GENERAL OBJECTIVE

At the end of the lesson plan women will be able to gain in-depth of knowledge regarding pre and postmenopausal health problems.

SPECIFIC OBJECTIVE: -
After the completion of the planned teaching women will be able to-
1) Define menopause
2) Discuss the Incidence of the menopause
3) Discuss the phases of menopause.
4) Enlist the causes of menopausal health problems
5) Describe the sign and symptoms of the pre and post-menopause
6) Explain the changes in the body during the menopause.
7) Enumerate the problems of pre and post-menopausal health.
8) List down types of abnormal menopause.
9) Explain the investigation of the pre and post-menopause.
10) Discuss the prevention of the pre and post menopause

Sr. Time Specific Content Teaching A.V Evaluation

no Objective Learning aids
activity

1. 2 min. Stimulate the INTRODUCTION Lecture cum PPT

critical thinking discussion
of females Menopause is the end of menstruation. The word
regarding topic. menopause comes from the Greek word ‘men’s’ meaning
‘monthly’ and ‘pauses’ meaning ‘cessation’. Menopause is the part
of a women’s natural ageing process when her ovaries produce
 lower level of Estrogen and progesterone when she no longer able
to become pregnant.

2. 2 min. Define DEFINITION Lecture cum PPT What is meaning of

menopause discussion menopause?
‘’Menopause means permanent cessation of
menstruation at the end of reproductive life due to loss of ovarian
follicular activity.’’
The clinical diagnosis is confirmed following
stoppage of menstruation (amenorrhea) for twelve consecutive
months without any other pathology. As such, a woman is
declared to have attained menopause only retrospectively. Serum
follicle stimulating hormone (FSH) level is found elevated around
the period of menopause (44-45 years). What is the
3. 2min Discuss the Lecture cum PPT incidence of
Incidence of the INCIDENCE discussion menopause?
menopausal Physiologic menopause
problems The normal decline in ovarian function due to ageing
begins in most women between ages 45 and 55 on average 51 and
result in infrequent ovulation, decreased menstrual function and
eventually cessation of menstruation.

Pathologic menopause
The gradual or abrupt cessation of menstruation before 40
years occur idiopathically in about 5% of women in USA

MENOPAUSAL TRANSITION
Is the period of time during which a women passes
 from the reproductive to the non-reproductive stage. This phase
covers 4-7 years on either side of menopause.
Discuss the What are the
4. 3min. phases of Lecture cum phases of
menopause. discussion PPT menopause?
PHASES OF MENOPAUSE

Premenopausal phase

Is the interval in which a women’s body begins

making the natural shifts from more-or-fewer regular cycles of
ovulation and menstruation toward permanent infertility or
menopause?

Menopausal phase

It is the end of menstruation. The age of menopause ranges

between 45-55 years, average being 50 years.

Post-menopausal phase

It is defined formally as the time after which a woman

has experienced 12 consecutive months of amenorrhea
Without period.

AGE OF MENOPAUSE

Age at which occurs is genetically predetermined.

The age of menopause is not related to age of menarche or age at
last pregnancy. It is also not related to number of pregnancies,
 lactation, use of oral pill, socioeconomic condition, race, height or
weight. Thinner women have early menopause. However, cigarette
smoking and severe malnutrition may cause early menopause. The
age of menopause ranges between 44-45 years, average being 50
years.

CLINICAL IMPORTANCE

Due to increased life expectancy, especially in

Enlist the causes Lecture cum What are the cause
5. 6min affluent society, about one third of life span will be spent during Flash card
of menopausal discussion of the menopausal
the period of estrogen deficiency stage with long term
health problems. health problems?
symptomatic and metabolic complication.

CAUSES OF MENOPAUSAL HEALTH PROBLEMS

Menopause occurs when the ovaries are totally depleted of
eggs and no amount of stimulation from the regulating hormones
can force them to work.
Describe the What are the sign
sign and  Surgical removal of the ovaries. and symptoms of
symptoms of the  Cancer chemotherapy and radiation therapy. Lecture cum the menopausal
6. 3min discussion Hand out
pre and post-  Premature ovarian failure transition?
menopausal
health
problems? SIGN AND SYMPTOMS OF MENOPAUSAL TRANSITION
 Irregular periods
 Vaginal dryness
 Hot flashes
 Night sweats
  Sleep problems
 Loss of libido
 Mood changes
 Weight gain and slower metabolism
Explain the What are the
changes in the  Thinning hair and dry skin changes in the
body during the  Loss of breast fullness Lecture cum body during the
7.. 8min menopause.  Fatigue discussion PPT menopause?
 Incontinence
 Low sex drive

Changes in the body during the menopause

PHYSIOLOGICAL CHANGES
The lack of Estrogen and progesterone causes many
changes in women’s physiology that affect their health and well-
being. The symptoms of menopause due to changes in the
metabolism of the body.

