POST MENOPAUSAL WOMENS’

HEALTH

- Dr. Mayuri A Khatavkar

1st MPT
(Community Physiotherapy)
 OBJECTIVES
 What is menopause and physiological and endocrine changes of the
menopause
 Systemic changes of menopause and their management
 Osteoporosis
 Physiotherapy management of pelvic floor dysfunction
 Rehabilitation post breast cancer
 Physiotherapy and gynaecological surgery
 Physiotherapy management of lymphoedema
MENOPAUSE
 Menopause is defined as the time when there has been no menstrual
periods for 12 consecutive months and no other biological or physiological
cause can be identified
 Menstrual cycle may increase to any duration , anovulation cycles occur or
menstrual loss varies (Whitehead and Godfree, 1992b)
 Post menopause is usually determines by 12 months of amenorrhoea or
complete lack of monthly menstruation (Khaw, 1992)
 Average age is 51 years [range is 49-55 years] (Wren and Eden, 1994)
 Early menopause may be due to living in high altitudes, undernourishment,
thinner women, cigarette smoking (Midgette and Baron,1990)
 Peri menopausal and post menopausal women contribute to 15-20% of the
population
Physiological changes in Menopause

 Vasomotor symptoms – flushing , palpitations , dizziness , nausea , headache

or fainting
 Prevalence of Urogenital symptoms – Urogenital prolapse Atrophic vaginitis,
Atrophy of bladder and urethra (E. Versi , A. Harvey et al , April 2001)
 Problems with connective tissue
 Psychological symptoms – Depressed mood , feeling of worthlessness,
crying , anxiety , early fatigue etc (Whitehead and Godfree, 1992c)
 Other changes – Muscle slackening as a result of loss of myocytes and
decreased type II fibres , subcutaneous fats also disappears (Evers and
Heineman, 1990)
Endocrine changes

 Oestrogen
 Androgen
 Progesterone
MENOPAUSAL SYSTEMIC CHANGES
AND THEIR MANAGEMENT
 Weight problems :-
 BMR – When a subject is at complete rest and no physical work
carried out, the energy required for activity of internal organs and to
maintain the body temperature is called as Basal metabolic rate
(Passmore and Eastwood, 1986)
 BMI
 Waist to Hip Ratio – good indicator of central obesity (android fat
distribution)
 Prevalence of overweight and obesity - 66%, with an average BMI
of 28.1 kg/m² (SD = 5.6) (Gonçalves TT et al, October 2013)
 Further consequences – CVD, hyperlipidaemia, NIDDM, OA, etc
 Management - post menopausal obesity Mx.pdf
 Musculoskeletal changes :-
 Estimated prevalence rates of MSK pain in postmenopausal women
ranges from 53.5% to 85.0%
 common locations of MSK pain include, pain over the neck, lumbar,
hip, and knee regions
 Reduced oestrogen production may lead to multiple musculoskeletal
changes like osteoporosis, sarcopenia (loss of skeletal muscle mass),
and muscle weakness which result in muscle-joint pain. (Arnold Wong,
April 2016)
 Reduced strength and muscular endurance may be because of
decreased muscle mass ; may leads to higher risks of falls and fractures
 Reduced physical activity -> reduced physical fitness
Mx of MSK problems.pdf
 Vascular changes :-
 Atherosclerosis
 Hypertension
 HDL-C reduced, increased cholesterol and reduced LDL- C
 Hypertriglycerite state
 Upper abdominal obesity
 Insulin resistance
 CHD
 Exercise prescription :-
 F – 1-3 times/wk on non consecutive days for 16 weeks
 I – 40% HR Max
 T – 40 mins
 T – Aerobic exercises ( Treadmill and bike ergometer )

 Ref - Combined Exercise Training in Postmenopausal Women , Costas et al , April 2013

