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Introduction-

During her life, a woman undergoes a lot of changes in her reproductive system which finally
ends in a condition called menopause. It is a natural life change that can be very distressing for
someone and not so for others. The word }menopause~ originates from the Greek word’s
‘men’ meaning month and ‘pauses’ meaning cessation.

In addition to the common symptoms that occur after natural menopause, special
considerations apply to women who have had their ovaries removed, particularly when
oophorectomy occurs before age 45 years. Women with premenopausal oophorectomy have
more severe and prolonged menopausal symptoms. Their risks of adverse mood, heart disease,
excessive bone resorption, sexual dysfunction, and cognitive disorders are increased compared
with the general population. Retention of the ovaries carries a survival benefit for women at
low risk of ovarian malignancy. Women facing oophorectomy should understand the balance of
risks and benefits in order to make an informed decision.

Definition-

What is surgical menopause?


Menopause means the final menstrual period. The average age of menopause is around 51
years, but most women will start to notice menopausal symptoms from around 47 years. This
may be noticed as the onset of hot flushes, night sweats or vaginal dryness or a change in
menstrual periods to more infrequent and sometimes heavier menstrual bleeding (1). Removal
of both ovaries (bilateral oophorectomy) before the normal menopause is called “surgical
menopause”.

Cause of surgical menopause-


Surgical menopause, on the other hand, is a type of induced menopause, as opposed to the
naturally occurring menopause. As the term suggests, surgical menopause is induced through a
surgical procedure, where the ovaries are removed. This procedure, known as oophorectomy, is
what ultimately causes menopause, completely stopping the menstrual cycle. There are several
causes that can lead to a situation where surgical menopause is deemed necessary:

Bilateral oopheroctomy procedure – this is the common procedure to remove both


ovaries. There are various situations where the medical condition of a woman may require this
procedure: cancer, trauma or high blood pressure.
Ovary failure –a woman's ovaries may fail to recover after a hysterectomy procedure (the
surgical removal of the uterus or womb). The damage to blood vessels in the area might be
irremediable and the surgeon will consider bilateral oopheroctomy the only feasible option.

Ovary damage due to chemotherapy or radiation therapy – this occurs in cervical,


endometrial, or ovarian cancer patients, and may render both ovaries completely
nonfunctional, also known as ovarian insufficiency. Generally, when this damage occurs, the
surgeon will immediately suggest an oopheroctomy procedure, to avoid further medical issues.

Indication-
Surgical menopause is commonly performed at the time of hysterectomy for benign (non
cancerous) disease, most commonly for heavy menstrual bleeding or fibroids (2). Another
common reason to remove normal ovaries at the time of hysterectomy is to reduce the risk of
ovarian cancer. This has been shown to be beneficial in women with an inherited increased
chance of developing ovarian cancer (gene mutations such as BRCA1 or BRCA2 or HNPCC) (3),
and for some women with very strong family histories of ovarian cancer, but is not
recommended for other women as the disadvantages of removing normal ovaries at the time of
hysterectomy are likely to be greater than their very small risk of ovarian cancer (4). Very little
is known about the impact of removing normal ovaries from postmenopausal women.

Some premenopausal women will elect to have their ovaries removed for other indications,
such as endometriosis or chronic pelvic pain. Depending on the circumstances, removal of the
ovaries may improve pain, but it is not always effective. Some doctors may suggest a trial of a
drug to bring on a short term “chemical menopause” before surgery to try and mimic the
effects of surgical menopause. However, it is not currently possible to predict how surgical
menopause will affect individual women.

There are other reasons why the ovaries are sometimes removed from younger women such as
recurrent ovarian cysts and premenstrual syndrome, but the evidence to support a benefit for
this is weak and normal ovaries should not be removed from younger women for these
indications.

Although surgical menopause is common, there have been remarkably few studies which have
followed women before and after oophorectomy to try and understand how surgery affects
their menopausal symptoms and short and long term health.

Effects-

a) Potential positive effects of surgical menopause


Reduced risk of ovarian cancer in women who are known to be at high inherited risk. Having
this operation also usually reduces anxiety about developing ovarian cancer. In some high risk
women, surgical menopause may also reduce their risk of breast cancer.

