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Menopause (Clinical Effects of Menopause (Osteoporosis (Bone densitometry…
Menopause
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Physiology
- as aging follicles become more resistant to gonadotropin stimulation, circulating FSH and luteinizing hormone (LH) levels increase.
- lead to stromal stimulation of the ovary, with a resultant increase in estrone levels and a decrease in estradiol levels.
- Inhibin levels also drop during this time because of the negative feedback of elevated FSH levels.
- the most significant change in the hormonal profile is the dramatic decrease in circulating estrogen levels. Without a follicular source, the larger proportion of postmenopausal estrogen is derived from ovarian stromal and adrenal secretion of androstenedione, which is aromatized to estrone in the peripheral circulation.
- Testosterone levels also decrease with menopause, but this decrease is not as marked as the decline in 17-estradiol.
- Androgen-to-estrogen aromatization can occur in adipose tissue, muscle, liver, bone, bone marrow, fibroblasts, and hair roots
Hormonal changes in the menopausal transition – FSH, E2, inhibins
- FSH levels begin to increase further,
- women whose menses occur at intervals of more than 3 months exhibit increased FSH, with a decrease in circulating estradiol and the inhibins
The postmenopausal phase
- The postmenopausal state (STRAW stages +1 and +2) elevated FSH and LH, low estradiol and progesterone, and well-preserved levels of testosterone. DHEAS decreases progressively.
- The major circulating estrogen at this time is estrone.
- Estrone levels are higher in obese women, who have more adipose tissue than lean women; this may explain why obese women are at greater risk of estrogen-related malignancies such as breast and endometrial cancer.
Menopause Markers
- Gonadotropin secretion increases: FSH, LH
- Endometrial hyperplasia can be suggested by ultrasonography (an endometrial thickness of > 5 mm),
- preceded by a period of duration of about 4 years during which the endocrine, biological and clinical features of changing ovarian function begin.
- A common feature is the development of cycle irregularity in women with a previous history of regular menses.
- This marks the onset of the menopausal transition (perimenopause).
- Stages of Reproductive Aging Workshop (STRAW):
Three stages (early (–5), peak (–4) and late (–3) reproductive) describe the years before the perimenopause.
Stage –3 regular cycles but elevated levels of follicle-stimulating hormone (FSH) in the follicular phase.
Stage –2 (the early menopause transition) is characterized by variable cycle length.
Stage –1 (late transition) two or more stopped cycles and 60 or more days of amenorrhoea.
Stage +1 first 5 years after the final menstrual period.
Stage +2 late postmenopause.
- reproductive ageing after 40 years is marked by a relatively rapid reduction in the number of primordial follicles and a consequent decrease in inhibin B secretion, with an increase in FSH that can maintain or increase estradiol and inhibin A secretion until follicular exhaustion occurs
- the permanent cessation of menstruation that results from loss of ovarian follicular activity.
- characterized by a continuation of vasomotor symptoms and by urogenital symptoms such as vaginal dryness and dyspareunia.
- Premature menopause – before 40th year
- Delayed menopause – cessation of menses after 54th year (less than 10% of females)
- Factors that lower the age of physiologic menopause:
smoking, hysterectomy, Fragile X carrier, autoimmune disorders, living at high altitude,
history of certain chemotherapy medications and/or radiation treatment.