heart disease, MI
• Risk factors: obese women with hypertension ,
previous thromboembolicepisodes 37
Stroke
• Incidence of stroke also increase in menopausal women

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Skin changes
• Collagen content is reduced, causing skin
to wrinkle

• The loss of collagen is more rapid in the first


few years after menopause

• 30% of skin collagen is lost within the first 5


years.

• The rate is 2% per year for the first 10 years


after menopause.

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CNS

• ER are abundant in the brain. E have a role in many brain


processes, and it’s absence result in physiologic and symptomatic
changes.

• E is important for
– cerebral blood flow
– cerebral glucose administration
– synaptic activity, neuronal growth
– survival of cholinergic neurons
– complex functions as cognition.

• The role of E deficiency in postmenopausal depression, declining


cognitive function, dementia, and Alzheimer's disease is not clear.
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Pyometra
• Years after menopause, women may develop senile pyometra
cervical stenosis
• Rx : drainage by cervical dialatation under GA

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