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Definition: Menopause is a period of life during which a woman gradually transitions from a reproductive state to a non-reproductive state, Subjective sensations and objective changes that occur during this period are called menopausal syndrome
PHASES OF THE CLIMACTERIC PERIOD Menopause - the time of the last menstruation Premenopause - the part of menopause preceding menopause Postmenopause - the period of life following menopause Perimenopause - the period during which signs of menopause syndrome or its consequences are observed.
Climacteric syndrome A complex of symptoms that complicates the physiological course of the menopausal period. Pathological menopause is observed in 25 - 30% of women.
Group 2 - medium-term - Urogenital disorders: vaginal dryness, pain during sexual intercourse, itching and burning, urethral syndrome, cystalgia, urinary incontinence - Skin and its appendages: dryness, brittle nails, wrinkles, dryness and hair loss
Group 3 late metabolic disorders: - Cardiovascular diseases - Osteoporosis - Senile dementia— Alopecia
Principles of treatment - Stages - Complexity - Individuality
Stages of treatment - Non-drug - Drug, non-hormonal - Hormonal - hormone replacement therapy (HRT)
Recommendations - Diet rich in calcium: dairy products (cottage cheese, yoghurts, cheeses, sour cream, milk), fish (especially dried fish with bones and sardines with bones), vegetables (celery, green salad, green onions, olives, beans), fruits (dried apples, dried apricots, figs), nuts (especially almonds, peanuts), sunflower seeds, sesame. — Limiting the consumption of animal fats, sugar and other refined carbohydrates, canned food, salt.
Non-hormonal therapy - Vitamin therapy - mineral complexes(alvitil, gerontovit, teravit, complivit, selmevit, female formulas, splat, fish fat, brewer's yeast, etc.) with the mandatory inclusion fat-soluble vitamins- antioxidants - A, E, C, D, which help correct homeostasis disorders.
Scheme according to Manuilova - In one syringe, intramuscularly for 20 - 25 days, vitamin PP 1%, starting from 1 ml, gradually increasing the dose to 5 ml by day 15, then reducing the dose to 1 ml by day 25 and novocaine solution 2%, starting with 1 ml according to the same scheme as a nicotinic acid. — B vitamins
Phytohormones Medicinal plants, which do not have an estrogenic effect, but have a positive effect on the typical symptoms of menopausal syndrome, as well as on the symptoms of premenstrual syndrome, algomenorrhea, menorrhagia, etc.
— Preparations containing Cohosh: klimandin, klimaktoplan, remens. Klimadinone has an estrogen-like effect, exhibits sedative properties, promotes the disappearance of vegetative-vascular and psycho-emotional climacteric disorders (hot flashes, sweating, sleep disturbances, nervous excitability, mood changes), reduces dryness of the vaginal mucosa. It is prescribed orally, 1 tablet 2 times a day (morning and evening) or in the form of a solution of 30 drops 2 times a day, for 3-6 months.
Correction of psycho-emotional disorders The drug Grandaxin is a tranquilizer that eliminates the somatic component of anxiety, autonomic dysregulation, autonomic disorders: brady or tachycardia, tremors in the hands, sweating, paleness or redness of the skin, dizziness, feeling of suffocation, gastrointestinal disorders, hormonal dysfunctions, relieves fear, anxiety, emotional tension
Antidepressant of plant origin - Gelarium hypericum, 1 tablet contains 285 g of dry extract of St. John's wort herb. Relieves anxiety, tension, improves mood. Use 1 tablet 3 times a day with water for at least 4 weeks.
Hormone replacement therapy Indications for HRT: - Menopausal syndrome. — After oophorectomy for non-malignant diseases — Postcastration syndrome. — Prevention of long-term consequences of the postmenopausal period
Contraindications for HRT - Tumors of the uterus, appendages, mammary glands. — Uterine bleeding of unknown origin — Acute thrombophlebitis. - Kidney and liver failure. — Severe forms diabetes mellitus. - Melanoma, meningioma. - History of breast, ovarian, or uterine cancer in the mother or siblings. - Sickle cell anemia.
Principles of HRT - Use only natural estrogens and their analogues. - Doses of estrogens are low and correspond to the early phase of proliferation of young women - Combination of estrogens with progestins or androgens to exclude hyperplastic processes in the endometrium. — With an intact uterus, estrogen monotherapy can be prescribed — The duration of hormonal prophylaxis and hormonal therapy is 5-7 years.
Research - Study of medical history, taking into account contraindications. — Vaginal examination, ultrasound examination of the pelvic organs. — Examination, palpation of the mammary glands, mammography. — Smear for oncocytology. — Measurement of blood pressure, height, body weight. — Coagulogram, determination of cholesterol levels, liver tests. — During the HCG process, repeat all of the above studies once a year, and control blood pressure at least once every 3 months.
Estrogens in combination with gestagens: Klimonorm, Divina, Klimen, cyclo-progynova Estrogens in combination with gestagens with antiandrogenic properties: Livial Estrogens + androgens: Genodian-depot
Methods of administration HRT drugs— Orally: cycloprogenova, Klimen, Klimonorm, Ovestin, Livial, Progenova — Transdermal: estraderm, skin ointments and patches — Intravaginal: ointments, suppositories — Sprays — in the nose. — Subcutaneous implants: capsules containing estradiol in crystalline form.
Premenopausal period Desensitization of receptor systems for steroid sex hormones in target organs (genitals). Desensitization of receptor systems for steroid sex hormones in target organs (genitals). Reduction in the number of maturing follicles in the ovaries. Reduction in the number of maturing follicles in the ovaries. Decreased estrogen production. Decreased estrogen production. Changes in the estradiol/estrone ratio. Changes in the estradiol/estrone ratio. The formation of inhibin is reduced. The formation of inhibin is reduced. Increase in the amount of FSH, LH later and to a lesser extent. Increase in the amount of FSH, LH later and to a lesser extent. An increase in the number of anovulatory cycles due to the absence of a pre-ovulatory surge of LH and FSH. An increase in the number of anovulatory cycles due to the absence of a pre-ovulatory surge of LH and FSH. Luteal phase deficiency menstrual cycle, lack of progesterone production. Insufficiency of the luteal phase of the menstrual cycle, lack of progesterone production. Stroma saves hormonal function, producing androstenedione and testosterone. The stroma maintains hormonal function, producing androstenedione and testosterone.
