POST GRADUATE INSTITUTE OF MEDICAL EDUCATION

OR RESEARCH, CHANDIGARH
NATIONAL INSTITUTE OF NURSING EDUCATION

SUBJECT:- OBSTETRICS AND

GYNECOLOGICAL NURSING
TOPIC :- MENOPAUSE

SUBMITTED TO:- SUBMITTED BY:-

Mrs. Sarita Pallavi
Tutor [Link](1st) year
NINE,PGIMER NINE,PGIMER,
CHANDIGARH CHANDIGARH
 MENOPAUSE

Introduction

In the middle age, every woman passes through a crucial period called menopause. The word
menopause is derived from the Greek words “meno” meaning month and “pause” meaning stop,
literally referring to the stoppage of monthly periods .It is a natural change. Menopause is neither a
disease nor a disorder but a normal physiological process. This change happens because the ovaries
gradually stop producing eggs and the levels of female hormones, particularly estrogen and
progesterone, decline.

Definitions

 “Menopause is defined as the permanent cessation of menstruation resulting from loss of ovarian
follicular activity, confirmed retrospectively after 12 consecutive months of amenorrhea, in the
absence of other physiological or pathological causes.” – WHO, 2024

 “Menopause is diagnosed after 12 consecutive months of amenorrhea in a woman over the age of
40, not attributable to other physiological or pathological causes.” —American College of
Obstetricians and Gynecologists (ACOG, 2015)

 “Menopause is defined as the physiological permanent cessation of menstruation due to ovarian

failure, usually occurring between 45–55 years.”—Shaw’s Textbook of Gynecology (17th Edition,
India)

Phases of menopause according to STRAW +10

The Stages of Reproductive Aging Workshop (STRAW) first developed a staging system in 2001,
which was revised in 2011 as STRAW +10 to include better menstrual criteria, supportive biomarkers,
and practical clinical applications. STRAW +10 is the internationally accepted framework that stages a
woman’s reproductive aging from full reproductive function through the menopausal transition to
postmenopause.
The STRAW +10 staging system categorizes a woman’s life into three main phases, further
broken down into specific stages:
 Reproductive Phase (Stages −5 to −3): This includes the early, peak, and late reproductive years.
The system adds subdivisions to the late reproductive stage (Stage −3) to better mark the initial
decline in ovarian function, characterized by subtle cycle changes and decreasing hormone levels
like Antimullerian hormone (AMH).
 Menopausal Transition (Stages −2 to −1): This phase is also known as perimenopause. The
STRAW+10 criteria simplify and specify the menstrual cycle changes that define entry into this
phase.
 Postmenopause Phase (Stages +1 to +2): This begins after the final menstrual period (FMP).
STRAW+10 subdivides the early postmenopause phase (Stage +1) to reflect new data on hormonal
shifts after menopause.
The ten criteria (or stages) of STRAW +10

Reproductive Phase
 Stage −5 (Early): Begins with menarche and ends when menstrual cycles become consistently
regular. Hormonal levels are normal.
 Stage −4 (Peak): Defined by regular menstrual cycles. Hormone levels are normal, and fertility is at
its highest.
 Stage −3b (Late): Menstrual cycles remain regular, but ovarian function begins to decline. AMH
and inhibin-B levels start to decrease, and antral follicle count (AFC) is lower, while FSH levels
remain normal.
 Stage −3a (Late): Subtle but persistent changes occur, such as shorter menstrual cycle lengths. FSH
levels become more variable and may start to increase. AMH and inhibin-B levels continue to
decrease.

Menopausal Transition (Perimenopause)

 Stage −2 (Early): Cycles become persistently variable in length, with consecutive cycles differing
by 7 days or more. FSH levels are elevated but variable, and AMH and inhibin-B levels are low.
 Stage −1 (Late): Marked by an interval of amenorrhea (no bleeding) for 60 days or longer. FSH
levels are typically elevated to above 25 IU/L, and vasomotor symptoms (like hot flashes) are
common. This stage lasts for 1 to 3 years on average.