Osteoporosis
 Osteoporosis is defined by the World Health Organization (WHO)
as a bone mineral density that is 2.5 standard deviations or more
below the mean peak bone mass (average of young, healthy adults)
as measured by DEXA
 Systemic skeletal d\o characterised by low bone mass and micro
architectural deterioration of bone tissue with a consequent increase
in bone fragility and susceptibility to fracture.
 Up to 15% of PBM-lost within 3 yrs following Menopause
 Oestrogen and osteoporosis - Osteoprotegin (OPG) is a compound
secreted by osteoblasts that inhibits osteoclastic activity. In vitro
studies show that oestrogen increases OPG secretion by osteoblasts
 Risk factors
 Gender
 Age
 Family history
 Race
 Low body weight
 Early menopause
 Loss of menstruation induced by anorexia and exercises
 Low physical activity levels , immobilization
 Inadequate calcium intake or impaired calcium absorption
 Alcohol
 Caffeine
 Smoking
 Nullipara
 Glucocorticoid use
 RA
 Signs and symptoms
 Loss of height – A loss of 4cm or more over ten years ; also with
decreased bone mineral density is a clinical marker
 Pain -- Rarely painful prior to fracture or compression or
Rib pain seen in established osteoporosis may be due to costal
impingement on pelvic bones
 Shortness of breath –Due to posture and shape of the thorax
 Hiatus hernia – Decrease in abdominal volume and associated
indigestion, heartburn or regurgitation
 Protuberant stomach
 Stress incontinence – Increased abdominal pressure –> also due to
straining as a result of constipation provoked by medications ,
especially calcium based
 Transparent skin – Skin is thin in those over age of 60 which is
suggestive of possible or existing osteopenia
 Dowager’s hump – Severe kyphotic deformity .
 Physiotherapy management for acute fractures
 Mobility and transfer
 Pain management
 Ice
 Superficial heat
 Electrotherapy
 Soft tissue manipulation – Effleurage and gentle muscle rolling
 Spinal mobilization techniques
 TENS – applied for 30mins ; pain gate mechanism
 Bracing
• Exercises :-

 Aims - (1) Strengthening the supportive axial musculature like spinal extensors
(2) Proprioceptive training -> improve posture and ambulation and decrease the
likelihood of future falls.

 Exercises should focus on strengthening back extension and may include

weighted or unweighted prone position extension exercises, isometric
contraction of the paraspinal muscles, and careful loading of the upper
extremities

 The Spinal Proprioception Extension Exercise Dynamic (SPEED) program

designed by Sinaki -> focuses on strengthening the spinal extensors using a
weighted kypho-orthosis and postural and proprioceptive training, through
twice-daily, 20-minute exercise sessions for 4-weeks

 Ref:- Vertebral compression fractures: a review of current management and multimodal therapy by Cyrus C Wong and
Matthew J McGirt , June 2013
Recent advances

 Osteoporotic lx #.pdf
Rehabilitation in osteoporotic vertebral
fracture
 Goals :
 Pain control
 Prevention of complications
 Use of orthopaedic corsets
 Specific physiotherapeutic training
 Bed mobility
 Neuromuscular stabilization exercises for thoraco lumbar spine
 Active / passive UL movements along with cervical spine
 TLSO for 8-12 wks
 Relaxing exercises
 Breathing exercises
 Rehabilitation phase can start during the corset wearing and has to proceed
after the orthopaedic corset is removed, generally in 8-12 weeks from the
acute event back-extensor muscle strengthening exercises, postural retraining
exercises, ergonomic and balance increasing exercises

 Ref – Rehabilitation in vertebral fractures , Elisa et al , 2010

 Physical therapy management for hip fractures
 Goals –
 Improving ROM of affected hip joint
 Early mobilization
 Pain free , independent ambulation
 Post op management
 Positioning
 Bed mobility and transfer
 Strengthening of unaffected LL and both UL
 AAROM for hip , ATM
 Static quads , gluts
 Ambulation -> Toe touch to PWB and then FWB over a period of 6
wks to 4 months
 Hydrotherapy
 Physical therapy management for DER fractures
 Fitness , ROM of shoulder, Balance and co ordination, fall prevention
can begin in hydrotherapy pool
 Pain-free wrist and finger movements
 Improve grip strength , hand function
 Postural correction
 Fall prevention
 Lifestyle modifications
 Physiotherapy in long tem for osteoporosis
 Goals
 Maintain and slow the loss of or increase bone density
 Reduce pain
 Prevent spinal deformity and vertebral fractures
 Prevention of falls
 Maintenance of mobility and independence
 Aquatic therapy for osteoporosis
 Benefits ->
 Decreased stress on weight-bearing joints due to the buoyancy of the
water
 Increased mobility due to diminished gravitational pull
 The ability to use varying levels of resistance for strengthening
 Increased sensory stimulation in brain
ACSM guidelines for exercise prescription