Postmenopausal period Disappearance of follicles in the ovaries. Disappearance of follicles in the ovaries. The main estrogen is estrone. The main estrogen is estrone. The biosynthesis of estrogen occurs in the stroma of abdominal adipose tissue and mammary gland tissue from androgens. The biosynthesis of estrogen occurs in the stroma of abdominal adipose tissue and mammary gland tissue from androgens. The formation of inhibin gradually ceases. The formation of inhibin gradually ceases. The maximum rise in FSH and LH occurs 2-3 years after menopause. The maximum rise in FSH and LH occurs 2-3 years after menopause. Decrease in FSH and LH levels 5-10 years after menopause. Decrease in FSH and LH levels 5-10 years after menopause. Achieving normal limits after postmenopausal years. Achieving normal limits after postmenopausal years. The adrenal glands are the “second sex gland.” The adrenal glands are the “second sex gland.” Progesterone is synthesized only by the adrenal glands. Progesterone is synthesized only by the adrenal glands.
Other hormonal changes in the perimenopausal period Decreased opioidergic activity (β-endorphins) and changes in the function of the serotonergic system. Decreased opioidergic activity (β-endorphins) and changes in the function of the serotonergic system. Predominance of sympathoadrenal reactions. Predominance of sympathoadrenal reactions. Disruption of the interaction and activity of the limbicoreticular complex and hypothalamic structures. Disruption of the interaction and activity of the limbicoreticular complex and hypothalamic structures. Increased ACTH, TSH, gonadotropic hormones. Increased ACTH, TSH, gonadotropic hormones. Disruption of the rhythmicity of the release of hypothalamic and pituitary hormones. Disruption of the rhythmicity of the release of hypothalamic and pituitary hormones. The reaction of peripheral endocrine organs is disrupted: the levels of cortisol, aldosterone, testosterone, and triiodothyronine increase. The reaction of peripheral endocrine organs is disrupted: the levels of cortisol, aldosterone, testosterone, and triiodothyronine increase.
Manifestations of menopausal syndrome 1 – early symptoms: 1 – early symptoms: - vasomotor (hot flashes, chills, increased sweating, headaches, hypotension, palpitations) - vasomotor (hot flashes, chills, increased sweating, headaches, hypotension, palpitations) - emotional and mental (irritability, drowsiness, weakness, anxiety, depression, forgetfulness, inattention, decreased libido) - emotional - mental (irritability, drowsiness, weakness, anxiety, depression, forgetfulness, inattention, decreased libido) 2 - medium-term: 2 - medium-term: - urogenital - vaginal dryness, pain during sexual intercourse, itching and burning, urethral syndrome, cystalgia , urinary incontinence. - urogenital – vaginal dryness, pain during sexual intercourse, itching and burning, urethral syndrome, cystalgia, urinary incontinence. - skin and its appendages – dryness, brittle nails, wrinkles, dryness and hair loss. - skin and its appendages – dryness, brittle nails, wrinkles, dryness and hair loss. 3 – late metabolic disorders: cardiovascular diseases, osteoporosis. 3 – late metabolic disorders: cardiovascular diseases, osteoporosis.
The main changes in hemostasis indicators in postmenopause Procoagulative and antifibrinolytic orientation. Procoagulative and antifibrinolytic orientation. Endothelial dysfunction with impaired production of biologically active substances. Endothelial dysfunction with impaired production of biologically active substances. Proatherogenic dyslipidemia, decreased activity of endogenous antioxidants. Proatherogenic dyslipidemia, decreased activity of endogenous antioxidants. Increased formation of endothelin 1 and thromboxane A 2 Increased formation of endothelin 1 and thromboxane A 2 Increased vascular tone and increased vasospastic reactions. Increased vascular tone and increased vasospastic reactions. Increased adhesive-aggregation properties of platelets and factor VIII activity Increased adhesive-aggregation properties of platelets and factor VIII activity Increased levels of fibrinogen, factor VII, antithrombin III, protein C Increased levels of fibrinogen, factor VII, antithrombin III, protein C
The fallopian tubes They become thinner due to a decrease in the muscle layer. They become thinner due to a decrease in the muscle layer. They are shortened. They are shortened. Their lumen narrows. Their lumen narrows. The epithelium atrophies. The epithelium atrophies. Eyelashes disappear. Eyelashes disappear.
Uterus Reduction in size. Downsizing. Decreased muscle mass. Decreased muscle mass. Increase in quantity connective tissue. Increased amount of connective tissue. Ratio of uterus and cervix 1:1 Ratio of uterus and cervix 1:1 Endometrial atrophy. Endometrial atrophy. Possibility of developing endometrial hyperplasia. Possibility of developing endometrial hyperplasia.
The cervix merges with the walls of the vagina. Fuses with the walls of the vagina. Atrophy. Atrophy. Narrowing of the cervical canal. Narrowing of the cervical canal. Obliteration in the isthmus region. Obliteration in the isthmus region. The glands are not functioning. The glands are not functioning. Disappearance of the mucus plug. Disappearance of the mucus plug.
Vagina Reduction in diameter and length. Reduction in diameter and length. Pale pink tint of the mucous membrane due to insufficient vascularization. Pale pink tint of the mucous membrane due to insufficient vascularization. Vaginal dryness. Vaginal dryness. Change in cellular composition: more parabasal than superficial cells. Change in cellular composition: more parabasal than superficial cells. Minimal glycogen production. Minimal glycogen production. Decreased number or complete disappearance of Dederlein rods. Decreased number or complete disappearance of Dederlein rods. Increased vaginal pH. Increased vaginal pH. Growth of streptococci, staphylococci, etc. Growth of streptococci, staphylococci, etc.