Postmenopause
 Stage +1a (Early): The 12-month period immediately following the final menstrual period (FMP).
This is often the time when vasomotor symptoms are at their most bothersome.
 Stage +1b (Early): The following 1-year period, during which FSH levels continue to increase and
estradiol continues to decrease.
 Stage +1c (Early): The period of 3 to 6 years when high FSH and low estradiol levels have
stabilized. The entire Early Postmenopause (Stages +1a through +1c) is estimated to last 5 to 8
years.
 Stage +2 (Late): The final stage, where the endocrine changes are less significant. Health concerns
shift to other areas associated with aging, including urogenital atrophy and bone health.
Hormonal physiology of menopause

Figure: Hormonal physiology of menopause

Age at Menopause
Age at which menopause occurs is genetically predetermined. The age of menopause is not related to
age of menarche or age at last pregnancy. It is variably related to lactation, use of oral pill,
socioeconomic condition, race, height. Thinner women have early menopause. However, cigarette
smoking living in high altitude may cause early menopause. The age of menopause ranges between 45-
55 years, average being 51.3 years. Late menopause is seen in women with high parity or higher BMI,
earlier menopause is seen in cases following chemotherapy, ovarian resection or women with smoking
habit.
Depending on the cause and/or timing of the end of menstruation, there are several types of
menopause:

 Natural menopause: This occurs when ovaries slowly stop functioning and the woman stops
menstruating as a result, For most women, this happens between the ages of 45 and 55 years, As
ovaries stop producing hormones such as estrogen and progesterone, body responds and adapts.

 Delayed menopause: If the menopause fails to occur even beyond 55 years, it is called delayed
menopause. The common causes are constitutional, uterine fibroids, diabetes mellitus and estrogenic
tumor of the ovary. The cases should not be neglected. In the absence of palpable pelvic pathology,
diagnostic curettage should be done and an early decision of hysterectomy should be taken in the
face of increased incidence of endometrial carcinoma.

 Induced menopause: Sometimes menopause does not occur on its own but it is brought on by a
deliberate action, such as surgery or medication that affects the ovaries, A hysterectomy or other
surgery that removes or damages the ovaries will cause an abrupt menopause. Usually, the woman
can anticipate this type of menopause and plan ahead for treating the sudden symptoms that can
result. A hysterectomy that removes only the uterus may not damage the ovaries and, therefore, will
not cause menopause, But if the ovaries are not removed. this is Surgical menopause.
Chemotherapy or radiation as a cancer treatment will make the ovaries shut down, and that, too, can
cause at least a temporary menopause.

 Premature or early menopause: This occurs when the woman stops menstruating before the age of
40 years. Early menopause is the one that occurs before the age of 45 years. Besides surgery, there
are many reasons a woman might go through menopause early, including:

 Smoking
 Heavy drinking
 Endocrine disorders
 Chemotherapy
 Chromosome defects
 Autoimmune disease
 Thyroid disease
Anatomical changes during menopause

The uterus becomes smaller and the ratio between the body and the cervix reverts to 1: 1 [Link]

endometrium glands too dilate before menopause sets in and cystic glandular hyperplasia reported in

some premenopausal woman causes metropathia haemorrhagica with irregular heavy bleeding.

The cervix becoms smaller and its vaginal portion is represented by a small prominence chin and lips at

the vaginal vault. The vaginal fornices gradually disappear as the cervix shrinks after the menopause, It

becomes narrow and it becomes pale, thin and gets dry easily causing senile vaginitis.

The vulva atrophies and vaginal orifice narrows and causes dyspareunia. The skin of vestibule and labia

minora becomes thin, pale and dry; there is considerable reduction in the amount of fat contained in the

labia majora. The pubic hair is reduced and becomes grey. The pelvic cellular tissue becomes lax and

the ligaments that support vagina and uterus lose their tone and predispose to prolapse of the genital

organs.

Apart from this, fat is deposited around the breasts, hips and abdomen. The mammary glandular atrophy

and disposition of fat often make the breasts more pendulous. The skin wrinkles, and hair grow around

the chin and lips . The epithelium of bladder and urethra becomes thin and more prone to damage and

infection, Hormonal changes can predispose menopausal women to conditions like osteoporosis,

coronary artery disease and neoplasm.

