creation date: 2025-05-01 21:07
tags: Anatomy & Physiology
Menopause
Definitions
Menopause is a normal condition involving the permanent end of menstrual cycles due to the cessation of production of reproductive hormones from the ovaries.
Menopause specifically refers to after 12 consecutive months of cessation has occurred. The period surrounding menopause is referred to as perimenopause.
Normally, this occurs between the ages 45-56, with the median age of natural menopause being 51.
Physiology
As women age, ovarian follicle quantity decreases due to atresia and ovulation. Additionally, granulosa cells reduce in numbers. This culminates in:
- Reduced estradiol and inhibin B
- Reduced AMH
- Elevated FSH and LH (loss of estrogen and inhibin negative feedback)
Decline in estrogen results in disruption of HPO axis and other manifestations.
Clinical Presentation
Signs & Symptoms
Vasomotor symptoms
These symptoms are common and seen during transitional years, with approximately 75% of women experiencing them with varying severity.
- Hot flashes (3-4 mins duration, unpredictable time)
- Night sweats
- Palpitations
- Migraines
Genitourinary symptoms
Occurs in 60% of women.
- Vaginal dryness
- Burning
- Pruritus
- Irritation
- Urinary symptoms (frequency, urgency, dysuria)
Psychogenic symptoms
Up to 70% of women may experience psychogenic symptoms.
- Anger/irritability
- Anxiety
- Depression
- Loss of concentration
- Loss of self-esteem/confidence
- Disturbances to sleep
Signs on physical
- Elevated BP
- Weight gain (average 5 lb over transition period)
- Increased fatty deposition and involution of breasts
- Vaginal dryness and urogenital atrophy
- Arthralgias and sarcopenia
History & Physical Exam
A thorough assessment of symptom burden should be performed.
Risk factors
Diagnosis
Criteria
Diagnosis of menopause or perimenopause is made clinically based on the patients age and the presence of characteristic symptoms.
Work-up
A workup is not necessary for routine diagnosis.
If the diagnosis is uncertain, FSH and estradiol levels can be measured.
- FSH >30 persistently
- Estradiol levels may be elevated compared to premenopause
In a patient younger than expected, additional workup should be performed for alternative causes of amenorrhea.
Differential
See amenorrhea.
Red Flags / Complications
Long term complications are associated with decreased estrogen levels. The most concerning are:
Cardiovascular disease
The risk of cardiovascular disease increases due to:
- Negative changes in lipid profile
- Impaired arterial endothelial function
- Activation of RAAS
Osteoporosis
Estrogen deficiency results in bone loss and decreased bone density at a rate of 3-5% during menopause for 5-7 years.
Management
The mainstay management of menopausal symptoms is menopausal hormone therapy (MHT). Note that the term hormone replacement therapy (HRT) may still be used but that is typically used to refer to hormone treatment of premature ovarian insufficiency or early menopause.
Indications and Initiation
The decision to start MHT depends on a number of factors. In general, it involves:
- Impact of symptoms of quality of life
- Patient’s calculated risk of cardiovascular disease and breast cancer
- Patient age
Generally, hot flashes, sleep disturbances, and mood lability are common reasons women seek out therapy. Initiation of MHT is safe for healthy, symptomatic women who are within 10 years of menopause or younger than 60 with no contraindications.
For patients with genitourinary syndrome of menopause only, low-dose vaginal estrogen is recommended over systemic estrogen.
Contraindications of MHT include:
- History of breast cancer
- Coronary heart disease
- Previous VTE event or stroke
- Active liver disease
- Unexplained vaginal bleeding
- High-risk endometrial cancer
- Transient ischemic attack
Regimens
Perimenopausal or early postmenopause
- Continuous 17-beta estradiol transdermal (0.025 mg) or oral (0.5 mg/day)
- Cyclic oral micronized progesterone 200 mg/day for first 12 days of calendar month
If withdrawal bleeding become bothersome or are later in postmenopause
- Continuous EPT (estradiol and progestin combined daily)
For surgical menopause
For women who have undergone hysterectomy and candidates for MHT, unopposed estrogen is given as endometrial hyperplasia is no longer a concern.
Follow-up and Monitoring
The starting dose is generally low and titrated up to relieve symptoms. However, if symptoms are not relieved by follow up and are severe, a higher dose can be initiated.
Other dose adjustments may include:
- Tapering following relief
- Adjustment to anticonvulsants (enzyme inducing meds will require higher dose)
- Adjustment to thyroid hormone replacement (oral estrogen can lower available T4)
Vaginal bleeding during therapy may require evaluation of endometrial hyperplasia.
Duration of Use and Discontinuation
The recommended duration of MHT is 5 years and not beyond age 60. However, as symptoms (particularly hot flashes) can persist for 10-20 years following final menstrual period, an individualized decision should be made.
For women who are not at increased risk of breast cancer or cardiovascular disease, the risk generally outweigh the risks starting at age 60.
When discontinuing hormone therapy, return of symptoms may occur. As such, a tapering regimen can be considered (eg. reduce by one pill per week)