Mammary glands Regression of glandular tissue. Regression of glandular tissue. Some parts of the mammary glands retain their normal lobular structure. Some parts of the mammary glands retain their normal lobular structure. Some parts contain only collecting ducts or residual microcysts. Some parts contain only collecting ducts or residual microcysts. The parenchyma actively metabolizes estrogens. The parenchyma actively metabolizes estrogens.
Treatment of pathology of the perimenopausal period Stage 1 – adherence to a rational work and rest regime, the use of physiotherapy, diet therapy, psychotherapy. Stage 1 – adherence to a rational work and rest regime, the use of physiotherapy, diet therapy, psychotherapy. Stage 2 - along with the measures of the first stage, pharmacological agents are used to promote normalization functional state CNS and autonomic nervous system, correction of ECG abnormalities, etc. Stage 2 - along with the measures of the first stage, pharmacological agents are used to help normalize the functional state of the central nervous system and autonomic nervous system, correct ECG abnormalities, etc. Stage 3 - use hormonal drugs in addition to the methods listed above. Stage 3 – use of hormonal agents in addition to the above methods.
The main provisions of HRT: Use only natural estrogens and their analogues. Use only natural estrogens and their analogues. Doses of estrogen are low and correspond to the level of endogenous estradiol in the early proliferation phase in young women. Doses of estrogen are low and correspond to the level of endogenous estradiol in the early proliferation phase in young women. A combination of estrogens with progestogens or (rarely) androgens. A combination of estrogens with progestogens or (rarely) androgens. If the uterus is removed, estrogen monotherapy can be prescribed in intermittent courses or continuously. If the uterus is removed, estrogen monotherapy can be prescribed in intermittent courses or continuously. The duration of prophylactic hormones and hormonal therapy ranges from 2-3 months to 10 years or more. The duration of prophylactic hormones and hormonal therapy ranges from 2-3 months to 10 years or more.
All women should be informed about the following issues: the possible impact of short-term estrogen deficiency, namely the occurrence of early typical symptoms CS, and the consequences of prolonged deficiency of sex hormones - osteoporosis, cardiovascular diseases, etc.; about the possible impact of short-term estrogen deficiency, namely the occurrence of early typical symptoms of CS, and the consequences of long-term deficiency of sex hormones - osteoporosis, cardiovascular diseases, etc.; about the positive effects of HRT, which can alleviate and eliminate early menopausal symptoms, as well as actually prevent osteoporosis and heart disease vascular diseases; about the positive effects of HRT, which can alleviate and eliminate early menopausal symptoms, as well as actually prevent osteoporosis and cardiovascular diseases; about contraindications and side effects HRT. about contraindications and side effects of HRT.
Indications for replacement therapy estrogen Early (40-45 years) and premature menopause (up to 40 years of age). Early (40-45 years) and premature menopause (before 40 years of age). Tides. Tides. Atrophic vaginitis. Atrophic vaginitis. Atrophic cystitis and urethritis, stress urinary incontinence. Atrophic cystitis and urethritis, stress urinary incontinence. High risk osteoporosis (osteoporosis in relatives, smoking, low weight, signs of osteoporosis according to radiological studies). High risk of osteoporosis (osteoporosis in relatives, smoking, low weight, signs of osteoporosis according to radiological studies). High risk of atherosclerosis (mystery of myocardial infarction or angina pectoris, hypertension, CVD in relatives, smoking). High risk of atherosclerosis (mystery of myocardial infarction or angina pectoris, hypertension, CVD in relatives, smoking).
Contraindications to estrogen replacement therapy: Absolute: Pregnancy. Pregnancy. Bleeding from the genitals unknown etiology. Bleeding from the genitals of unknown etiology. Acute thrombosis. Acute thrombosis. Cholelithiasis. Cholelithiasis. Liver diseases. Liver diseases. Relative: History of leg vein thrombosis or pulmonary embolism. History of leg vein thrombosis or pulmonary embolism. History of breast cancer. History of breast cancer. History of uterine cancer. History of uterine cancer. Endometriosis, uterine fibroids. Endometriosis, uterine fibroids. Melanoma. Melanoma.
Positive effect of HRT Elimination of hot flashes. Elimination of hot flashes. Reducing the risk of osteoporosis. Reducing the risk of osteoporosis. Reducing the risk of CVD. Reducing the risk of CVD. Reducing total cholesterol and LDL levels. Reducing total cholesterol and LDL levels. Promotion HDL level Increasing HDL levels
Negative effects of HRT Increased risk of breast cancer. Increased risk of breast cancer. Increased risk of endometrial hyperplasia and uterine cancer. Increased risk of endometrial hyperplasia and uterine cancer. Increased risk cholelithiasis. Increased risk of cholelithiasis. Increased risk of leg vein thrombosis. Increased risk of leg vein thrombosis. High doses of estrogen increase blood pressure High doses of estrogen increase blood pressure
Complications with HRT Bloody issues from the genitals. Bloody discharge from the genitals. Pain in the mammary glands. Pain in the mammary glands. Mood changes. Mood changes. Weight gain and fluid retention. Weight gain and fluid retention.