 Figure : Anatomical change during Menopause

Physiological aspects related to menopause

Many women experience symptoms of menopause around their mid 40s as physiological change related
to menopause begin. These symptoms can be both emotional and physical. These are symptoms of
menopause associated with the lower levels of estrogen and progesterone, and their effect on various
organs,
Symptoms of menopause are classified depending on their time of onset, and mainly due to
hypoestrogenic state which influences the functioning of various organ systems of the body.
SYMPTOMS OF MENOPAUSE
Immediate Intermediate Late ( hidden)
 Decline in fertility and  Genital atrophy  Osteoporosis
menstrual irregularties
 Skin and hair changes  Cardiovascular changes
 Vasomotor changes (hot
 Musculoskeletal symptoms  Dementia
flashes and hot flushes )
 Urinary symptoms(dysuria  Sexual disturbances
,increased frequency ,
recurrent lower UTI) ( dyspareunia and decreased
libido )

 Ocular change

 Weight gain

Menstruation pattern

Changes to the menstrual pattern are the first noticeable symptoms of menopause. Some women may
experience menstruation every 2-3 weeks, whereas others may not menstruate for months altogether.
Some women may experience sudden cessation of menstruation without any change in pattern.

Vasomotor symptoms

Vasomotor symptoms are experienced by majority of women during the menopausal transition, although
their severity, frequency and duration vary widely among them. These symptoms are a result of
vasomotor instability caused by fluctuating levels of estrogen. Hot flushes, hot flashes and night
sweats are common vasomotor symptoms, Hor flushes are experienced as visible red flush of skin and
perspiration and usually lasts for 1-5 minutes, Hot flashes are sudden warm sensation neck, head and
chest. Dizziness, numbness and tingling of fingers and toes and headache are also vasomotor symptoms
during menopause.

Genital Symptoms

Dryness, itching and discomfort of the vagina tend to occur during perimenopause. Some women may
appearance dyspareunia, or pain during sex. This pain is due to lowering estrogen levels due to vaginal
dryness. This lower level also causes vaginal atrophy .Vaginal atrophy is an inflammation of the
vagina that happens as a result of the thinning and shrinking of the tissues, as well as decreased
lubrication. In some cases, vaginal dryness, itching and discomfort may become severe and eventually
get worse without medical attention. Some women may experience postcoital bleeding, Uterine
prolapse, atrophic vaginitis and endometritis and its symptoms may also be experienced by
postmenopasual women.
Osteoporosis

The long-term effects clinically manifest later and have a long-term effect on the quality of life.
Postmenopausal osteoporosis is due to oestrogen deficiency and trabecular bone as oestrogen increases
osteoblastic activity and decreases osteoclastic activity. In this deficient state, bone resorption will
increase. The phase of bone formation is shortened, and osteoporosis occurs.

Cardiovascular Diseases

Coronary artery disease is one of the leading reasons of death in postmenopausal women. The risk is
increased by several factors such as diabetes mellitus, hypertension, obesity and dyslpidaemia. A drop in
oestrogen levels has been connected with an increased risk of cardio-vascular disease. The risk of
adverse outcomes escalates with earlier age at the time of menopause.

Dementia

Oestrogens have a direct effect on neuronal growth, neurotransmitter production and vasculature of the
CNS. estrogen deficiency can cause cognitive decline. Dementia especially Alzheimer disease is seen
usually in geriatric woman.

Psychological aspects related to menopause

Psychological changes arise primarily from hormonal fluctuations (decline in estrogen, progesterone,
and androgens), combined with age-related life stressors, social factors, and health transitions.

 Mood Changes

Irritability and emotional lability : Rapid changes in mood and increased sensitivity to stress.

Depression : Women with a prior history of depression are at higher risk; perimenopausal decline in
estrogen affects serotonin regulation.

Anxiety and nervousness : Fluctuating hormone levels, sleep disturbances, and psychosocial stress can
precipitate anxiety episodes.

Emotional instability : Minor life stressors may lead to exaggerated emotional responses.

 Sleep Disturbances and Fatigue

Insomnia : Difficulty falling or staying asleep, often linked to vasomotor symptoms like night sweats.

Daytime fatigue : Poor sleep quality contributes to irritability, low mood, and reduced productivity.

Impact on mental health : Chronic sleep disruption can exacerbate anxiety and depressive symptoms.
  Sexual and Self-Image Concerns

Loss of libido : Decline in estrogen and androgen levels reduces sexual desire.