Reduced pelvic pain for women with menopause than dense adhesions around the ovary.

b) Potential negative effects of surgical menopause


Sudden and more severe onset of menopausal symptoms: in particular; hot flushes, night
sweats and vaginal dryness

Loss of bone density and increased risk of osteoporosis and fracture

Impaired sexual function due to reduced desire and to discomfort from vaginal dryness

Reduced sex drive (libido) associated with loss of ovarian testosterone production

Loss of fertility

Increased risk of cardiovascular (heart) disease

Surgical menopause may have other adverse effects on health including affecting mood
(increased depression), cognition (thinking), dementia and potential increased risk of
Parkinson’s disease but the evidence for these is not well established. Large population based
studies have reached different conclusions about whether surgical menopause impacts on
cardiovascular, cancer or all cause mortality(5).

Management of surgical menopause


Ideally, a menopause specialist should review younger women prior to surgical menopause to
explain the potential consequences of surgery and to make a plan for symptom management
and long-term health.

Current international guidelines (6) advise use of HRT for all women who undergo menopause
under the age of 45 years provided that they do not have other contraindications to HRT (6).
Treatment should continue until the average age of menopause (51 years) and then be
reviewed. Those with a personal history of breast cancer should avoid both HRT and tibolone,
as they have been associated with an increased risk of breast cancer recurrence (7). For high
risk (BRCA1 and BRCA2) women without a personal history of breast cancer, observational data
suggest that HRT appears to be safe (8). Women should be aware that discontinuation of HRT
will be associated with a recurrence of hot flushes and night sweats in around 50% of cases.
Use of HRT will resolve hot flushes and sweats in 80-90% of women, although there is evidence
that hot flushes and night sweats as well as vaginal dryness may persist despite HRT use in
younger women (9). There are no specific guidelines on the type of HRT to use but oestrogen
only HRT is generally prescribed for those women who have had a hysterectomy (removal of
the uterus). Women who retain their uterus should use an oestrogen and progestogen
combination preparation.

(Refer to AMS Information Sheets -“Combined Hormone Replacement Therapy”


www.menopause.org.au/for-women/information-sheets/23-menopause-combined-hormone-
replacement-therapy and “Oestrogen Only Therapy” www.menopause.org.au/for-
women/information-sheets/22-menopause-oestrogen-only-therapy)

For women who have had both hysterectomy and bilateral oophorectomy (both ovaries
removed) for endometriosis, taking HRT has the potential to reactivate residual disease. This
has been reported with all HRT preparations including tibolone. There is no consensus on HRT
regimens in this population, but it seems reasonable to use low dose oestrogen only
preparations in younger women and to discontinue oestrogen if symptoms of endometriosis
recur and consider using a non-hormonal agent to treat hot flushes. In some circumstances,
particularly if endometriosis has involved the bowel, progestogen may be added to the
oestrogen.

In those without contraindications to HRT, suggest starting treatment within a week following
oophorectomy.

Offer patients a follow up within 6 weeks to ensure treatment is adequate. Consider adding
vaginal oestrogens to systemic HRT for vaginal dryness and ensure that issues regarding sexual
function are addressed.

Consider supplemental testosterone in younger women with reduced libido following surgical
menopause (10).

Ongoing management of women after surgical menopause

Discuss evidence based lifestyle strategies for maintaining bone and cardiovascular health.
These may include, diet, exercise, smoking cessation and adequate calcium and Vitamin D
levels.

Ensure that vasomotor symptoms and vaginal dryness are effectively managed. Younger
women may require higher doses of oestrogen to manage their symptoms, but there is very
little evidence to support this and low doses should be used in the first instance to minimise
exposure.
Women who are postmenopausal below the age of 45 years are entitled to Medicare Bone
Density (DXA) scans. These should be performed at 2 yearly intervals. HRT (unless
contraindicated) is the best management option for these women with low bone density.