Mandatory examinations are: blood pressure measurement; blood pressure measurement; determination of the level of glucose, lipoproteins, FSH, E2 in blood serum, TSH, T3, T4; determination of the level of glucose, lipoproteins, FSH, E2 in blood serum, TSH, T3, T4; gynecological examination with oncocytology (PAP - cervical smear); gynecological examination with oncocytology (PAP - cervical smear); Ultrasound of the endometrium with mandatory assessment of its thickness; Ultrasound of the endometrium with mandatory assessment of its thickness; Palpation of the mammary glands and mammography Palpation of the mammary glands and mammography
If the thickness of the endometrium is up to 5 mm, HRT is not contraindicated; up to 5 mm - HRT is not contraindicated; up to 8 mm - you can prescribe progestogens for days (Duphaston 20 mg/day, MPA 30 mg/day, Norkolut or premolutor 5 mg/day) and repeat ultrasound on the 5th day of menstruation; up to 8 mm - you can prescribe progestogens for days (Duphaston 20 mg/day, MPA 30 mg/day, Norkolut or premolutor 5 mg/day) and repeat ultrasound on the 5th day of menstruation; more than 8 mm - hysteroscopy and diagnostic curettage uterus. more than 8 mm - hysteroscopy and diagnostic curettage of the uterus are indicated.
Short-term and long-term indications for HRT Short-term indications Therapeutic effects on symptoms: Neurovegetative Neurovegetative Cosmetic Cosmetic Psychological Psychological Urogenital Urogenital Long-term indications Prevention: Prevention: Osteoporosis Osteoporosis IHD IHD Depression Depression Alzheimer's disease Alzheimer's disease
Estrogens and progestogens used for HRT Natural estrogens Progestogens Human: estradiol estradiol estriol estriol estrone estrone Esters: estradiol valerate estrone sulfate piperazine estrone sulfate Conjugated: estrone sulfate sodium equilin sulfate Medroxyprogesterone NorethisteroneNorgestrel Progesterone
Hormone replacement therapy Estrogen monotherapy Estrogen monotherapy for 3-4 weeks with 5-7 day breaks (Progynova, Ovestin 1-2 mg/day) or continuously. Estrogens in combination with gestagens Estrogens in combination with gestagens Cliogest - estradiol (2 mg) and norethisterone acetate (1 mg). Livial – 2.5 mg active substance tibolone. Cliogest and Livial are prescribed continuously. Divitren is presented with estradiol valerate for 70 days and in the last 14 days a gestagen is added - medroxyprogesterone acetate. Divitren is presented with estradiol valerate for 70 days and in the last 14 days a gestagen is added - medroxyprogesterone acetate. Estrogen monotherapy with the addition (10-14 days) of progestogens every second and third month Estrogen monotherapy with the addition (10-14 days) of progestogens every second and third month
Methods of administration of HRT drugs Oral route of administration Oral route of administration Parenteral administration: intramuscular, transdermal (patch), subcutaneous and cutaneous (ointment). Parenteral administration: intramuscular, transdermal (patch), subcutaneous and cutaneous (ointment).
Observation of patients receiving HRT Mammography aged 5 years with an uncomplicated personal and family history 1 time in 2 years; age with an uncomplicated personal and family history, 1 time every 2 years; if aggravated - annually; if aggravated - annually; after 50 years - annually. after 50 years - annually. Blood coagulation test Definition lipid profile Blood pressure measurement, ECG. First control after 3 months, subsequently every 6 months.
The climacteric period (Greek klimakter stage; age transition period; synonym: menopause, menopause) is a physiological period of human life, during which, against the background of age-related changes in the body, involutionary processes in the reproductive system dominate.
Menopause in women. The menopause is divided into premenopause, menopause and postmenopause. Perimenopause usually begins at the age of 45-47 years and lasts 2-10 years until the cessation of menstruation. The average age at which the last menstruation occurs (menopause) is 50 years. Early menopause is possible before the age of 40 and late menopause is possible after the age of 55. The exact date Menopause is established retrospectively, no earlier than 1 year after the cessation of menstruation. Postmenopause lasts 6-8 years from the date of cessation of menstruation.
The rate of development of K. p. is determined genetically, but the time of onset and course of different phases of K. p. can be influenced by factors such as the woman’s health, working and living conditions, dietary habits, and climate. for example, in women who smoke more than 1 pack of cigarettes per day, menopause occurs on average at 1 year 8 months. earlier than non-smokers.
The psychological reaction of women to the onset of K. p. can be adequate (in 55% of women) with gradual adaptation to age-related neurohormonal changes in the body; passive (in 20% of women), characterized by the acceptance of K. p. as an inevitable sign of aging; neurotic (in 15% of women), manifested by resistance, reluctance to accept the changes taking place and accompanied by mental disorders; hyperactive (in 10% of women), when there is an increase in social activity and a critical attitude towards the complaints of peers.
Age-related changes in the reproductive system begin in the central regulatory mechanisms of the hypophysiotropic zone of the hypothalamus and suprahypothalamic structures. The number of estrogen receptors decreases and the sensitivity of the hypothalamic structures to ovarian hormones decreases. Degenerative changes in the terminal areas of the dendrites of dopamine and serotonergic neurons lead to disruption of the secretion of neurotransmitters and the transmission of nerve impulses to the hypothalamic-pituitary system. Due to a violation of the neurosecretory function of the hypothalamus, the cyclic ovulatory release of gonadotropins by the pituitary gland is disrupted; the release of lutropin and follitropin usually increases from the age of 45, reaching a maximum approximately 15 years after menopause, after which it begins to gradually decrease. An increase in the secretion of gonadotropins is also due to a decrease in the secretion of estrogen in the ovaries. Age-related changes in the ovaries are characterized by a decrease in the number of oocytes (by the age of 45, there are about 10 thousand of them). Along with this, the process of oocyte death and atresia of maturing follicles accelerates. In the follicles, the number of granulosa and theca cells, the main site of estrogen synthesis, decreases. No degenerative processes are observed in the ovarian stroma, and it retains hormonal activity for a long time, secreting androgens: mainly the weak androgen - androstenedione and a small amount of testosterone. The sharp decrease in estrogen synthesis by the ovaries in postmenopause is to some extent compensated by the extragonadal synthesis of estrogen in adipose tissue. Androstenedione and testosterone formed in the ovarian stroma in fat cells (adipocytes) are converted by aromatization into estrone and estradiol, respectively: this process is enhanced by obesity.