Body image concerns : Menopausal weight gain, skin changes, and hair loss may lower self-esteem.

Reduced sexual confidence : Vaginal atrophy and dryness may contribute to dyspareunia, affecting
intimate relationships and psychological well-being.

Social aspects related to menopause

Menopause is not only a biological and hormonal change but also a major social transition that affects a
woman’s roles, responsibilities, relationships, and societal interactions. The social impact is influenced
by culture, family dynamics, occupational status, and community support.

 Family and Household Dynamics

Women often continue to manage household chores, caregiving for children or grandchildren, and
supporting spouses.

Menopausal symptoms such as fatigue, mood swings, irritability, and hot flashes can affect their
performance, leading to role strain.

Example: A woman experiencing insomnia and irritability may struggle with cooking, cleaning, and
family responsibilities, causing stress and potential family conflicts.

Encourage family support, shared responsibilities, and understanding of menopausal changes.

 Career and Professional Life

Menopausal women often face challenges in professional life due to vasomotor symptoms, cognitive
changes, and sleep disturbances.

Example: A nurse experiencing night sweats and fatigue may find it harder to manage patient care.

Flexible work schedules and understanding colleagues can help adaptation.

 Social Relationships and Support

Menopause affects marital and social relationships. Reduced libido and vaginal dryness may lead to
sexual dissatisfaction, while mood swings can affect communication with family and peers.

Example: A woman experiencing irritability may have arguments with her spouse, impacting family
harmony.
Strong social support (friends, peer groups, or community programs) helps women share experiences,
cope better, and reduce feelings of isolation.

Supportive communication with partners and sexual counseling can improve relationship satisfaction.

 Cultural and Societal Perceptions

Cultural beliefs shape how menopause is experienced and perceived.

Positive perception: In some cultures, menopause is seen as freedom from menstruation and
childbearing, gaining respect and social status.

Negative perception: Other cultures associate menopause with aging, loss of fertility, and reduced
femininity, leading to stigma or low self-esteem.

Cultural stigma can lead to social isolation and low self-esteem

 Life Transitions and Adjustment

Menopause often coincides with major life transitions, including:

 “Empty nest syndrome” when children leave home.

 Career changes or retirement.

 Increased responsibilities for elderly care.

These transitions can lead to social role adjustments, stress, and potential feelings of isolation.

Encourage participation in community activities, social engagement, and new hobbies to facilitate
adaptation

DIAGNOSIS OF MENOPAUSE
 Cessation of menstruation for consecutive 12 months during climacteric.
 Average age of menopause : 51.5 years
 Appearance of menopausal symptoms: hot flash and night sweats.
 Vaginal cytology-showing maturation index of at least 10/85/5 (features of low estrogen).
 Serum estradiol : <20 pg/ml
 Serum FSH and LH: >40 mlU/mL (three values at weeks interval required).
 HORMONE REPLACEMENT THERAPY

INTRODUCTION

Hormone Replacement Therapy (HRT) is one of the most significant therapeutic advances in the care of
women during the menopausal transition and beyond. Menopause is not merely the end of menstruation,
but a biological milestone associated with estrogen deficiency that affects almost every organ system.
The decline in ovarian hormones brings troublesome vasomotor symptoms, progressive urogenital
atrophy, accelerated bone loss, and an overall decline in quality of life. HRT, by supplementing
estrogen alone or in combination with progestogen, aims to recreate the hormonal milieu of a
younger woman, thereby restoring physiological balance. Beyond symptomatic relief, it offers
preventive benefits such as protection against osteoporosis and improvement of skin, sexual health, and
general well-being.

DEFINTION

HRT (Hormone Replacement Therapy) is defined as “The administration of estrogen alone or in

combination with progesterone, intended to replace the hormones that the ovaries no longer
produce after menopause, for the relief of menopausal symptoms and prevention of long-term
estrogen deficiency–related conditions.”

INDICATIONS OF HORMONE THERAPY

 Relief of menopausal symptoms

 Relief of vasomotor symptoms
 Prevention of osteoporosis
 To maintain the quality of life in menopausal years.