1) Increased cholesterol level in the blood

Hyperlipidemia or an increase in the level of cholesterol
and lipids in the blood is common. This led to gradual rise in the
risk of heart disease and stroke after menopause.

2) Bone metabolism
Normally bone formulation (osteoblastic activity) and
bone resorption (osteoblastic activity) are in balance depending on
many factors (age, endocrine, nutrition and genetic) following
menopause there is a loss of bone mass by about 3-5 % per year.
This is due to deficiency of Estrogen. Postmenopausal women
runs a high risk for fracture of bones due to osteoporosis.

CHANGES IN THE GENITAL ORGANS

1) Ovaries
Shrink in size, become wrinkled and white. There is
thinning of the cortex with increase in medullary components.
There is abundance of stromal cells which have got secretory
activity.
2) Fallopian tube

Show features of atrophy. The muscles coat become

thinner, the cilia disappear and the plicae become less prominent.

3) The uterus

It becomes smaller and the ratio between the body and

the cervix reverts to the 1:1 ratio. The endometrium becomes thin
and atrophic. In some women, however, with high endogenous
Estrogen, the endometrium may be proliferative or even
hyperplastic. The cervical secretion becomes scanty.

4) The vagina
The vaginal mucous membrane becomes thin and
loses its rigidity after the menopause. Decreased secretion make
vagina dry. Sexual intercourse become painful and difficult due to
pain from the dry vagina.
5) The vulva

It shows features of atrophy. The labia becomes flattened

and the pubic hair becomes scantier. The end result is a narrow
introitus.

6) Breast fat

Is reabsorbed and the glands atrophy. The nipples

decrease in size. Ultimately, the breast becomes flat and
pendulous.

7) Bladder and urethra

It under go similar changes to those of the vagina. The

epithelium becomes thin and is more prone to damage and
infection. There may be dysuria, frequency, urge or even stress
incontinence.

8) Loss of muscles tone

It leads to pelvic relaxation, uterine descent and

anatomical changes in the urethra and neck of the bladder. The
pelvic cellular tissue become scanty and the ligaments supporting
the uterus and vagina lose their tone. As such pre-existing
weakness gets aggravated.

CHANGES IN THE GENERAL APPEARANCE

1) Skin
The skin loses its elasticity and becomes thin and
Fine. This is due to the loss of elastin and collagen from The skin.
2) Weight
Weight increase is more likely to be the result of
 irregular food habit due to mood swing. There is more deposition
of fat around hips, waist and buttocks.
Enumerate the 3) Hair What are the
menopausal Hair become dry and coarse after menopause. There problems
problems. may hair loss due to the decreasing level of estrogen. Of pre and post-
5 Lecture cum menopausal?
4) Voice
8. min discussion Chart
Voice become deeper due to thickening of vocal cords.

CHANGES IN THE CARDIOVASCULAR SYSTEM

Risk of cardiovascular disease is high in

postmenopausal women due to deficiency of estrogen. estrogen
prevents cardiovascular disease by several ways. It increases high
density lipoprotein (particularly HDL2) and decrease low density
lipoprotein (LDL) and total cholesterol.

PROBLEMS OF PRE AND POST-MENOPAUSE

In majority, apart from cessation of menstruation, no

more problems are evident. In some women, symptoms appear.
The important problem and health concerns of menopause:

 Vasomotor problems.
 Genital and urinary problems
 Vaginal
 Sexual dysfunction
 Skin and hair.
  Psychological problems
 Social problems
 Osteoporosis and fracture.
 Cardiovascular disease.
 Cerebrovascular disease.

VASOMOTOR PROBLEMS

a) Hot flashes

Hot flashes are incidents where the women in

menopause gets a sudden feeling of warmth and flushing that
starts in the face and quickly spread all over the neck and upper
body . This `hot flashes’ can occur at any time of the day or night.
They vary in number from 1 in every one hour to as one in every
15 mints. The hot flashes are often associated with profuse
sweating.
b) Night sweat

Night sweat are closely related to hot flashes Both usually occur
simultaneously. Sweat can occur any time of the day or night, they
are more common at night. The sweat can be severe enough to
wake up the women from a sound sleep and may make it difficult
for her to go back to sleep. The sudden waking up from sleep can
cause palpitation and sometimes panic attacks.

GENITAL AND URINARY SYSTEM

Estrogen plays an important role to maintain the

epithelium of vagina, urinary bladder, and the urethra. Estrogen
deficiency produces atrophic epithelial changes in these organs.
This may cause dyspareunia and dysuria.

VAGINA

Minimal trauma may cause vaginal bleeding.

Dyspareunia, vaginal infection, dryness, purities and leucorrhoea
are also common. The urinary symptoms are urgency, dysuria and
recurrent urinary tract infection and stress incontinence.