Clinically, premenopause is characterized by menstrual irregularities. In 60% of cases, cycle disorders of the hypomenstrual type are observed - intermenstrual intervals increase and the amount of blood lost decreases. 35% of women experience excessively heavy or prolonged menstruation, and 5% of women experience menstruation that stops suddenly. Due to disruption of the maturation process of follicles in the ovaries, a gradual transition occurs from ovulatory menstrual cycles to cycles with incomplete yellow body and then to anovulation. In the absence of the corpus luteum in the ovaries, the synthesis of progesterone sharply decreases. Progesterone deficiency is the main cause of the development of such complications of uterine bleeding as acyclic uterine bleeding (so-called menopausal bleeding) and hyperplastic processes of the endometrium (see Dysfunctional uterine bleeding). During this period, the incidence of fibrocystic mastopathy increases.
Age-related changes lead to the cessation of reproductive function and a decrease in the hormonal function of the ovaries, which is clinically manifested by the onset of menopause. Postmenopause is characterized by progressive involutional changes in the reproductive system. Their intensity is much higher than in premenopause, since they occur against the background of a sharp decrease in estrogen levels and a decrease in the regenerative potential of target organ cells. In the first year of postmenopause, the size of the uterus decreases most rapidly. By the age of 80, the size of the uterus, determined by ultrasound, is 4.3´3.2´2.1 cm. The weight of the ovaries by the age of 50 decreases to 6.6 g, by 60 - to 5 g. In women over 60 years, the mass of the ovaries is less than 4 g, the volume is about 3 cm3. The ovaries gradually shrink due to the development of connective tissue, which undergoes hyalinosis and sclerosis. 5 years after menopause, only single follicles are found in the ovaries. Atrophic changes occur in the vulva and vaginal mucosa. Thinning, fragility, and slight vulnerability of the vaginal mucosa contribute to the development of colpitis.
In addition to the listed processes in the genitals, changes occur in other organs and systems. One of the main reasons for these changes is the progressive deficiency of estrogens - hormones with a wide biological spectrum of action. Atrophic changes develop in the muscles of the pelvic floor, which contributes to prolapse of the walls of the vagina and uterus. Similar changes in the muscle layer and mucous membrane of the bladder and urethra can cause urinary incontinence during physical stress.
Mineral metabolism changes significantly. The excretion of calcium in the urine gradually increases and its absorption in the intestine decreases. At the same time, as a result of a decrease in the amount of bone substance and insufficient calcification, bone density decreases - osteoporosis develops. The process of osteoporosis takes a long time and is unnoticeable. It can be detected radiographically if there is a loss of at least 20-30% of calcium salts. The rate of bone loss increases 3-5 years after menopause; During this period, bone pain intensifies and the incidence of fractures increases. The leading role of a decrease in estrogen levels in the development of osteoporosis in the breast is confirmed by the fact that in women who have been taking combined estrogen-gestagen drugs for a long time, the preservation of bone structure and the calcium content in them is significantly higher and the clinical manifestations of osteoporosis are less common.
During menopause, immune defense gradually decreases, the frequency of autoimmune diseases increases, and weather lability develops (reduced resistance to temperature fluctuations). environment), age-related changes occur in the cardiovascular system. The level of low and very low density lipoproteins, cholesterol, triglycerides and glucose in the blood increases; body weight increases due to hyperplasia of fat cells. As a result of disruption of the functional state of higher nerve centers against the background of a decrease in estrogen levels in the body, a complex of vegetative-vascular, mental and metabolic-endocrine disorders often develops (see Menopausal syndrome).
Prevention of complications of K. p. includes the prevention and timely treatment of diseases of various organs and systems - cardiovascular diseases, diseases of the musculoskeletal system, biliary tract, etc. Physical exercise is important, especially during fresh air(walking, skiing, jogging), dosed in accordance with the recommendations of the therapist. Useful hiking. Due to weather instability and adaptation features, it is recommended to choose zones for recreation whose climate does not differ sharply from the usual one. The prevention of obesity deserves special attention. The daily diet for women who are overweight should contain no more than 70 g of fat, incl. 50% vegetable, up to 200 g of carbohydrates, up to 11/2 liters of liquid and up to 4-6 g of table salt with normal protein content. Food should be taken at least 4 times a day in small portions, which promotes the separation and evacuation of bile. To eliminate metabolic disorders, hypocholesterolemic drugs are prescribed: polysponin 0.1 g 3 times a day or cetamifene 0.25 g 3 times a day after meals (2-3 courses of 30 days at intervals of 7-10 days); hypolipoproteinemic drugs: linetol 20 ml (11/2 tablespoons) per day after meals for 30 days; lipotropic drugs: methionine 0.5 g 3 times a day before meals or 20% choline chloride solution 1 teaspoon (5 ml) 3 times a day for 10-14 days.
In the countries of Europe and North America, women in the CP are widely prescribed estrogen-gestagen drugs to compensate for hormonal deficiency and to prevent associated age-related disorders: uterine bleeding, blood pressure fluctuations, vasomotor disorders, osteoporosis, etc. Epidemiological studies conducted in these countries have shown that the risk of developing endometrial, ovarian and breast cancer in women taking estrogen-gestagen drugs is lower than in the population. In the USSR, a similar method of preventing pathology of the p. is not accepted; these drugs are used mainly for therapeutic purposes.
Menopause in men occurs more often at the age of 50-60 years. Atrophic changes Testicular glandulocytes (Leydig cells) in men of this age lead to a decrease in testosterone synthesis and a decrease in the level of androgens in the body. At the same time, the production of gonadotropic hormones of the pituitary gland tends to increase. The speed of involutionary processes in the gonads varies significantly; It is conventionally believed that K. p. in men ends at approximately 75 years.