Special group of women to whom HT should be prescribed:

 Premature ovarian failure

 Gonadal dysgenesis
 Surgical or radiation menopause

BENEFITS OF HORMONE THERAPY

 Improvement of vasomotor symptoms (70-80%)

 Improvement urogenital atrophy
 Increase in bone mineral density (2-5 %)
 Decreased risk in vertebral and hip fractures (25-50%)
 Reduction in colorectal cancer (20%)
 Possibly cardioprotection
RISKS OF HORMONE THERAPY

 Endometrial cancer: When estrogen is given alone to a woman with intact uterus, it causes
endometrial proliferation, hyperplasia and carcinoma. It is therefore advised that a progestin
should be added to estrogen replacement therapy to counterbalance such risks.

 Breast cancer: Combined estrogen and progestin replacement therapy for a long-term(5years),
increases the risk of Breast cancer slightly. Adverse effects of hormone therapy are related to the
dose and duration of therapy.

 Venous thromboembolic (VTE) disease has been found to be increased with the use of
combined oral Estrogen and progestin . Transdermal estrogen use does not have the same risk
compared to oral Estrogen.

 Coronary heart disease (CHD): Combined HT therapy shows a relative hazard of

[Link] has not been observed to be a risk of HT.

 Stroke : Oral but not transdermal oestrogen is associated with a small increase in the risk of
stroke.

 Lipid metabolism: An increased incidence of gallbladder disease has been observed following
ERT due to Rise in cholesterol (in bile).

 Dementia, Alzheimer disease not benefited.

Contraindications of HRT

 Estrogen-dependent neoplasm in the body

 Existing cardiac disease
 Active liver disease
 Gallbladder disease
 Known, suspected breast cancer
 Previous ovarian/endometrial cancer
 Undiagnosed genital tract bleeding
 History of venous thromboembolism or active DVT
 Untreated hypertension
 Prior Stroke, myocardial infarction
 AVAILABLE PREPARATIONS FOR HORMONE THERAPY

The principal hormone used in HT is estrogen. This is ideal for a woman who had her uterus removed
(hysterectomy) already. But in a woman with an intact uterus onlv estrogen therapy leads to endometrial
hyperplasia and even endometrial carcinoma. Addition of progestins for last 12-14 days each month can
prevent this problem. Commonly used estrogens are conjugated equine estrogen CEE (0.3,0.45 or
0.625-1.25 mg/day) or micronized estradiol (1-2 mg/day). Oral : CEE (O.3mg)+ MPA (2.5 mg OR 5
mg)Progestins used are medroxyprogesterone acetate (MPA) (1.5-5 mg/day) or micronized
progesterone (100-200 mg/day) or dydrogesterone (5-10 mg/day).

Considering the risks, hormone therapy should be used with the lowest effective dose and for a
shortest period of time. Low dose oral conjugated estrogen 0.3 mg daily is effective and has got
minimal side [Link] interval may be modified as daily for initial 2-3 months then it may be
changed to every other day for another 2-3 months and then every third day for the next 2-3 months. It
may be stopped thereafter if Symptoms are controlled.

 Oral estrogen regime: CEE, 0.3 mg,O.45mg or 0.625 mg is given daily for woman who had
hysterectomy.

 Estrogen and cyclic progestin: For a woman with intact uterus, estrogen is given continuously
for 25 days and progestin is added for last 10 days.
 Continuous estrogen and progestin therapy: Continued combined therapy can prevent
endometrial Hyperplasia. There may be irregular bleeding with this regimen.

Transdermal administration: This route avoids the ‘first pass hepatic metabolism’. Effects of
oral estrogens on lipids, clotting factors may be beneficial. Risks of venous thromboembolism or
gallbladder disease are not increased compared to oral route.

 Subdermal implants: Implants are inserted subcutaneously over the anterior abdominal wall
using local Anesthesia. 17 beta -estradiol implants 25 mg, 50 mg or 100 mg are available and can
be kept for 6 [Link] method is suitable in patients after hysterectomy. Implants maintain
physiological E2 to E1 ratio.

 Percutaneous estrogen gel: 1 g applicator of gel, delivering 1 mg of estradiol daily, is to be

applied onto the skin over the anterior abdominal wall or thighs. Effective blood level of
estradiol (90-120 pg/ml) can be maintained.