SEXUAL DYSFUNCTION

Estrogen deficiency is often associated with decreased

sexual desire. This may be due to psychological changes
(depression and anxiety) as well as atrophic changes of the
genitourinary system.

SKIN AND HAIR

There is thinning, loss of elasticity and wrinkling of the

skin. Skin collagen content and thickness decrease by 1 to 2 % per
year. Estrogen receptors are present in the skin and maximum are
present in the facial skin. Estrogen replacement can prevent this
skin loss during menopause. After menopause, there is some loss
of pubic and axillary hair.

PSYCHOLOGICAL CHANGES

There is increased frequency of anxiety, headache,

insomnia, irritability, dysphasia, anxiety, fatigue, memory loss,
irritability, sleep disturbances, mood disturbances, low self-esteem
 depression. They also suffer from dementia, mood swing and
inability to concentrate.
Diminished interest in sex may be due to emotional
upset or may be secondary to painful intercourse due to a dry
vagina.

DEMENTIA

Estrogen improves cerebral perfusion and cognition.

However it is not clear whether estrogen therapy prevents vascular
dementia and Alzheimer disease.

SOCIAL CHANGES

The feeling that a women holds about herself and her

Social relationship as well as the symptoms she experiences can be
List down the What are the types
defined by the culture in which she live. Women vary in there
types of of abnormal
subjective experiences of symptoms. Not all of the women’s
abnormal menopause?
perceive changes in the body are reflected in the mirror; some are Lecture cum
menopause.
9. 3min derived from women’s perception of herself based on the account discussion PPT
of other expectation vary and are adjusted to actual
experience.

OSTEOPOROSIS AND FRACTURE

Osteoporosis occurs in postmenopausal women due

to estrogen loss, deficiency of calcium and vitamin D or
 hereditary. Osteoporosis may lead to back pain, loss of height and
kyphosis and fracture of bones. Fracture may involve vertebral
body, femoral neck or distal forearm.

CARDIOVASCULAR AND CEREBROVASCULAR

EFFECTS

Risks of ischemia, heart disease, coronary artery disease

and stroke are due to atherosclerotic changes, vasoconstriction and
thrombus formation.

TYPES OF ABNORMAL MENOPAUSE

 PREMATURE MENOPAUSE
Explain the If the menopause occurs at or below the age of 40, it What are the
investigation is said to be premature. investigation
regarding pre regarding pre and
and post- Lecture cum post-menopause?
 DELAYED MENOPAUSE
10. 4min menopause. discussion PPT
If the menopause fails to occur even beyond 55 years,
it is called delayed menopause.

 ARTIFICIAL MENOPAUSE

Permanent cessation of ovarian function done by

artificial means eg surgical removal of ovaries by radiation,
chemotherapy is called as artificial menopause.
What are the
 Discuss the  SURGICAL MENOPAUSE prevention of pre
prevention of and post
pre and post- Menstruating women who have bilateral menopause
menopausal oophorectomy, experience menopausal symptoms. It is Lecture cum problem?
11. 5min problems. sometimes more troublesome than natural menopause. discussion PPT

 DELAYED MENOPAUSE

The ovarian function may be suppressed by

external gamma radiation in women below the age of 40.

INVESTIGATION OF PRE AND POST MENOPAUSE

 Cessation of menstruation for consecutive 12 months

during climacteric.
 Average age of menopause: 50 years.
 Appearance of menopausal symptoms ‘hot flash’ and
‘night sweat ’.
 Vaginal cytology showing features of low estrogen.
 Serum estradiol is less than 20 pg/ml.
 Serum FSH and LH is greater than 40 mIu/ml at 1 week
interval for three times.

PREVENTION OF PRE AND POST MENOPAUSE

PROBLEMS
 1) NON-HORMONAL TRATMENT

There are variety of menopausal treatments both

natural and medical that can alleviate the symptom of
menopause:
1. Dressing in light layers can alleviate hot flashes and night
sweats; avoiding caffeine , alcohol and spicy foods
Can also minimize these symptoms.
2. Menopause and weight gain tend to go together due to life
style changes than to the hormonal changes. Reducing
dietary fat intake and regular exercise help to combat
weight gain during menopause.
3. Menopause can lead to osteoporosis. Calcium, magnesium
and vitamin D can help restore bone density, which
naturally deteriorates after age 30 due to reduced estrogen
level.
4. Menopause decreases vaginal elasticity, leading to vaginal
Dryness. Vitamin E can help as can kegal exercises which
Help restore elasticity. Using water based lubricants
during sexual intercourse also minimizes discomfort
Related to vaginal dryness.
5. Menopause often lead to dry, itchy skin, and weak thin
Hair that breaks and that has lots of split ends. Flax seed
oil(found in poultry , dairy, red meat and whole grains)
can help restore hair and skin’s healthy appearance , as
Can vitamin E.

