Physiology of

Menopause
Dr Samaa Nazer

Consultant - Assistant Professor

King Abdulaziz University

Menopause
Menopause :Perminent cessation of menstruation caused by
failure of ovarian follicular development in the
presence of adequate gonadotrophin stimulation.

Climacteric :The physiologic period in a women's life during

which there is regression of ovarian function.
Premature ovarian failure :Cessation of menstruation due to depletion of
ovarian follicles before the age of 40y.

Menopause
Menopause Age
Median - 51.4, range of 48-55 yrs
Median for perimenopause - 47.5 years, median length of 4
years
Premature menopause -caused by genetic abnormalities on
the long and short arm of X chromosome
Earlier menopause:
surgical causation (30%)
family history of early menopause
cigarette smoking, blindness
abnormal chromosome karyotype
precocious puberty
left-handedness
Later age :
obesity
higher socioeconomic class

Menopause & Society

In most societies in the western
world, about 13 % to 14% of the
population are older than 50 years.

Average age of menopause in USA is

50-51 year

Types of Menopause
Physiologic menopause
Iatrogenic menopause :Surgical, radiation therapy
,chemotherapy, infection and tumer

physiology of the perimenpausae

Shorten of menstrual cycle length or anovulatory
cycle and prolong cycle
Shorten of the follicular phase ,no of follicles
FSH
inhibin hormone
Estradiol level fluctuate but remain within the
wide range
Progesterone level fluctuate depending on the
presence &adequacy of ovulation
Androgen level steadily during the transitional
period

Ovarian Dysfunction
Women are born with about 1.5 million ova
At menarche 400,000 ova
Most women menstruate about 400 times
between menarche & menopause
With menopause, the ovary is no longer
capable of responding to pituitary
gonadotropins production of estrogen
&progesterone

Physiology of menopause
Ovarian dysfunction
Few remaining follicular units present
but those are no longer capable of
normal response despite stimulation
by marked of gonadotropins.

OVARIAN DYSFUNCTION
Degeneration of granulosa & thica cells

Failure to react to endogenous gonadotrophine

Estrogen

FSH & LH

Changes in hormones metabolism

associated with menopause
Androgens : androgen level due to stromal cell
stimulation by endogenous gonadotrophins
Androstenedion (adrenal)
Testosterone level
This lead to defeminization hirsutism
,virilism,

Con.
Estrogen :
In preimenpausal women ,the main
Estrogen is E2
In post menopause is E1(from the
peripheral conversion of
Androstenadione)

Clinical manifestation of
menopause

Target organ response to Esterogen

CVS
Urogenital system
Bone
Skin &teeth
Brain
Symptoms related to estrogen
Vasomotor instability
Altered menstrual function
Vaginal atrophy
Urinary tract symptom
Osteoporosis

Cardiovascular system
changes
Leading cause of death - twice as many women die
of cardiovascular disease than of cancer

Incidence rates of coronary heart disease in both

men and women were similar 6-10 years after the
menopause
Serum cholesterol increases significantly at 1-2
yrs or more after the menopause - marked by an
increase in triglycerides, an increase in LDL,
decrease in HDL - and are less cardio protective

Genitourinary system changes

Atrophy of vaginal epithelium -> atrophic vaginitis (itching,
burning, discomfort, dyspareunia and vaginal bleeding)
Urologic: 30% drop in urethral closure pressure at rest and
during stress in postmenopausal women because of atrophy of
the urethral mucosa, varying degrees of bladder and urethral
prolapsed and loss of UV angle
Atrophic urethritis -> urgency, frequency, dysuria, suprapubic
pain, UTI
Atrophic cystitis -> urge incontinence, frequency, dysuria, and
nocturia
Descent of uterus due to decreased collagen in uterosacral
ligaments and cardinal ligament

Menopause &Osteoporosis
25% of women have radiological evidence of
osteoporosis by 60; by 80Y 1 in 4 have fractured a
hip; after age 65 1 in 3 have a vertebral fracture
15% of women with hip fracture after age 80 will die
of complications within 6 months
Initial period of up to 4-5 years after the menopause
there is accelerated loss of bone at rate of 1-2% per
year; trabecular bone mainly
Bone loss is mainly in the trabecular type while
cortical type occur later .
Three most common fractures in postmenopausal
women - vertebrae, ultra distal radius and neck of
femur

Menopause &osteoporosis
Risk factors:
white or Asian
reduced weight for height
early spontaneous menopause or surgical menopause
family history of osteoporosis
low dietary calcium intake
low vitamin D intake
high caffeine intake
high alcohol intake
high protein intake
cigarette smoking
endocrine disorders - diabetes mellitus,
hyperthyroidism, Cushing disease

Hot Flushes

Cause of hot flushes: the mechanism is

not known, but data indicate that symptom
result from a defect in central
thermoregulatory function
A pulse of LH is released with the onset
of each hot flush, therefore a central
hypothalamic mechanism
Development of hot flushes more than1
year prior to the menopause is probably
not due to estrogen deficiency but to
other factors such as stress

Hot flushes &menopause

Onset : 10% prior to menopause
50% after cessation of menses
it has abrupt onset, last for 30 sec - 5min
Flush preceded by increase in digital
perfusion, followed by increases in skin
temp, circulating norephinephrine levels
and LH levels, heart rate

Skin and Teeth

Significant decrease in epidermal thickness
and collagen content postmenopausally,
healing of skin is generally slower
Postmenopausal estrogen maintains
premenopausal levels of synthesis of
collagen and prevents thinning of skin and
retards wrinkling process
Women ingesting estrogen
postmenopausally are less likely to loose
teeth

Other systemic symptom

Anxiety ,depression ,irritability ,fatigue
headaches, tiredness, lethargy,
nervousness, depression, sleep difficulties,
inability to concentrate, hot flushes
Sleep latency interval is increased and
amount of REM is decreased
The mechanism is not clear ??
Postmenopausal women have lower level of
plasma -endorphin

THANK YOU