 Transdermal patch: 17ẞ Estradiol (0.025, 0.05,0.75 or 0.1 mg/day) applied over the buttock
twice weekly. Skin reaction, irritation and itching have been noted with their use: Indications
for use of the transdermal route as a first line management: Migraine, Diabetes, Controlled
hypertension,existing gall bladder disease, Hyperlipidaemia, Obesity, previous venous
thromboembolism 0.05 mg Estradiol with 140 µg or 250 µg norethindrone acetate. Commons
side effects associated with estrogen use include: breast tenderness, bloating and abnormal
uterine bleeding.
 Vaginal cream: Conjugated equine vaginal estrogen cream 1.25 mg daily is very effective
especially when Associated with atrophic vaginitis. It also reduces urinary frequency, urgency
and recurrent [Link] with symptoms of urogenital atrophy and urinary symptoms and
who do not like to have systemic HT, are suitable for such treatment.

 Progestins: In patients with history of breast carcinoma or endometrial carcinoma, progestins

may be used ,It may be effective in suppressing hot flashes and it prevents osteoporosis. MPA,
2.5-5 mg/day can be used.

 Levonorgestrel intrauterine system (LNG-IUS) : with daily release of 20 ug of levonorgestrel

per 24 hours, it protects the endometrium from hyperplasia and cancer. At the same time it has
got no systemic progestin side effects. Estrogen can be given by any route. It can serve as
contraception and HT when given in a perimenopausal women.

 Tibolone: Tibolone is a steroid (19-nortestosterone derivative) having weak estrogenic,

progestogenic and androgenic properties. It prevents osteoporosis, atrophic changes of vagina
and hot flashes. It increases libido. Endometrium is atrophic. A dose of 2.5 mg per day is given.

 Testosterone: Androgen replacement in women with hypoactive sexual desire disorder (HSDD)
is found beneficial. It improves mood, bone, muscle mass and quality of life. Short-term use is
suggested.

 Parathyroid hormone (PTH): Recombinant PTH (teriparatide) is given by injection (SC) to

prevent osteoporosis and fracture. It increases the number of osteoblast cells and their activity
and reduces apoptosis of osteoblast cells. PTH is safe and well-tolerated. At low daily doses (20
µg/day, SC) teriparatide, its anabolic effects predominate. Side effects are leg cramps, nausea
and headache. Use for more than 2 years is not recommended.

Alternative therapies are:

 Antidepressants (SSRI/SVRIs)
 Isofovin
 Gabapentin
 Phytoestrogens
 Clonidine
 Behavioral therapy
 Acupuncture

 Antidepressants (SSRI)/serotonin norepinephrine reuptake inhibitors: These drugs are found to

relieve hot flushes. Common drugs are: fluoxetine (20 mg), venlafaxine (75 mg), paroxetine
(12.5 mg), or escitalopram (10 mg). Side effects are: nausea, dry mouth and less common is
sexual dysfunction.
 Gabapentin: In doses from 300-900 mg. Side effects are: Fatigue, dizziness, rarely ataxia
 Cognitive behavioral therapy: "Talk therapy" with teaching sessions to cope up with the
symptoms.
 Acupuncture-appears to be effective to improve the symptoms of frequency and severity of hot
flushes
 Stellate Ganglion Block with bupivacaine was found to be beneficial.

DURATION OF HORMONAL THRAPHY USE

Generally, use of HT for a shortest period as long as the benefits outweigh the risks. Individual
woman need counseling with annual or semiannual review. Reduction of dosage should be done as
soon as [Link] women should maintain optimum nutrition, ideal body weight and
perform regular [Link] woman should be informed with updated knowledge as regard
the relative merits and possible Risks of continuing HT.

MONITORING PRIOR AND DURING HORMONE THERAPY

Base level parameter of the following and their subsequent check up (atleast annually) are

mandatory.

 Physical examination including pelvic examination.

 Blood pressure recording

 Breast examination and mammography

 Cervical cytology

 Pelvic ultrasonography (TVS) to measure endometrial thickness (normal < 5 mm).

 Any irregular bleeding should be investigated thoroughly (endometrial biopsy hysteroscopy).

 Ideal serum level of estradiol should be 100 pg/mL during HT therapy, Serum level of estradiol

is useful to monitor the HT therapy rather than that of serum FSH.