HORMONAL THERAPY
The hormonal therapy is indicated in menopausal
women to overcome the short term and long term consequences of
estrogen deficiency.

INDICATION OF HORMONAL THERAPY

 Relief from menopausal symptoms.

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

Spatial group of women to whom Hormonal Therapy should

be prescribed :
 Premature ovarian failure.
 Gonadal dysgenesis.
 Surgical or radiation menopause.

BENEFITS OF HORMONAL THERAPY

 Improvement of vasomotor symptoms (70-80%)

 Improvement of urogenital atrophy.

 Increase in bone mineral density ( 2-5% )

 Decreased risk in vertebral and hip fracture (25-50%)

RISK OF HORMONAL 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
(ERT) to counter balance such risks.

 BREAST CANCER
Combined estrogen and progestin replacement
therapy for a long term, increase the risk of breast cancer
slightly. Adverse effect of hormone therapy are related to
the dose and duration of therapy.
 VENOUS THROMBOEMBOLIC DISEASE

(VTE) 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 hormonal therapy shows a relative

hazards of CHD. Hypertension has not been observed to be a risk
of HT.

 LIPID METABOLISM
An increased incidence of gallbladder disease has
been observed following ERT due to rise in cholesterol.
  Dementia, Alzheimer disease not benefited.

CONTRAINDICATION OF HORMONAL THERAPY

 Known, suspected or history of breast cancer.

 Undiagnosed genital tract bleeding.

 Estrogen dependent neoplasm in the body.

 History of venous thromboembolism or active deep vein

thrombosis.

 Active liver disease.

 Prior cholestasis disease.

 Gallbladder disease.

 Prior endometriosis.

AVAILABLE PREPARATION FOR HORMONAL

THERAPY

 ORAL ESTROGEN REGIME

CEE 0.3 mg or 0.625 mg is given daily for women 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 12-14
days.

 CINTINUOUS ESTROGEN AND PROGESTIN

THERAPY Continued combined therapy can
prevents endometrial hyperplasia. There may be irregular
bleeding with this regimen.
 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.

 TRANSDERMAL PATCH

It contains 3.2 mg of 17B-estradiol releasing about

50 ug of estradiol in 24 hours. It should be applied below the waist
line and changed twice a week. Skin reaction, irritation and itching
have been noted with their use.

 VAGINAL CREAM
12.
Conjugated equine vaginal estrogen cream 1.25 mg
daily is very effective specially when associated with atrophic
vaginitis. It also reduces urinary frequency, urgency and
recurrent infection.
  PROGESTIN

In patients with history of breast carcinoma or

endometrial carcinoma, progestin may be used.

13.  LEVONORGESTREL INTRAUTERINE SYSTEM

(LNG-IUS)

With daily release of 10 mg of levonorgestrel per 24

hours, it protects the endometrial from hyperplasia and cancer. It
can serve as contraception and HT when given in a per
menopausal woman.

 TIBOLONE
14. Tibolone is steroid. It prevents osteoporosis, atrophic
changes of vagina and hot flashes. It increase libido.
Endometrial is atrophic. A dose of 2.5 mg per day is given.

 TESTOTERONE

Androgen replacement in woman with hyperactive

sexual desire disorder (HSDD) is found beneficial. It improves
mood, bone, muscle mass and quality of life. Short term use is
suggested.

 PARATHYROID HORMONE

Recombinant PTH (teriparatide) is given by injection

(sc) to prevent osteoporosis and fracture. PTH is safe and well
tolerated. At low daily doses (20ug/day SC). Slide side effects are
leg cramps, nausea and headache

SUMMARY

We will discuss about the define menopause, Incidence

of the menopause, phases of menopause, causes of menopausal
health problems, sign and symptoms of the pre and post-
menopausal health, changes in the body during the menopause.
Problems of pre and post-menopausal health, types of abnormal
menopause, investigation of the pre and post-menopause health
problems prevention of pre and post menopause problems.

CONCLUSION
Menopause is characterized by metabolic,
hormonal and clinical changes, low sexual desire often reduces
women’s quality of life and causes personal distress. By providing
symptomatic treatment we can manage the symptoms and also by
providing hormonal therapy that also helps to reduce symptoms. In
this also we are providing symptomatic treatment and hormonal
therapy.

BIOLIOGRAPHY

 DC Dutta’s, Testbook of gynecology, hiralal konar, 7 th

edition, Jaypee publication.

 Annamma Jacob, A comprehensive, Textbook of

midwifery and gynecological nursing, fourth edition,
 Jaypee publication.
 Kamini Rao, Textbook of midwifery and obstetric for
nurses,

 A.V. Raman, maternity nursing, family newborn and

women’s health care, 19th edition.
 Shirish S. sheth, essential of gynecology 2 nd edition, Jaypee
publication.