Menopause - Weintraub

Question 1

Definition of menopausal transition

Perimenopause

Menopause

Answer 1

Menopausal transition — Begins with menstrual cycle length variation and elevated serum FSH and ends with the final menstrual period (recognized after 12 months of amenorrhea)
Stage -2 (early) – A variable cycle length [>7 days different from normal (21-35 days)].
Stage -1 (late) - ≥2 skipped cycles and an interval of amenorrhea ≥60 days

Perimenopause - “around the menopause“ begins in stage -2 of the menopausal transition and ends 12 months after the last menstrual period

• Stage +1 (early) - The first five years after the final menstrual period. Complete dampening of ovarian function and accelerated bone loss
• Stage +2 (late) begins five years after the final menstrual period and ends with death

Menopause —12 months of amenorrhea after the final menstrual period. It reflects complete, or near complete, ovarian follicular depletion and absence of ovarian estrogen secretion

Question 2

What is the average age of menopause?

What is considered early and late menopause?

What factors into this?

Answer 2

Average age at menopause is approximately 51 years
5% it occurs after age 55 (late menopause)
5% between ages 40 to 45 years (early menopause)
Menopause prior to 40 is premature ovarian failure
Unlike menarche, the average age of menopause has not changed much over time
Factors that play a role in determining an individual woman’s age of menopause:
Genetics
Ethnicity
Smoking reduces by 2 years
Reproductive history (earlier without children)
Other factors

Question 3

How are hormones changing in early/late menopausal transition?

Answer 3

Early menopausal transition:
Menstrual irregularity begins
Inhibin B concentrations fall
Decline in follicular number
Serum FSH levels begin to rise
Relative preservation of E2 secretion (normal or high E2 levels) due to increased aromatase activity
Low luteal phase progesterone concentrations

Late menopausal transition:
Cycle variability increases
Remarkable fluctuations in serum FSH and E2 (high FSH and low E2 are suggestive but not evidence of menopause)
Ovarian follicle depletion, no E2 secretion but continued androgen production under LH stimulation

Question 4

What are the clinical manifestations of menopause?

Answer 4

1. Menstrual/hormonal irregularities
   - progesterone deficiency –> long term unopposed estrogen –> anovulation (biopsy if > 6months) –> endometrial hyperplasia possible
2. Vasomotor Problems
   - Hot flashes (75% of women but only 20% ask the doctor), early on, like pheochromocytoma-sudden bursts of sweats and redness, palpitations, several times/day, self limited, may cause sleep distrubances (which can also be primary)
3. Geniurinary symptoms
   - Dyspareunia
   - vaginal dryness (3%-50% of women post menopause)
   - atrophic vaginitis (dryness and itching)
   - pale, lack of rugae
   - Increase in pH
   - Increased risk of UTI (persistent/recurrent)
   - Sexual dysfunction (from decreased blood flow, lubrication from atrophy, neuropathy)
   - Decreased urethral seal (urinary and stress incontinence and urgency)
   - Depression (also nonhormonal contributions but decreases in postmenopause)
   - Breast tenderness and pain
4. Health changes - long term
   - osteoporosis/bone loss
   - cardiovascular disease
   - dementia

Question 5

What are the differential diagnoses with menopause?

Answer 5

Hyperthyroidism
-Irregular menses
-Sweats (different from hot flashes)
-Mood changes
Menstrual cycle changes
-Pregnancy
-Hyperprolactinemia
-Thyroid disease
Atypical hot flashes and night sweats
-Medications
-Carcinoid
-Pheochromocytoma
-Underlying malignancy

Question 6

What are the current recommendations on hormone therapy?

What are contraindications?

Answer 6

Postmenopausal hormone therapy is currently recommended for short-term management of moderate-to-severe vasomotor flushes
Long-term use for prevention of disease is no longer recommended
Short-term therapy is considered to be 2-3 years, and not more than 5 years

Doesn’t prevent cardiovascular disease

Meant to help in transition

Estrogen is used, progestin is added if no hysterectomy

Contraindications:
A history of breast cancer
Coronary heart disease
A previous venous thromboembolic event or stroke
Active liver disease
High risk for these complications

Both systemic and vaginal estrogen are effective for genitourinary atrophy symptoms, but vaginal estrogen may have more local effect without high systemic level