 Summary for selection of HRT in low-risk women

Condition Type of HRT

Perimenopausal women Continuous estrogen cyclical progestogen
Hysterectomised women Estrogen only
Early menopause May require higher estrogen dose
Malabsorption syndrome Non-oral route therapy

Postmenopausal, low libido HRT, testosterone, tibolone

Young women with surgical induced menopause Subcutaneous implants of estrogen

Progress in Hormone Therapy

Low dose HT: Women with intact uterus with 0.3 mg CEE and MPA 1.5 mg is found effective to
control the vasomotor symptoms. Similarly 1 mg of estradiol and norethisterone acetate 0.5 mg orally,
are also effective and have significant bone sparing effect. Progestogen is added in the HT to minimize
the adverse effects of estrogen. Hormone therapy should be used with lowest effective dose and for
the shortest 2period of time as possible (ACOG, 2008). Dose interval may be modified before
stopping the therapy. To minimize the systemic adverse effects of progestogen, LNG-IUS is being used.
It is primarily used as a contraceptive. Estrogen component is delivered by oral or by transdermal route
or as an implant. A small size LNG-IUS has been developed that releases 10 µg LNG per day. This
reduced size LNG-IUS is suitable for the postmenopausal women as the size of the uterus is also small.

CONCLUSION
Menopause is a physiological phase in a woman's life and is also a part of growth and development. The
alteration in female hormones and related changes result in menopausal symptoms. In addition to
menopausal symptoms, these changes place women at risk for many conditions like osteoporosis, heart
disease and cancers. Lifestyle plays a significant role in a sound menopausal transition. All peri-
menopausal women should receive knowledge about menopausal self-care management. Assessing the
symptoms and learning needs and providing appropriate interventions, including health education are
roles of nurses related to menopausal care.
 RECENT ADVANCEMENTS IN HRT : Old vs New

Aspect Old HRT New HRT

Dose Given in higher doses : CEE = 0.625mg Now given in lower doses(e.g:
(same dose for all women). CEE = 0.3mg), safer but still
effective
Route of Mostly oral tablets More use of skin patches, gels,
administration vaginal creams – safer for heart
and blood clot risk.
Timing of start Started late, sometimes many years after Best started within 10 years of
menopause. menopause → gives more
benefit and fewer risks.
Risk understanding Thought to cause many risks (cancer, Now understood better: low dose
stroke, clots) → many women stopped + right route = lower risk,
using. . especially if started early.
Bone health Used for bone protection but concerns about Now proven that low dose HRT
risks limited use. improves bone strength and
prevents fractures.
Special groups Often avoided in women with health Now, with careful doctor
problems (diabetes, cancer survivors). guidance, personalized HRT can
be used even in special groups.
Duration Sometimes used for many years without Now advised: shortest time
limit. needed and then slowly stop if
possible.
Delivery forms Only tablets or simple patches. New forms: advanced patches, skin
gels, tiny implants that release
hormones slowly.
 RECENT RESEARCH STUDIES

Safety of menopause hormone therapy in postmenopausal women at higher risk of

venous thromboembolism : a systematic review
Authors: Amy Hicks , Danielle Robson ,Bianca Tellis , Sally Smith , Scott Dunkley,Rodney Babe

Year of publication: 2025

Abstract

Objective: Studies have shown that oral estrogen with or without progestogen increases the risk of

venous thromboembolism (VTE). Recent data suggest that transdermal estrogen confers little to no

increased risk of VTE. There is no systematic review that examines menopause hormone therapy (MHT)

use in women with risk factors for VTE. This systematic review therefore aims to summarize the

evidence in this population.

Method: The OVID Medline, Embase, PubMed and CENTRAL online databases were searched. A

total of 762 studies were screened and 10 were included in the study.

Results: Six studies were case-control studies, two were randomized controlled trials (RCTs), one was

an RCT that contained a nested case-control study and one was a cohort study. Studies were

heterogeneous in their definition of menopause, dose, form and route of administration of MHT, and the

underlying VTE risk factor being assessed. In women with risk factors for VTE, transdermal estrogen

conferred no increased risk of VTE. Oral estrogen alone has the next safest profile, and oral estrogen

plus a progestogen conferred the highest increased risk of VTE.