 Warm up (5-10 minutes)

 Progressive weight bearing (25 minutes)
 Resistance exercises with large muscle groups (20 minutes)
 Resistance exercises with small muscle groups (10 minutes)
 Abdominal strengthening (5 minutes)
 Stretching and balance (5 minutes)
 Progressive weight bearing exercises-
 Progressive weight bearing movement –
a) Walking while wearing a vest (10 to 25 pounds )
b) circuit training - skipping, jogging, hopping and jumping (with weights)
[ Intensity -> minimal heart rate range of 50% and 70% of maximal heart rate
(MHR) and a maximum of 80% of MHR ]
 Stepping/stair climbing –
a) 4 sets of 30 steps (120 steps) at a pace of two seconds per step
b) Climbing up and down stairs for ten sets of 30 steps (300 steps)
 Resisted exercises for large muscle groups
 Back extension
 latissimus dorsi pull-down using a supinated grip
 leg press
 rotary torso
 seated one-arm dumbbell military press
 seated row
 weighted marching using ankle weights
 squat using a hack squat machine or Smith squat depending on the facility.
[ Intensity - Two sets of six- to eight-repetition maximum with 45
seconds to one minute of rest between sets were performed ]
 Resistance exercises with small-muscle groups
 Ball exs
 Band exercises for adduction/retraction of scapula, scapular
depression and extension of thoracic spine, and external rotation of
humerus.
 The free weight exercises on ball included arm raises, and prone
rowing beginning with 1- to 3-pound dumbbells ( three sets of six to
eight repetitions )
 Abdominal strengthening –
 Pelvic tilts -> progressed to heel lifts, foot lifts
 Knee-ups
 Toe taps
 Leg slides
( three sets of six to eight repetitions )

 Stretching and balance –

 Pectoralis stretch
 Single leg balancing
 Single leg toe raises
 Single leg balancing while simultaneously lowering the torso toward the
ground and raising the opposite leg behind the body toward the ceiling
Physiotherapy management of pelvic floor
dysfunction
 It is the inflammation of the upper genital tract relating to the
fallopian tubes as well as the ovaries
 Symptoms - Pelvic pain -> bilateral and limited to lower abdomen,
spreads upwards if general peritonitis ensues.
 Discharge from the vagina and dysuria also occur.
 Menstrual irregularity
 Uterine bleeding
Physiotherapy management – acute stage

 Aims to lower the pain and inflammation

 SWD
 given for 5-10 minutes for a time of three days a week
 cross- fire method
 site – 1st half -> antero-posteriorly through the pelvis lying position
and 2nd half -> side lying using the legs curled up or perhaps in
sitting position OR electrodes placed over the pelvic outlets and also
the lumbo-sacral area of the spine.
Physiotherapy in chronic stage
 Aims - Relieving pain, Promote healing round the area, Increase function.
 Modalities – SWD
 TENS at low back for the symptomatic relief as it works at both spinal-
cord level and higher brain centres to inhibit the transmission of
nocioceptors thus relieving the thought of pain.
 Moist hot pack
 Relaxation of PFM with Biofeedback including surface EMG may be
used
 For strengthening the pelvic floor musculature instruct the individual to
tighten the pelvic floor as though attempting to stop the the flow of urine.
Hold for 3-5 seconds and relax. Repeat Ten times per session. These
exercises are through with empty bladder.
 Elevator exercises
 Contract the pelvic floor as with the strengthening exercises then
allow total voluntary release and relaxation from the pelvic floor
muscles. This activity could be coordinated with breathing
 Utilization of surface EMG for feedback is invaluable for enhancing
understanding of holding patterns and resting tone
Rehabilitation after breast cancer

