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Menopause��Lecture 21

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Menopause

At birth, the female has 1-2 million oocytes

• By puberty, only 440,000 oocytes remain

• By age 30-35 the number has dropped to

100,000

• Follicular maturation is induced by the

pituitary release of Follicle Stimulating

Hormone (FSH)

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Menopause

With advancing age, the remaining oocytes

become increasingly resistant to FSH

• FSH gradually rises until menopause when

it is usually greater than 30 mIU/ml

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Menopause

Menopause is defined as the absence of

menstrual periods for at least 6 months in a

woman over 40

• In the USA, the average age of a woman at

menopause is 51

• 1% of women will undergo menopause

before age 40\

• Women who smoke cigarettes and who are

malnourished will have earlier menopause

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Menopause-Symptoms�

• First symptoms are often menstrual

irregularities

– Menstrual cycles shorten or lengthen

• Hot flushes and vasomotor instability

– sudden sensation of warmth, skin of face and

chest will become flushed

– then patient will experience a chill

– this is the result of lower estrogen levels

– more bothersome at night

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Menopause-Symptoms

• Sleep disturbance

– The time it takes to fall asleep is longer than

when the woman was younger

– Total length of time asleep is shorter

• Vaginal dryness/genital tract atrophy

– vaginal mucosa and endometrium become thin

and dry

– irritation, difficulty with sexual intercourse may

develop

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Menopause-Symptoms

• Mood changes

– Depression, crying spells may develop

• Skin and nails

– skin and nails become thinner

• Osteoporosis

– Bone density is lost at a rate of 1-2% per year

after menopause

– Risk of hip and vertebral fracture increases as

soon as 5 years after menopause

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Menopause-Symptoms

• Cardiovascular Lipid changes

– Total cholesterol increases, high density

lipoprotein (HDL) cholesterol decreases, and

low density lipoprotein increases

– Risk of heart attack and stroke increases in

women after menopause

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Menopause Diagnosis

• Use symptoms and signs

• Do not depend upon FSH

• FSH will often not rise until late in the

perimenopausal period and may fluctuate

• Normal FSH does not exclude the

perimenopause

• Consider thyroid disease if FSH is normal

• No need for biopsy prior to staring HRT

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Menopause-Therapy

• For asymptomatic women, no therapy or

treatment is necessary

– Calcium intake should be at least 1500

milligrams a day

– Weight bearing exercise will help in preventing

osteoporosis

• For symptomatic women or for prevention

of osteoporosis and heart disease, hormonal

therapy is useful

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Nursing role: Menopause

Through health teaching:

nurses can help a woman appreciate that loss of uterine function may make almost no change in her life and,
for a woman with dysmenorrhea (painful menstruation) or with no desire for more children, it may be a welcome change

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Osteoporosis

is an age-related diseaseis an age-related disease of boneis an age-related disease of bone that leads to an increased risk of fractureis an age-related disease of bone that leads to an increased risk of fracture. In osteoporosis the bone mineral density (BMD) is reduced, bone microarchitecture is disrupted, and the amount and variety of proteins in bone is altered
common in women after menopause
a bone mineral density 2.5 standard deviations below peak bone mass

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Signs and symptoms

Fractures: vertebral collapse, fractures of the long bones.

Falls risk: the increased risk of falling associated with aging leads to fractures of the wrist, spine and hip.

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Risk factors

Nonmodifiable:

FemaleFemale sex (estrogenFemale sex (estrogen deficiency following menopauseFemale sex (estrogen deficiency following menopause), while in men (a decrease in testosterone levels).

Those with a family history of fracture or osteoporosis are at an increased risk.