Because of the increased risk of cardiovascular disease associated with early menopause, and in
particular with surgical menopause, assessment of cardiovascular risk factors (including blood
pressure, serum fasting glucose and fasting lipid levels) should be considered with further
management as appropriate. It remains unclear whether HRT protects against cardiovascular
disease after surgical menopause.

Consider psychological support in view of the potential increased risk of depression in this
population.

Use of Hormone Replacement Therapy (HRT) may reduce these risks, but again there is
insufficient evidence. The proven value of HRT after surgical menopause is in managing
vasomotor symptoms and maintaining bone density

Hormone replacement therapy-


The HRT is indicated in menopausal women to overcome the short-term and long-term
consequences of oestrogen deficiency.

Not all women require HRT

70-85% of women remain healthy need only good nutrition and healthy life style.

BENEFITS
Improvement of vasomotor symptoms.

Improvement urogenital atrophy.

Increase in bone mineral density.

Decreased risk in vertebral and hip fractures.

Reduction in colorectal cancer.

Possibly cardio protection.

Indications of HRT-

1) Women having climacteric symptoms


Vasomotor symptoms

Urinary symptoms

Sexual dysharmony

Established osteoporosis on x-ray /B.M.D. Measurements

2) All asymptomatic high-risk women having


Premature menopause (surgical / spontaneous)

Family history of osteoporosis

Thin, small sedentary women

Poor diet, excess alcohol

CVD, Alzhemeir’s disease, colonic cancer

Corticosteroid & other medications

High urinary calcium / creatinine

Low plasma estradiol

Contraindications of HRT

Breast cancer, uterine cancer or family history of cancer.

Previous history of thromboembolic episode.

Liver & gall bladder disease.

DRUGS USED IN HRT-


Estrogen

Progesterone

Other drugs:

Tibolone

Raloxifene

Soya
Bisphosphonates

Women with hysterectomy is advised for oestrogen,but with intact uterus oestrogen combined
with progestin to prevent endometrial hyperplasia

Estrogen therapy-

Short term estrogen therapy


1) To releive symptoms like; hot flush, night sweats, palpitations, disturbed sleep

In smallest effective dose for 3-6 months Oral: -

Conjugated equine estrogen (CEE): 0.625 mg daily

Ethinyl estradiol : 0.01mg

Micronised estrogen : 1-2g

Natural estrogens

Oral premarin(Conjugated equine estrogen (CEE): 0.625 mg daily)

Ethinyl estradiol(0.01mg),Evalon(1-2mg), micronized oestrogen are effective.

Oestrogen &cyclic progestin-Medroxy progestrone(10mg) or primolut-N (2.5mg) daily for 10-


12d each month.

Combined hormone therapy(femet). 2mg 17-β-oestrodiol & 1mg of norethisterone acetate

2) for dyspareunia, urethral syndrome and senile vaginitis

Local estrogen cream(oestriol: 1/2g-everyday-10-12 days each month for- 3-6 months)

Estring(vaginal ringàreleases 5-10microgram - 3months)

Long term therapy:


For delaying osteoporosis

Reduce the risk of CV disease

Beyond 8-10yr

Oral Preparations of estrogen

Continuous oestrogen and progestin therapy


Transdermal Preparations of estrogen

Subdermal/ cutaneous implant (estradiol)

Percutaneous oestrogen gel

Progesteron preperation

Transdermal Preparations of estrogen-

Transdermal (estradiol): -
Patches: contains: 3-4mg; releases 50 micro gm / 24 hour twice weekly.

Gel :for improving collagen in skin 75 micro gm / 24 hours daily.

ESTROGEN: TRANSDERMAL

Advantages.
Low dose, pure estradiol.

Avoids intestine & liver metabolism.

Reduces serum triglyceride & insulin resistance.

No thromboembolic risk or hypertension

Disadvantages.
More expensive

Not well tolerated in warm climates

Variable absorption.

ESTROGEN: IMPLANTS
Sub cutaneous implant (estradiol): -

25 / 50 / 100 mg. 6 monthly.

Advantages.
Pure estradiol, 6 monthly insertion, high level of estradiol in blood.
Avoids first pass effects

Better response in severe osteoporosis.