 Aims of Physiotherapy management :-

 Regain their preoperative shoulder ROM and function within three
months of surgery
 Maintain their ROM over time after surgery
 Obtain knowledge of lymphoedema, its prevention and an
awareness of its early signs
 Not have their wound drainage or length of hospital stay adversely
affected by the commencement of shoulder movement
 Minimize the effect of the development of secondary complications
on their ultimate physical recovery
 Physiotherapy management
 Improve shoulder ROM and function
 Factors influencing recovery of ROM –
 Age
 H/o previous shoulder problems
 Vigorous early movements
 Development of cording (axillary web syndrome/ lymphatic
cording))
 Principles of exercise after breast cancer surgery –
 Assisted movements initially
 Slow and rhythmical
 Sustained movements and stretches incorporated after 14-21 days
 Limiting point is discomfort and not the pain
 Care with the vigour of the exercises performed to minimize interference
with the regeneration of lymphatic channels
 Scar massage may be required to facilitate exercise ability
 Continued for 6-12 months post operatively as the soft tissues tend
to continue to remodel and contact during this period
 Gradual progression of the type, duration and repetition of the
exercises with the development of warm up and warm down with
the specific exercises
 Patient position – supine ; raise affected arm above the level of heart
for 45 minutes for 2 or 3 times a day so as to help to decrease the
swelling
 In the same position - opening and closing of hand 15 to 25 times
 Elbow flex-ext for 3 to 4 times/day
 Deep breathing exercises for 6 times/day
 Wand exs – In crook lying position , shoulder flex X 5sec hold X 5-
7 times
 Elbow winging – crook lying for 5-7 times
 Shoulder blade stretch
 Shoulder blade squeeze
 Side bends
 Pectoralis stretching
 Wall pushes

Ref- Guidelines by American Cancer Society

Physiotherapy and gynaecological
conditions
 Pre operative programme –
 Assess for the risk factors
 Patient education
 Teach post op skills
 Assessment and treatment –
 Respiratory
 Circulatory
 Mobility
 Strengthening
 Post op management for abdominal surgery
PODo POD1 POD2 POD3
Deep breaths, DBE/ hr Pelvic rocking Cont of previous exs
inspiratory holds
Supported Supported coughs Supported coughs BSS for longer
huffs/coughs and splinthing period

LL exs Calf stretching Deep breaths, Hall ambulation

inspiratory holds
If moist cough -> BSS for 10mins Incentive spirometry PFM strengthening
Removal of (5reps with 5 sec
secretions ; ACBT hold * 4-5 times per
day)

LL circulatory
exs/quarter hr,
ATM/15 mins
U/L UL exs
 Post discharge advice –
 After 6 weeks of surgery -: Daily brisk walk – 30-40 mins/ thrice a
week
 Abdominal exs – Twice a day
 Avoid high impact activities for 10-12 wks
 Posture and back care and ergonomics
 Lifting weight -> around 1kg for 6 wks , heavy weights post 8 wks
 Post op management for vaginal surgery
PODo POD1 POD2
Deep breaths, Cont previous exs Abdominal drawing
inspiratory holds in
Supported coughing BSS Pelvic rocking
Circulatory exs - Hall ambulation
ATM (short distance)
PFM retraining
 Discharge within 3 -7 days
Physiotherapy management of
lymphoedema
 Lymphoedema can be primary or secondary
 Primary – aplasia / hypoplasia or hyperplasia
 Causes of secondary lymphoedema -> Surgery and/ radium
treatment , Varicose veins strippng, Liposuction, Infection, Trauma,
Filariasis, Chronic venous insufficiency
 Factors inhibiting development of lymphoedema

Lympholymphatic New anastomosis developed

anastomosis between blocked area
Collateral lymhatic circulation Surviving lymphatics dilate
and form collateral circulation
Lymphovenous anastomosis Lyphatic vessels drain into
nearby nerve
Phagocytic system Monocytes migrate from blood
vessels to interstitium and
change into macrophages and
reduce amount of proteins
 Grading for lymphoedema according to International society for
lymphology