In the vast majority of men, age-related decline in the function of the gonads is not accompanied by any manifestations that disrupt the general habitual state. In the presence of concomitant diseases (for example, vegetative-vascular dystonia, hypertension, coronary heart disease), their symptoms are more clearly manifested in K. p. Often the symptoms of these diseases are mistakenly regarded as pathological menopause. The possibility of a pathological course of K. p. in men is debated. A number of researchers believe that, if organic pathology is excluded, clinical manifestations of pathological menopause can include certain cardiovascular, neuropsychiatric and genitourinary disorders. Cardiovascular disorders characteristic of pathological menopause include sensations of hot flashes to the head, sudden redness of the face and neck, palpitations, pain in the heart, shortness of breath, increased sweating, dizziness, and an unstable increase in blood pressure.
Characteristic psychoneurological disorders are increased excitability, fatigue, sleep disturbance, muscle weakness, headache. Possible depression, causeless anxiety and fear, loss of previous interests, increased suspiciousness, tearfulness.
Among the manifestations of dysfunction genitourinary organs dysuria and disturbances of the copulatory cycle are noted with a predominant weakening of erection and accelerated ejaculation.
A gradual decrease in sexual potency is observed in menopause in most men and, in the absence of other manifestations of pathological menopause, is considered a physiological process. When assessing sexual function in men in K., it is also necessary to take into account its individual characteristics.
Treatment of pathological menopause is usually carried out by a therapist after a thorough examination of the patient with the participation of the necessary specialists and excluding the connection of existing disorders with certain diseases (for example, cardiovascular, urological). It includes the normalization of the work and rest regime, dosed physical activity, and the creation of the most favorable psychological climate. Psychotherapy is a mandatory component of treatment. In addition, medications are prescribed that normalize the function of the central nervous system. (sedatives, tranquilizers, psychostimulants, antidepressants, etc.), vitamins, biogenic stimulants, drugs containing phosphorus, antispasmodics. In some cases, anabolic hormones are used; In order to normalize the disturbed endocrine balance, medications of male sex hormones are used.
Menopausal syndrome.
Endocrine and psychopathological symptoms that occur during the pathological course of menopause.
The cause of this condition is, firstly, a deficiency of estrogen (sex hormones) due to age-related endocrine changes in a woman’s body. It should be noted that menopause (the last uterine bleeding caused by ovarian function) occurs in all women, but not all of them suffer from menopausal syndrome. It occurs when the body’s adaptive systems decrease, which, in turn, depend on many factors. The likelihood of its occurrence increases in women with heredity aggravated by the pathology of menopause and cardiovascular diseases. The occurrence and further course of menopausal syndrome is adversely affected by such factors as the presence of pathological character traits, gynecological diseases, especially uterine fibroids and endometriosis, premenstrual syndrome before the onset of menopause. Social factors are also of great importance: unsettled family life, dissatisfaction with sexual relationships; suffering associated with infertility and loneliness: lack of satisfaction in work. The mental state is aggravated in the presence of psychogenic situations, such as serious illness and death of children, parents, husband, conflicts in the family and at work.
Symptoms and course. Typical manifestations of cpymacteric syndrome include hot flashes and sweating. The severity and frequency of hot flashes varies, from single to 30 per day. In addition to these symptoms, there is an increase in blood pressure and vegetative-spucy crises. Mental disorders are present in almost all patients with CS. Their nature and severity depend on the severity of vegetative manifestations and personal characteristics. In severe cases of menopause, weakness, fatigue, and irritability are observed. Sleep is disturbed, patients wake up at night due to severe hot flashes and sweating. There may be depressive symptoms: low mood with anxiety about one’s health or fear of death (especially during severe crises with palpitations, suffocation).
Fixation on one’s health with a pessimistic assessment of the present and future can become a leading factor in the clinical history of the disease, especially in people with an anxious and suspicious character.
During menopause, women may experience ideas of jealousy, especially those who had a jealous character in their youth, as well as people who are prone to logical constructions, touchy, stuck, punctual. Ideas of jealousy can take such hold of the patient that her behavior and actions become dangerous towards her husband, his “mistress” and herself. In such cases, hospitalization is required to avoid unpredictable consequences.
Ideas of jealousy usually arise in women who do not receive sexual satisfaction. The fact is that during the premenopausal period (before the onset of menopause), many women have an increased sexual desire, which for various reasons (impotence in the husband, sexual illiteracy, rare sexual relations for objective reasons) is not always satisfied. In cases where rare marital relationships are not associated with sexual disorders in the husband, suspicion and thoughts of possible betrayal may arise, which are supported by an incorrect interpretation of real facts. In addition to ideas of jealousy, sexual dissatisfaction (with increased sexual desire) contributes to the emergence of psychosomatic and neurotic disorders (fears, emotional imbalance, hysterics, etc.). After menopause, some women, on the contrary, experience a decrease in sexual desire due to atrophic vaginitis (vaginal dryness), which entails a decrease in interest in sexual activity and ultimately leads to disharmony in marital relationships.
Menopausal symptoms appear in most women long before menopause and only in a small proportion after menopause. Therefore, the period of menopause often stretches for several years. The duration of the course of CS depends to a certain extent on personal characteristics that determine the ability to deal with difficulties, including diseases, and adapt to any situation, and is also determined by the additional influence of sociocultural and psychogenic factors.
Treatment. Hormonal therapy should be prescribed only to patients without severe mental disorders and when mental illness is excluded. It is advisable to carry out replacement therapy with natural estrogens in order to eliminate estrogen-dependent symptoms (hot flashes, sweating, vaginal dryness) and prevent long-term consequences of estrogen deficiency (cardiovascular diseases, osteopoprosis - loss of bone tissue, accompanied by its fragility and fragility). Estrogens help not only reduce hot flashes, but also increase tone and improve overall well-being. Progestogens (progesterone, etc.) themselves can reduce mood, and in the presence of mental disorders they aggravate the condition, so gynecologists in such cases prescribe them after consultation with a psychiatrist.