Disadvantages.
Needs surgical procedure

Unable to control absorption

Difficult to remove pellet

Progesterone

Role in HRT

Prevents endometrial hyperplasia and cancer in non-hysterectomised women

Implant may replace oestrogen, where estrogen is c/I or sensitive

Prevents breast cancer

Improves bone mineral density

primolut-N 2.5mg ,

medroxyprogestrone & duphaston

Mirena IUCD- levonorgestrel

Tibolone

Synthetic derivative of 19-nor-testosterone.

Weak oestrogenic, progestogenic, & androgenic action.

Endometrial hyperplasia

Elevates the mood, relieves the VM symptom, improves sex drive & reduces bone resoption.

Cardioprotection

SE: wt gain, oedema, tenderness in breast, GI symptom& vaginal bleed.

Raloxifene
Non steroidal comp., SERM, reduces the risk of fracture by 50%, esp. vertebra by BMD by 2-
3%.

It causes 10% reduction in total cholesterol & LDL & HDL level.

It does not raise the level of triglycerides, so cardio protective for long term.

Reduces osteoporosis

Side effects
*hot flushes, cramps, venous thrombosis, retinopathy.

Contraindications
*venous thrombosis

*should be given with oestrogen

*hepatic dysfunction

*stop the drug 72 hr before surgery

*indomethacin, naproxen,ibuprofen,diazepam

Soya-

Isoflavone.

Abt 11g soya- 2-4mg phytoestrogen-oetrogenic- non steroid plant product.

45-60mg soya daily –protective- breast cancer, liver disease &other side effect.

cholesterol ,LDL,TG & marginal HDL.

Antiviral, antifungal & anticarcinogenic.

Bisphosphonates

etidronate, tiludronate reduce bone resorption through the inhibition of osteoclastic activity.

Elidronate(10mg/Kg f body wt-2W followed by a gap of 2-3M & this course is repeated for 10
such cycles.

Not given with Ca.(absorption )

Overdose- hypocalcemi
Calcitonin-

It inhibit Osteoclast activity

*nasal spray(single dose of 200IU daily for 3M)

Subcutaneous inj. Of Calcitonin-GI symptoms ,aneamia &inflammation of joint cause poor


complaints so also the high cost

Clonidine-

*treat hot flushes

*effective in HT

*dose 0.2-0.4mg daily.

THE RISKS OF HRT


Vaginal bleeding

Thromboembolism

Endometrial cancer if E2 is taken alone

Brest cancer due to progestogen if HRT is taken over 5yrs.

CHD in a women with CVD

MONITORING PRIOR TO & DURING HRT


A base level parameter of the following and their subsequent check up (at least 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)

DURATION OF HRT
Generally used for a period of 3-5 years has been advised.

Dosage should be reduced gradualists

Menopausal women should maintain optimum nutrition, ideal body

weight and perform regular exercise.

NURSING MANAGEMENT
Nurses can encourage women to view menopause as a natural change resulting in freedom
from symptoms related to menses. No relationship exists between menopause and mental
health problems; however, social circumstances (e.g. adolescent children, ill partners, and
dependent or ill parents ) that may coincide with menopause can be stressful.

Measures should be taken to promote health. The nurse explains to the patient that cessation
of menses is a normal occurrence that is rarely accompanied by nervous symptoms or illness.
The current expected lifespan after menopause for the average woman is 30 to 35 years, which
may encompass as many years as the child bearing phase of her life. Normal sexual urges
continue, and women retain their usual response to sex long after menopause. Many women
enjoy better health after menopause than before, especially those who have experienced
dysmenorrhea. The individual woman’s evaluation of herself and her worth, now and in the
future, is likely to affect her emotional reaction to menopause. Patient teaching and counseling
regarding healthy lifestyles, health promotion and health screening are of paramount
importance.

Provide education,support and assistance to cope with the phase.

Accurate information is given to increase adjustability.

Educate about risks and benefits of H.R.T.

Advise use of topical estrogen preparations to relieve vaginal discomfort.

Stress on importance of weight bearing exercises,cessation of smoking and alcohol.

Good perineal hygiene and increased fluid intake helps prevent UTIs.

Kegel’s exercises.