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Dr Vikram Talaulikar MD FRCOG PhD What University College London Hospital happens during Women’s Health, University College of menopause London transition? BMS certified Menopause Specialist Trainer for BMS principles and practice of menopause care Menopausal transition Life expectancy for women is on the rise Spend significant number of years of their life in the menopausal phase Menopausal transition involves a myriad of physical, endocrine, and psychological changes These are influenced by ethnic, geographic and socio-cultural factorsEvolution of menopause • Besides humans, killer whales, short-finned pilot whales, belugas, giraffes and narwhals experience menopause • Older females forego the option to bear more children so that they can support their existing ones. By helping their children and grandchildren are passed down the generationsure that their genes • There is still plenty of research that is needed Stages during the journey towards menopause • Pre-menopause – before hormonal changes start • Peri-menopause – hormonal fluctuations (Usually for 2-5 years between 45-50) • Menopause – periods stop (always retrospective diagnosis 1 year Symptoms present after the last menstrual period) • Post-menopause – 1 year since periods have stopped and thereafter Timing of menopause • Median age 51 (46 in India) • 10% before 45 Age of onset of Menopause • 1% of women < 40 25 20 • 0.1% of women < 30 15 perc0t Coulam Obstet Gynecol 1986 5 0 0 10 20 30 40 50 60 Factors affecting onset and duration of menopause transition Age at menopause is influenced by - diet, exercise levels, smoking status, socio-economic background, body mass index (BMI), ethnicity, cultural beliefs, and concurrent medical/gynaecological health issues High BMI - later onset of the menopausal transition African American women have been shown to have a longer duration of menopausal transition Earlier onset of menopause in low- and middle-income countries, and smoking has been associated with earlier menopausal transitionAge-related decrease in primordial follicles Faddy MJ, Gosden RG, Gougeon A et al Hum Reprod 7:1342, 1992 Endocrine changes A rise in follicle stimulating hormone (FSH) Anovulatory menstrual cycle patterns Circulating serum levels of oestradiol, FSH, and luteinising hormone (LH) can fluctuate widely In women above the age of 45 with typical menopausal symptoms, routine hormone blood tests are NOT NECESSARY for the diagnosis of menopause Endocrine changes • Hormone changes typically cause irregular menstrual cycles with shortening of the cycle length followed by long gaps • Circulating testosterone levels do not change significantly leading to symptoms of androgen excess Symptoms Symptoms associated with the menopausal transition affect more than 80% of women and are severe in about one-third It is thought that earlier symptom development in the transition signals a longer duration of bothersome symptoms Symptoms Vasomotor symptoms which include hot flushes and night sweats are the commonest affecting more than 80% Other common symptoms include disturbed sleep, tiredness, depressed mood, brain fogging, joint pains, low libido, vaginal dryness and heightened anxiety Hot flushes can last several minutes, starting with a flushing sensation that spreads along the upper part of the body Changes to thermoregulation in the central nervous system Women who have a narrow thermoregulatory zone are more prone Hot flushes Variety of hypothalamic neurotransmitters implicated including neurokinin B (NKB) signalling from kisspeptin, neurokinin B and dynorphin (KNDy) neurons to neurokinin 3 receptor (NK3R)-expressing median preoptic nucleus neurons Among the various interventions available, hormone replacement therapy is the most effective treatment Severe and persistent vasomotor symptoms are associated with an increased risk of cardiovascular disease in future lifeGenitourinary syndrome of menopause Chronic progressive condition Symptoms of urogenital atrophy (vaginal dryness, burning, irritation, tissue shrinkage, and dyspareunia) Bladder symptoms such as urgency and frequency and pelvic organ prolapse Oestrogen deficiency causes the vaginal mucosa to become thin, with a reduction in superficial cells, reduction in glycogen and lactobacilli and a rise in the pH of vaginal secretions (>5) There is a reduction in collagen and elastin content and altered vaginal smooth muscle function If the condition is not reversed, it increases the chances of urinary tract infections Impacts at least about 50% of menopausal women and remains significantly underreported Sexual problems The decline in sex steroids with age and menopausal transition can also cause sexual dysfunction such as dyspareunia, reduced libido, arousal difficulties, and difficulties achieving orgasm Effects of other life events, emotional fluctuations, vaginal atrophy, and other chronic illnesses may play a role Risk of depressive symptoms and depressive disorders Mood Associations between poor sleep and hot flushes, anxiety, depressive changes symptoms, and low oestrogen levels Multifactorial - personal, psychosocial, and lifestyle factors Sleep and cognition Although it appears that cognitive functioning declines during the menopause transition (often described as brain fog by women) and returns to baseline towards the end of transition process Sleep difficulties and other sleep disorders such as sleep apnoea, insomnia, and restless leg syndrome are common during the menopausal transition (40% of women) Bones, muscles and connective tissues • Oestrogen deficiency following menopause also has a negative effect on connective tissue, joints, bone matrix, muscles and skin • A healthy lifestyle that incorporates regular exercise is key Osteoporosis Symptomless condition with↑ fracture risk: • 360,000 fractures every year (UK) • 80,000 hip fractures • Cost £2 billion alone • women > men • ↑ risk at menopause • decreased bone mineral density (BMD) • higher rates of bone turnover Before the menopause, women in general have a lower risk of being affected by coronary heart disease After the menopause, the risk increases Oestrogen is heart friendly- keeps bad cholesterol levels low Heart and blood and reduces the risk of fatty plaques building up inside the blood vessel walls vessels Loss of oestrogen hormone production from ovaries during coronary arteries narrowing, build-up of plaque in blood vessels (atherosclerosis) The blood vessels can become stiffer and cause high blood pressure Menopausal transition Every woman's experience of the menopausal transition is unique One-size-fits-all approach to the management of symptoms does not work