In practice, combined estrogen-progestin drugs are often used to avoid the side effects of pure estrogens. However, long-term, and sometimes unsystematic and uncontrolled, use of various hormonal drugs leads, firstly, to the persistence of cyclical fluctuations in a state such as premenstrual syndrome (pseudo-premenstrual syndrome) and the formation of psychological and physical hormonal dependence and hypochondriacal personality development.
The climacteric period in such cases extends for many years. Mental disorders are corrected with the help of psychotropic drugs (tranquilizers; antidepressants; neuroleptics in small doses such as frenolone, sonapax, etaprazine; nootropics) in combination with various types psychotherapy. Psychotropic drugs can be combined with hormones. The prescription of treatment in each case is carried out individually, taking into account the nature and severity of psychopathological symptoms, somatic disorders, and the stage of hormonal changes (before or after menopause).
In principle, menopausal syndrome is a transient, temporary phenomenon, caused by a period of age-related neuro-hormonal changes in a woman’s body. Therefore, the overall prognosis is favorable. However, the effectiveness of therapy depends on the influence of many factors. The shorter the duration of the disease and the earlier treatment is started, the fewer various external influences (psychosocial factors, somatic diseases, mental trauma), the better the treatment results.
Climacteric period. Vitamin E is also used in cosmetology for... from the onset of puberty to menopausal period, however their number depends on...
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CRITICAL PERIODS IN A WOMAN'S LIFE AND OPTIONS FOR CORRECTION OF REPRODUCTIVE HEALTH DISORDERS DURING THESE PERIODS Professor of the Department of Obstetrics and Gynecology of VSMU, Doctor of Medical Sciences N.I. Kiseleva
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The problem of morbidity among women during menopause Up to 85% of women suffer from typical menopausal disorders Up to 78% of women experience hot flashes About 50% of women suffer from depressive disorders, nervousness, irritability, insomnia, memory loss About 50% of women have arterial hypertension And ischemic disease hearts The quality of life for many women decreases significantly during menopause
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Barret - Connor E., Groady K.A., Smetnik V.P., 2004 Menopause is a natural period in a woman’s life, however, the high frequency and severity of symptoms of sex hormone deficiency significantly reduce the quality of life and turn this period into a kind of disease
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Menopause ~ 51 years + 1 year Postmenopause Menopausal transition ~ 65-70 years Old age ~ 45 years Perimenopause Fertile period + 1.5 – 2 years 3 – 5 years Early Late Revision of the Council of Societies for the Study of Menopause (COMS) of the International Menopause Association, 1999, Yokohama, Japan Menopause
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Estrogens Estrone LG FSH Years Dynamics of hormone levels during menopause Kulakov V.I., Smetnk V.P. “Guide to menopause”, 2001, Moscow
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Neuroendocrine dysfunction of the hypothalamus in menopause β-endorphin activity norepinephrine dopamine change in thermoregulation hot flashes hyperhidrosis hypertension obesity A.R. Genazzani, 2002
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Neuroendocrine dysfunction of the limbic system in menopause norepinephrine serotonin A.R. Genazzani, 2002 dopamine changes in mood and habits excitability depression insomnia headache (migraine) decreased cognitive function
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Factors increasing the risk of cardiovascular diseases in postmenopause Group I – metabolic factors: 1 – changes in lipid and lipoprotein metabolism 2 – changes in insulin and carbohydrate metabolism 3 – changes in hemostasis and fibrinolysis Group II – non-metabolic changes: 1 – dysfunction of endothelial cells 2 – changes in function heart and hemodynamics 3 – other mechanisms V.P. Smetnik, “Consilium-Medicum”, No. 11, volume 3, 2001
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QUALITY OF LIFE is an individual's perception of their position in life in the context of the culture and value system in which they live and in accordance with their goals, expectations, standards and concerns. Quality of life makes it possible to assess the subjective measure of well-being and satisfaction with living conditions; individual perception of life in areas related to health makes it possible to determine a subjective assessment physical condition, psychological functions, degree social adaptation, which is necessary for the doctor to understand the patient’s problems, contributes to the formation of the correct individual therapeutic approach.
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QUALITY OF LIFE allows you to assess the subjective measure of well-being and satisfaction with living conditions, individual perception of life in areas related to health, determine a subjective assessment of physical condition, psychological functions, the degree of social adaptation, which is necessary for the doctor to understand the patient’s problems, contributes to the formation of the correct individual therapeutic approach.