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Risk factors

Potentially modifiable

Excess alcohol
Vitamin D deficiency
Tobacco smoking: tobacco smoking inhibits the activity of osteoblasts
MalnutritionMalnutrition -include low dietary calcium and/or phosphorus, magnesium, zinc, boron, iron, fluoride, copper, vitamins A, K, E and C
UnderweightUnderweight/inactiveUnderweight/inactive - bone remodelingUnderweight/inactive - bone remodeling occurs in response to physical stress, and weight bearing exercise can increase peak bone mass achieved in adolescence.^[
Excess physical activity - excessive exercise can lead to constant damages to the bones which can cause exhaustion of the structures
Heavy metalsHeavy metals - a strong association between cadmium, lead and bone disease has been established.
Soft drinks –

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Diagnosis

Clinical decision rule
Dual energy X-ray absorptiometry: Osteoporosis is diagnosed when the bone mineral density is less than or equal to 2.5 standard deviations below that of a young adult reference population.

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Screening

The U.S. Preventive Services Task ForceThe U.S. Preventive Services Task Force (USPSTF) recommended in 2002 that all women 65 years of age or older should be screened with bone densitometry.

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Treatment

Nutrition:
Calcium
Vitamin D
Exercise
Multiple studies have shown that aerobics, weight bearing, and resistance exercises can all maintain or increase BMD in postmenopausal women.

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Epidemiology

It is estimatedthat 1 in 3 women and 1 in 12 men over the age of 50 worldwide have osteoporosis.
It is responsible for millions of fractures annually, mostly involving the lumbar vertebraeIt is responsible for millions of fractures annually, mostly involving the lumbar vertebrae, hip, and wrist.
Fragility fractures of ribs are also common in men.

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Prevention

Lifestyle
Exercise
Nutrition
Medication: Just as for treatment, bisphosphonate can be used in cases of very high risk.

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Female Genital Mutilation, Cervical Cancer, Breast Cancer

Lec. 22

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Female Genital Mutilation (FGM)

Definition: FGM comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons.

The practice is mostly carried out by traditional circumcisers, who often play other central roles in communities, such as attending childbirths. Increasingly, however, FGM is being performed by medically trained personnel.

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�Who is at risk?�

Procedures are mostly carried out on young girls sometime between infancy and age 15, and occasionally on adult women. In Africa, about three million girls are at risk for FGM annually.

Between 100 to 140 million girls and women worldwide are living with the consequences of FGM. In Africa, about 92 million girls age 10 years and above are estimated to have undergone FGM.

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�Who is at risk?�

The practice is most common in the western, eastern, and north-eastern regions of Africa, in some countries in Asia and the Middle East, and among certain immigrant communities in North America and Europe.

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Procedures

Female genital mutilation is classified into four major types:

Clitoridectomy: partial or total removal of the clitoris (a small, sensitive and erectile part of the female genitals) and, rarely, the prepuce (the fold of skin surrounding the clitoris) as well.

Excision: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (the labia are "the lips" that surround the vagina).

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Procedures

Infibulation: narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the inner, and sometimes outer, labia, with or without removal of the clitoris.

Other: all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterizing the genital area.

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Health Consequences

FGM has no health benefits, and it harms girls and women in many ways. It involves removing and damaging healthy and normal female genital tissue, and interferes with the natural functions of girls' and women's bodies.

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Health consequences

Immediate complications can include severe pain, shock, haemorrhage (bleeding), tetanus or sepsis (bacterial infection), urine retention, open sores in the genital region and injury to nearby genital tissue.

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Health consequences

Long-term consequences can include:

recurrent bladder and urinary tract infections;
cysts;
infertility;
the need for later surgeries. For example, the FGM procedure that seals or narrows a vaginal opening (type 3 above) is surgically changed to allow for sexual intercourse and childbirth, and sometimes stitched close again afterwards;
an increased risk of childbirth complications and newborn deaths

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�Causes�

The causes of female genital mutilation include a mix of cultural, religious and social factors within families and communities.

FGM is often considered a necessary part of raising a girl properly, and a way to prepare her for adulthood and marriage.
FGM is often motivated by beliefs about what is considered proper sexual behavior, linking procedures to premarital virginity and marital fidelity. FGM is believed by some to reduce a woman's libido and help her resist "illicit" sexual acts.

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�Causes�

FGM is associated with cultural ideals of femininity and modesty, which include the notion that girls are “clean” and "beautiful" after removal of body parts that are considered "male" or "unclean".
Though no religious scripts prescribe the practice, practitioners often believe the practice has religious support.