Conclusion: Transdermal MHT appears safe in women with risk factors for VTE. Oral MHT, notably

oral estrogen plus a synthetic progestogen, does increase relative risk. More contemporary data are

required to confirm these findings.

Effectiveness and safety of hormone replacement therapy in the treatment of

menopausal syndrome: a meta-analysis

Authors: Yu Tang, Rui Ma, Lili Zhang ,Xuemei Sun ,Yanping Wang

Year of publication: 2025

Abstract

Objective: To comprehensively evaluate the efficacy and safety of hormone replacement therapy
(HRT) in managing menopausal syndrome through a meta-analysis.
Methods: A systematic search was conducted across Pubmed, Embase, and Cochrane Library
databases utilizing keywords such as "menopause", "hormone replacement therapy", and "menopausal
syndrome" from their inception until July 2024. Randomized controlled trials (RCTs) related to HRT's
role in treating menopausal symptoms were included. Two researchers independently reviewed
literature, extracted data, and assessed study quality. Meta-analysis was performed using RevMan 5.3
software, incorporating calculations of standardized mean difference (SMD) and odds ratio (OR), using
either fixed-effects or random-effects models.
Results: A total of 24 studies, involving 5089 patients, were included in the analysis. Among these,
3062 patients received HRT as the HRT group, while 2027 patients without HRT comprised the control
group. The pooled results: (1) In subgroups with estradiol-containing drugs, the change in Kupperman
menopause index (KMI) in the HRT group was significantly smaller than that in the control group
[SMD=-1.21 (-1.43, -0.98), P<0.001]; while in the subgroups didn't use estradiol as control intervention,
the change in KMI in the HRT group was also smaller than that of the control group [SMD=-0.39 (-0.67,
-0.10), P=0.007]. (2) The change in menopause-specific quality of life questionnaire (MENQOL) scores
in the HRT group was significantly smaller than that of the control group [SMD=-0.43 (-0.60, -
0.27), P<0.001]. (3) The improvement in estradiol (E2) levels in the HRT group was greater than that of
the control group [SMD=1.08 (0.66, 1.49), P<0.001]. (4) In the subgroup where the control intervention
was placebo, the change in follicle stimulating hormone (FSH) level in the HRT group was significantly
lower than that of the control group [SMD=-0.65 (-1.05, -0.24), P=0.002]; while in the subgroup where
the control intervention was acupuncture, there was no significant difference of the change in FSH level
between the HRT group and the control group [SMD=0.13 (-0.21, 0.47), P=0.45]. (5) The vaginal pH in
the HRT group was significantly lower than that of the control group [SMD=-0.97 (-1.08, -
0.87), P<0.001]. (6) The maturity change in vaginal exfoliated cells in the HRT group was greater than
that of the control group [SMD=0.99 (0.82, 1.16), P<0.001]. (7) The improvement in lumbar bone
density in the HRT group was significantly greater than in the control group [SMD=1.52 [1.33,
1.71], P<0.001]. (8) In the three subgroups with different drug regimens of estradiol plus norethindrone
acetate, estradiol, and conjugated equine estrogen/estradiol, the improvements in hip bone density in the
HRT group were all greater than in the control group [SMD=1.00 (0.72, 1.27), P<0.001/SMD=1.36
(1.11, 1.60), P<0.001/SMD=0.57 (0.11, 1.04), P=0.02]. (9) No significant difference in the changes in
total cholesterol (TC) [SMD=0.20 (-0.25, 0.64), P=0.39], low-density lipoprotein (LDL) [SMD=0.29 (-
0.16, 0.74), P=0.20], and high-density lipoprotein (HDL) [SMD=0.01 (-0.43, 0.46), P=0.95] between
the two groups. (10) Treatment-emergent adverse events (TEAE) occurred equally in both groups
[OR=0.93 (0.78, 1.13), P=0.48].
Conclusion: HRT can enhance the quality of life and vaginal health in women experiencing
menopausal symptoms, elevate estrogen levels, and improve bone density, while demonstrating a
favorable safety profile with no significant increase in adverse events or dyslipidemia risk. Further
investigations involving multi-center, large-scale studies with long-term follow-up are warranted to
substantiate this conclusion.
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