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Classification of menopausal disorders Early symptoms Vasomotor: hot flashes chills increased sweating hypotension or hypertension headaches palpitations Psycho-vegetative: irritability drowsiness weakness anxiety depression forgetfulness inattention Vasomotor and psycho-vegetative disorders constitute a symptom complex called climacteric syndrome V.P. Smetnik, L.G. Tumilovich “Non-operative gynecology ", 2003, Moscow
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Classification of menopausal disorders Medium-term symptoms Urogenital: vaginal dryness, pain during sexual intercourse, itching and burning, cystalgia, urinary incontinence Skin and its appendages: dryness, brittleness of nails, wrinkles, dryness and hair loss
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Classification of menopausal disorders Late symptoms cardiovascular diseases osteoporosis Metabolic disorders V.P. Smetnik, L.G. Tumilovich “Non-operative gynecology”, 2003, Moscow
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Atypical forms CS (occurs in 13% of patients) Climacteric cardiomyopathy (myocardial dystrophy) Sympathetic-adrenal crises 80% of “healthy” women (without hot flashes) have psychovegetative disorders Seizures bronchial asthma, not amenable to traditional therapy “Dry” conjunctivitis, stomatitis, laryngitis The vast majority of patients first turn to a therapist and other specialists, and not to a gynecologist V.P. Smetnik, L.G. Tumilovich “Non-operative gynecology”, 2002, Moscow
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Menopausal syndrome Hypertension Myocardial dystrophy Therapist Depression Panic attacks Memory loss Psychiatrist Neurologist Urogenital atrophy Urinary disorders Urologist Decreased vision Dry conjunctivitis (Sjögren's syndrome) Ophthalmologist Atrophic skin changes Cosmetologist Osteoporosis, osteoarthritis Rheumatologist Traumatologist Neurologist
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~ 51 years ~ 65-70 years ~ 45 years Menopausal transition Perimenopause Postmenopause Climacteric syndrome Urogenital atrophy Osteoporosis The optimal start of therapy is the period of “menopausal transition” During this period, the frequency and severity of climacteric disorders is maximum
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Menopause Therapy Non-medicinal: adherence to a daily routine, exercise, balanced nutrition, exercise therapy, sanatorium treatment; physiotherapy Medication: antidepressants that DO NOT AFFECT ESTROGEN RECEPTORS, sedatives, vitamins, microelements 2. AFFECTING ESTROGEN RECEPTORS Hormonal (HRT) Non-hormonal phyto-SERM (Climadinon) homeopathic remedies
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NON-HORMONAL DRUG THERAPY Sympatholytic reserpine, ¼ tablet. 1-2 times a day. Adrenergic blocker obzidan, 1/4 tablet 2-3 times a day. Stugeron 25 mg 3 times a day. If parasympathetic reactions predominate, belladonna tincture 5-10 drops per day is indicated, antihistamines: tavegil 1 mg or suprastin 0.25 mg 1 - 2 times a day. Inhibitory effect on vegetative and emotional excitability Belloid and bellataminal (2-3 tablets per day) provide relief. Vitamins B1, B6, E help normalize changes in homeostasis. For psycho-emotional disorders, neurotropic drugs are indicated - tazepam (0.01 g 1 - 3 times a day), for severe disorders - frenolone (2.5 mg 1 - 2 times a day). Psychotropic stimulants are also recommended - nootropil, cerebrolysin, aminalon.
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INDICATIONS FOR HRT hot flashes, night sweats depression, sleep disturbances dyspaurenia, vaginal dryness frequent urination, dysuria urinary incontinence IHD osteoporosis
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DRUGS Combined HRT estrogen progestogen drugs (microgynon, femoden, anovlar) natural estrogens: estradiol valerate, micronized estradiol; conjugated estrogens: estrone sulfate, equilins; estriol and its derivative - extriol succinate, natural or synthetic gestagens: medroxyprogesterone, progesterone acetate, cyproterone acetate, norgestrel, levonor-gestrel, norethisterone acetate and a new generation of progestogens - desogestrel, gestodene, norgestimate
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EXAMINATION BEFORE PRESCRIBING HRT history contraindications examination of the condition of the genitals (ultrasound), mammary glands smears for oncocytology blood pressure, height, body weight coagulogram blood cholesterol
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Contraindications for HRT: Vaginal bleeding of unknown origin; Acute serious disease liver; Acute deep vein thrombosis; Acute thromboembolic disease; Breast cancer (current; if in history, then exceptions are possible); Endometrial cancer (current; if in history, then exceptions are possible); Endometriosis (estrogens monotherapy is contraindicated); Congenital diseases associated with lipid metabolism - hypertriglyceridemia V.P. Smetnik, L.G. Tumilovich “Non-operative gynecology” 2003.
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KlimadinonÒ Composition: 1 film-coated tablet contains: 20 mg of dry extract of cohosh rhizome, which corresponds to 20 mg of dried medicinal plant material. 100 g of solution contains: 12 g of liquid extract of cohosh rhizome, which is equivalent to 2.4 g of dried medicinal plant material. Ethanol content: 35.0 – 40.0% (volume).
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Klimadinon Special extract BNO 1055, which is part of Klimadinon, contains highly specific and organoselective phytoestrogens (“Phyto-SERM” - selective estrogen receptor modulator) Black cohosh extract BNO 1055 selectively binds to estrogen receptors of the central nervous system, bones, ovaries, without affecting the uterus and without stimulating endometrial growth
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KlimadinonÒ Indications for use: Vegetative-vascular and mental disorders during pre-, menopause and postmenopause (“hot flashes”, increased sweating, dizziness, headaches, sleep disturbances, increased excitability, mood changes, apathy, palpitations, etc.)
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Klimadinon Side effects: In rare cases, pain in the upper abdomen is possible. Possible allergic reactions to the components of the drug. Contraindications: Individual increased sensitivity to the components of the drug. Klimadinon should not be used to treat patients with estrogen-dependent tumors. Klimadinon solution should not be used to treat patients suffering from alcoholism (contains ethanol)
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Place of Klimadinon in the treatment of climacteric disorders lung syndrome and moderate severity Negative attitude towards HT Contraindications to HRT Upcoming surgical treatment Examination period Impossibility of consultation with a gynecologist Oncological diseases reproductive organs history at any stage after surgery
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CONCLUSIONS The drug Klimadinon is effective in the treatment of menopausal syndrome in perimenopausal women and can significantly reduce the clinical manifestations of menopausal syndrome due to the regression of neurovegetative and psycho-emotional symptoms. According to daily monitoring Blood pressure, under the influence of treatment with Klimadinon, the pressure load on the woman’s body is significantly reduced, and the circadian rhythm of blood pressure is normalized. Thus, the drug exhibits therapeutic efficacy for labile hypertension in perimenopause and can be used in a program for the prevention of hypertension. Klimadinon improves the quality of life in perimenopausal women with moderate and severe climacteric syndrome in the following areas: psychological, level of independence, social relationships, general quality of life and health status. Promotes improved sleep and rest, opportunities for purchasing new information and skills, ability to work, which is a consequence complete absence or a significant reduction in the clinical manifestations of menopausal syndrome. The first signs of the therapeutic effectiveness of Klimadinon are determined already in the 3-4th week of treatment; the duration of the course of treatment is individual in each case. Klimadinon does not contain synthetic hormones and is suitable for long-term therapy.
