Puberty and Menopause

Puberty is the gradual development of secondary sexual characteristics. It is the period in which girls and boys convert from childhood to adulthood.

• Age of puberty — 10–16 years.
• Peak age of puberty — 13 years.
• Estrogen is the hormone responsible for secondary sexual characteristics.

Stages, according to Tanner and Marshall

The male equivalent landmark, noted in the margin, is the adam's apple (कंठमणि).

Precocious puberty

Also called early puberty — the change appearing before its time (समय से पहले यौवन में बदलाव दिखाना).

Girls who exhibit any secondary sexual characteristic before 8 years of age, and menarche before 10 years of age.

It divides in two:

• Males develop breasts and other feminine characteristics
• Females develop a deeper voice and facial hair

Diagnosis: wrist X-ray. (The wrist X-ray is what gives the bone age — Wrist X-ray से Age का पता लगायेंगे.)

Management:

• GnRH agonist therapy
• Danazol

Delayed puberty

Also called post-cocious puberty.

Girls who do not exhibit any secondary sexual characteristic before 13 years of age, and whose menarche is as late as 16 years of age.

Treatment: HRT — hormone replacement therapy, with estrogen.

Permanent cessation or stoppage of the menstrual cycle at the end of reproductive age, due to loss of ovarian follicular activity.

Important points

• Age of menopause — 45–55 years.
• Early menopause — menopause before 40 years of age.
• Late or delayed menopause — menopause after 55 years of age.
• Premenopause — menopause before 45 years.
• The age of menarche does not affect the age of menopause.
• A maternal history of menopause does not affect the menopause of her daughter.
• Malnourished, anaemic, smoking and thinner women may have an early menopause.

Thyroid disease shifts it either way:

• Hypothyroidism → delayed menopause: T3 and T4 decrease → TSH increases → FSH increases.
• Hyperthyroidism → early menopause.

Mechanism of menopause

From there the chain splits in two:

Organ changes during menopause

1. Ovary — the ovary shrinks, atrophying in size, and ovarian hormone decreases.

2. Fallopian tube — shrinks in size.

3. Vagina — shrinks in size; the pH becomes alkaline or neutral; dyspareunia, painful sexual intercourse; senile vaginitis.

4. Uterus — shrinks in size, with an increased chance of uterine prolapse.

5. Cardiovascular system. Estrogen governs the lipids — HDL (high density lipoprotein), LDL (low density lipoprotein), VLDL, FFA (free fatty acid) and chylomicron. Normally estrogen raises HDL, the good cholesterol, and lowers LDL, the bad cholesterol.

6. Skeletal system. Bone mass falls 3–5% per year. Estrogen increases calcium absorption, so:

7. Integumentary system — the skin. Loss of elasticity, and more chances of infection.

Signs and symptoms of menopause

1. Vasomotor symptoms. Hot flush is the most characteristic symptom of menopause.

• Sudden intense feeling of warmth.
• Increased body temperature.
• Short duration — 2 to 10 minutes.
• Mostly at night time.
• Unknown aetiology.
• Perspiration — sweating.
• Unbearable (असहनीय).

2. Genito-urinary symptoms

• Alkaline pH of the vagina.
• Dryness of the vagina, atrophic vaginitis.
• Dyspareunia — difficult and painful sexual intercourse.
• Apareunia — absence of sexual intercourse.
• Dysuria — difficulty in urination.
• Stress incontinence.

3. Psychological symptoms — headache, insomnia, irritability, depression, anorexia.

4. Health hazards — atherosclerosis, myocardial infarction, osteoporosis, atrophic vaginitis.

Diagnosis of menopause

1. Regular stoppage of the menstrual cycle for the last 1 year, plus age more than 45 years.
2. Normal estrogen level — 50–300 pg/ml.
3. Menopause estrogen level — 10–20 pg/ml.
4. Normal FSH level — 2–10 mIU/ml.
5. Normal LH level — 3–8 mIU/ml.
6. Menopause FSH and LH level — more than 40 mIU/ml.
7. Normal progesterone level — 1–6 ng/ml. Menopause progesterone level — 1–2 ng/ml.

pg/ml = picograms per millilitre.

Management of menopause

1. Non-hormonal therapy

• Increase vitamin D and calcium in the diet.
• Daily requirement of vitamin D in menopause — 15 mg/day, against a normal of 10 mg/day.
• Daily requirement of calcium in menopause — 1.2–1.5 g/day, that is 1200–1500 mg/day, against a normal requirement of 600–800 mg/day.
• Tab Clonidine — for hot flush.

2. Hormone replacement therapy (HRT)

• If the uterus is intact → both estrogen and progesterone.
• If the uterus is not intact → only estrogen therapy.

HRT needs continuous monitoring of the estrogen level weekly, because estrogen causes hyperplasia.

Artificial menopause

Deliberate stoppage of the menstrual cycle permanently. It is of two kinds.

Radiation menopause:

Menstruation resumes for 2 years, so contraceptive advice is still given.

Surgical menopause — oophorectomy, removal of the ovary.

Hysterectomy — removal of the uterus. It may be vaginal or abdominal.

1. Sub-total hysterectomy — removal of the fundus and body; the cervix remains.
2. Total hysterectomy — entire or complete removal of the uterus.
3. Pan hysterectomy — total hysterectomy with bilateral salpingo-oophorectomy (bilateral = both sides, salpingo = fallopian tube).
4. Extended hysterectomy — pan hysterectomy with removal of the upper one-third of the vagina.
5. Radical hysterectomy — extended hysterectomy with the surrounding lymph nodes.

After surgical menopause there is no need to give a contraceptive.