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Causes

Religious leaders take varying positions with regard to FGM: some promote it, some consider it irrelevant to religion, and others contribute to its elimination.
In most societies, FGM is considered a cultural tradition, which is often used as an argument for its continuation.

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International Response

In 1997, the World Health Organization (WHO) issued a joint statement with the United Nations Children’s Fund (UNICEF) and the United Nations Population Fund (UNFPA) against the practice of FGM. A new statement, with wider United Nations support, was then issued in February 2008 to support increased advocacy for the abandonment of FGM.

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Islam & FGM

"Genital clitoris mutilation is not an Islamic practice. It is in fact against Islamic teaching. Clitoral mutilation performed in several African countries including Egypt are traditional practice and has nothing to do with Islam, although several misguided muslim group practiced the tradition."

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Extra Readings

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Cancer of the Cervix

About 1 in 200 women develop cervical cancer. It can occur at any age with two peaks in incidence ocurring in women in their thirties and fifties. The highest incidence of cervical cancer occurs in South America.

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Causes�

Cervix cancer (with the exception of some rare types) is caused by Human Papilloma Virus. There are over 100 types of this virus but only some are associated with cervical cancer. The most common are types 16, 18, 31, 33, and 45. The virus alters the genes in the cells allowing them to make proteins (called E6 and E7) that promote cancer.

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Causes

Almost any woman who has been sexually active can develop cancer of the cervix.
However, it is more frequent in women who have had more partners.
It is also more common in women whose husbands / boyfriends have had more sexual partners.
Immunodeficiet women (such as those with AIDS, after an organ transplant, or those on steroids) are also more likely to develop cervix cancer.

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Symptoms�

Cervix cancer can cause a number of symptoms. Sometimes cervix cancer presents with abnormal vaginal bleeding, discharge, or bleeding after intercourse. When advanced, cervix cancer can present by causing back ache from a blockage of the tubes from the kidneys to the bladder (ureters).

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Treatment�

Treatment depends on how advance the disease is. A measure of how advanced the disease is called the 'Stage' (I - IV). In it’s very early stages it can be treated with an operation to remove a cone of tissue from the cervix (cone biopsy). Fertility is preserved following a cone biopsy but in some cases the miscarriage rate may be slightly higher afterwards.

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Treatment

If the cancer is at a higher (but still low) stage it can be treated by an operation called a ‘radical (or Wertheims) hysterectomy’. This involves excision of the womb and tissue either side of it called the parametrium. The complications are greater than after a standard hysterectomy and some women have bowel and urinary problems afterwards. Other complications include nerve damage, bleeding, thromboembolism (economy class syndrome), and infection.

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Treatment

If a cervix cancer is more advanced, the therapy is normally a combination of chemotherapy and radiotherapy (chemoradiotherapy). The side effects from this may include narrowing of the vagina (stenosis), changes in bowel habit, and urinary side effects. In the worst cases it can cause bad damage to the bowel (radiation enteritis) and bladder (radiation cystitis).

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Recurrence

Cervix cancer that returns after initial treatment it is often fatal. Some treatments exist in some circumstances. If the cancer returns at the top of the vagina and no where else, an operation called ‘exenteration’ is sometime appropriate. This operation may involve removal of the vagina, bowel and even bladder and is associated with a high complication rate.

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Survival�

The aim of treatment for early stage cervical cancer is curative. For stage 1 disease with negative lymph nodes this can be achieved in 19 out of 20 cases. When the disease is more advanced, the prognosis is less good.

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Prevention�

Women who have regular smear tests are much less likely to develop cervix cancer. In the UK, women who are not virgins are recommended to have a smear test every three years until the age of fifty and then five yearly until 65.

Reference: http://www.womb.org.uk/Cervical_cancer.htm

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Breast Cancer

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Breast Cancer

Is the Cancer that forms in tissues of the breast, usually the ducts (tubes that carry milk to the nipple) and lobules (glands that make milk). It occurs in both men and women, although male breast cancer is rare.� �

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Breast cancer

Because there is no specific cause of breast cancer, it is combination of hormonal, genetic and possible environment events.