GRADE 1 GRADE 2 GRADE 3

Pitting oedema Non pitting Elephantiasis
Reduces with No reduction with Increased volume,
overnight elevation elevation skin changes,
frequent bouts of
infection
No fibrotic changes fibrotic changes
 Measurements
 Circumferential measurements
 Plethysmography or volumetry
 Tonometry
 Bio-impedance measurements
 Physical therapy management
 Manual lymphatic drainage - slow light repetitive stroking and circular
massage movements done distal to proximal towards lymph nodes. Done
with limb in elevation.
 Elevation – Limb is kept in elevation almost entire day.
 Compression bandages, garments, pumps – No stretch, non elastic
bandages or garments are recommended as they provide low compressive
forces on edematous tissues. They provide higher working pressure with
active muscular contractions because of their less yielding nature than
high stretch bandages.
 Skin care and hygiene – Meticulous attention to skin care and protection
of oedematous limb is necessary for self management.
 Exercises
 Deep Breathing and Relaxation Exercises - It has been suggested that the
use of abdominal-diaphragmatic breathing assists in the movement of
lymphatic fluid as the diaphragm descends during a deep inspiration and
the abdominals contract during a controlled, maximum expiration
creating a gentle, continual pumping action that moves fluids in the
central lymphatic vessels, which run superiorly in the chest cavity and
drain into the venous system in the neck.
 Flexibility Exercises to minimize soft tissue and joint hypomobility,
particularly in proximal areas of the body.
 Strengthening and Muscular Endurance Exercises - Both isometric and
dynamic exercises using self-resistance, elastic resistance, and weights
or weight machines are appropriate if done against light resistance and
by progressing resistance and repetitions gradually.
 Cardiovascular Conditioning Exercises - Activities such as upper
extremity ergometry, swimming, cycling, and walking increase
circulation and stimulate lymphatic flow done at low intensity for 30
mins when lymphedema is present.
 Lymphatic Drainage Exercises/pumping exercises -> move fluids
through lymphatic channels ; The exercises follow a specific sequence
to move lymph away from congested areas
 Upper Extremity Exercises
 Active circumduction with the involved arm elevated while lying
supine.
 Bilateral active movements of the arms while lying supine or on a foam
roll.
 Bilateral hand press while lying supine or sitting.
 Shoulder stretches (with wand, doorway, or towel) while standing.
 Active elbow, forearm, wrist and finger exercises of the involved arm.
 Bilateral horizontal abduction and adduction of the shoulders.
 Overhead wall press while standing.
 Finger exercises.
 Partial curl-ups.
 Rest with involved upper extremity elevated.
 Lower Extremity Exercises
 Alternate knee to chest exercises.
 Bilateral knees to chest.
 Gluteal setting and posterior pelvic tilts.
 Single knee to chest with the involved lower extremity.
 External rotation of the hips while lying supine with both legs elevated
and resting on a wedge or wall.
 Active knee flexion of the involved lower extremity while lying supine.
 Active plantarflexion and dorsiflexion and circumduction of the ankles
while lying supine with lower extremities elevated.
 Active hip and knee flexion with legs externally rotated and elevated
against a wall.
 Active cycling and scissoring movements with legs elevated.
 Bilateral knee to chest exercises, followed by partial curl-ups.
 Rest with lower extremities elevated

 Hydrotherapy -: 45 minutes hydrotherapy (15 minutes of slow rhythmical

exercise + 20 minutes of whole body exercise + 10 minutes of cool-down )
given three times a week for four weeks (Box et al , 2004)
 PREVENTION OF LYMPHEDEMA

 Avoid static dependent positioning of lower extremity such as

prolonged sitting or standing.
 Elevate involved limbs and perform repetitive pumping exs frequently.
 Avoid vigorous, repetitive activities with involved limb. Avoid
carrying heavy loads.
 Wear compressive garments while exercising.
 Avoid hot environments or use of local heat.
 Keep skin clean and supple, use moisturizers.
 Pay immediate attention to cuts, skin abrasion, insect bite, blister or
burn.
 Protect hands and feet.
 Avoid contact with harsh detergents and chemicals.
 Use caution while cutting nails.
 Avoid hot baths, whirlpools, saunas that elevate core body
temperature.