Etiology: hormones produced by ovaries has an important role in breast cancer such as steroidal and progesterone.

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Breast cancer

Breast cancer elicits fears related to loss of body image and sexuality, surgery, and death. the exact cause of breast cancer is not clearly known. Furthermore, there is currently no cure for advanced disease, and there is no definitive way of preventing it.

About 18% of breast cancer diagnoses are among women in their 40s, while about 77% of women with breast cancer are older than 50 when they are diagnosed.

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Breast Cancer: Early Detection

The goal of screening exams for early breast cancer detection is to find cancers before they start to cause symptoms.
Screening refers to test and examinations used to detect a disease, such as cancer, in people who do not have any symptoms.
Early detection means applying a strategy that results in an earlier diagnosis of breast cancer than otherwise might have occurred.

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The size of a breast cancer and how far it has spread are the most important factors in predicting the prognosis of a woman with this disease.

Finding a breast cancer as early as possible greatly improves the likelihood that treatment will be successful.

Early detection tests for breast cancer save thousands of lives.

Breast Cancer: Early Detection cont’d

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Risk Factors

age
race
environment
personal choices such as smoking, drinking, and diet.
Obesity and high-fat diets
Lack of Physical activity:
Family History
Reproductive and menstrual history
Hormone replacement therapy
Early Menarche
Late Menopause
Not having children
Oral contraceptives
Radiation exposure
Alcohol intake
Benign breast disease and mammographic density�

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Risk Factors You Cannot Change always

Gender: Simply being a woman is the main risk factor for developing breast cancer. Because women have many more breast cells than men do and perhaps because their breast cells are constantly exposed to the growth-promoting effects of female hormones, breast cancer is much more common in women. Men can develop breast cancer, but this disease is about 100 times more common among women than men.

Genetic risk factors: Recent studies have shown that about 5% to 10% of breast cancer cases are hereditary as a result of gene changes (mutations). The most common gene changes are those of the BRCA1 and BRCA2 genes. Normally, these genes help prevent cancer by making proteins that keep cells from growing abnormally.

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The risk of developing breast cancer is increased if the woman:

has 2 or more relatives with breast or ovarian cancer.
Breast cancer occurs in a relative (mother, sister, grandmother or aunt) younger than age 50 on either side of the family. The risk is higher if your mother or sister has a history of breast cancer.
Has relatives with both breast and ovarian cancer.
Has 1 or more relatives with 2 cancers (breast and ovarian, or two different breast cancers).
Has male relatives with breast cancer.
You have a family history of breast or ovarian cancer and Ashkenazi Jewish heritage.
Has family history includes a history of diseases associated with hereditary breast cancer such as Li-Fraumeni or Cowdens Syndromes.

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Early Detection Methods: Diagnostic Procedures

Breast self exam (BSE)
Clinical breast examination (CBE)
Mammography
Ultrasonograpgy
Magnetic resonance imaging
Fine needle aspiration

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What is Mammography ?

22% reduction in breast cancer mortality ≥ 50

15% reduction in breast cancer mortality

40-49 yrs of age

US Preventive Services Task Force summary report Ann Intern Med 2002;137:347-360

The X-Ray Machine

For Mammography

Is abreast imaging that can detect nonpalpable lesion and assist in diagnosing palpable masses

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�Mammographic Sensitivity�

98% in women ≥ 50 with fatty breasts

30-69% sensitivity in women with dense breasts, particularly low if < 50 or at increased risk

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Cancers Seen Only on US

Early invasive cancers with good prognosis

Additional detection virtually all in dense and heterogeneously dense breasts

Half of the cancers seen only on US were in women at high risk (7-9 per 1000)

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References��

The Wikipedia website
NIH web sites for infertility, STIs, and SDs

http://www.nlm.nih.gov

WHO Website and documents on STIs
http://www.cancer.gov/cancertopics/types/breast
American Cancer Society.: Cancer Facts and Figures 2008. Atlanta, Ga: American Cancer Society, 2008.
Research articles from JAMA