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Natural menopause: defined retrospectively after 12 consecutive months of amenorrhea in a nonpregnant woman ≥40 years of age:
Perimenopause/menopausal transition (MT): defined as the period from the onset of irregular menses to the final menstrual cycle. Begins on average 4 years before menopause. Starts at mean age of 47 years.
Postmenopause: usually >1/3 of a woman's life
Primary ovarian insufficiency: irregular or cessation of menses before age 40 years
The median age of menopause is 51 years.
5% of women undergo menopause after age 55 years; another 5% between ages 40 and 45 years.
Occurs earlier in Hispanic women and later in Japanese American women as compared with Caucasians
As women age, the number of ovarian follicles decreases: Ovarian production of estrogen varies and then decreases. Follicle-stimulating hormone (FSH) production varies and then increases.
Inadequate estradiol production leads to absence of the luteinizing hormone (LH) surge and failure to ovulate. These cycles result in anovulation and lack of progesterone production.
Eventual failure to produce estradiol leads to thinning of endometrial lining and eventual menses cessation.
Surgical menopause: Removal of functioning ovaries leads to immediate menopause.
Sex chromosome abnormalities (e.g., Turner syndrome and fragile X syndrome)
Family history of early menopause
Smoking (earlier age of onset by 2 years)
Chemotherapy and/or pelvic radiation (permanent or reversible)
Decrease risk of CVD by:
Decrease risk of osteoporotic fractures by:
Cessation of menses:
Vasomotor symptoms: sudden feeling of warmth, most commonly over face, neck, and chest, with average duration of ∽3 minutes; intervals unpredictable
Urogenital atrophy in up to 50% 2[B]:
Anxiety, depression: Some studies show a new diagnosis of depression is 2.5 times more likely to occur during the MT as compared to premenopause.
Sleep disturbance: Arousal from sleep and chronic insomnia may be linked with vasomotor symptoms.
Joint pain with unclear link to loss of estrogen
Change in intensity and severity of migraines
Skin thinning, mild hirsutism, brittle nails
Decrease in breast size and change in breast texture
External, speculum, and bimanual pelvic exams: atrophic vulva and vaginal mucosa; increased risk for uterine prolapse
U.S. Preventive Service Task Force (USPSTF) recommends mammogram every 2 years from ages 50 to 74 years.
Lab testing for menopause is not required; the patient's age and symptoms establish the diagnosis.
If laboratory confirmation is desired:
Estrogens, androgens, and oral contraceptive pills (OCPs) may alter lab results.
TSH and prolactin level if pituitary disease is suspected
Vaginal bleeding in a postmenopausal patient should be evaluated by transvaginal ultrasound (TVUS) and/or endometrial biopsy (EMB). If endometrial stripe is ≪5 mm on TVUS, EAC is unlikely.
USPSTF recommends bone mineral density (BMD) screening with dual energy x-ray absorptiometry (DEXA) scan in postmenopausal women >65 years, or ≪65 years if the risk for fracture is equivalent to that of a 65-year-old woman (using the FRAX tool to assess, http://www.shef.ac.uk/FRAX/). Risk factors include a previous history of fractures, low body weight, cigarette smoking, and family history of osteoporotic fracture.
Abnormal BMD and DEXA scan results:
Z-score measures age-matched mean bone density (not clinically useful).
The primary indication for HT is the treatment of moderate to severe vasomotor symptoms.
HT also helpful with sleep disorders, urogenital atrophy, and lowers risk of osteoporotic fractures and colorectal cancer; may help with mood symptoms.
In women with an intact uterus, give estrogen with progestin as unopposed estrogen carries an increased risk of EAC.
Treatment regimens include, but are not limited to:
MenoPro app is free for iPhones and iPad from The North American Menopause Society (NAMS). It has two modes: one for clinicians and one for patients to aid in shared decision making. It allows users to progress through questions to evaluate cardiovascular and reproductive organ cancer risk 3.
American Congress of Obstetricians and Gynecologists (ACOG) recommends HT should be individualized with lowest effect dose given for the shortest duration of time needed to relieve vasomotor symptoms. Lower doses have similar symptom reduction profiles for many patients. Results of ultra-low-dose regimens are mixed 4[A].
Although generally well tolerated, side effects of HT include breast tenderness, vaginal bleeding, bloating, and headaches.
For osteoporosis: women with a history of hip or vertebral fracture or personal history of osteoporosis should be treated with one of the following:
For vulvar/vaginal atrophy:
Although there is no increased risk of endometrial hyperplasia or EAC, women with bleeding on these treatments should be evaluated with TVUS or EMB. Patients with h/o hormone-dependent cancer should meet with a gynecologist before using medication.
Paroxetine (7.5 mg/day) is approved for treatment of vasomotor symptoms. This SSRI demonstrated modest decrease in hot flushes.
Other SSRI/SSNIs: venlafaxine (37.5 to 75 mg/day) or fluoxetine (20 mg/day) and citalopram (20 mg/day) shown to reduce hot flushes as compared to placebo
Gabapentin (300 to 900 mg/day) shown to have an effect on lowering hot flushes compared to placebo
Clonidine (.05 mg BID) may be used to treat mild hot flashes, less effective than SSRI/SRNIs.
Note that most trials of second-line therapies have been brief (i.e., a few months).
Soy isoflavone in placebo-controlled trials showed a mixed effect in reducing hot flashes.
Red clover, black cohosh, reflexology, aerobics, and magnet therapy showed no impact on hot flashes when compared with placebo.
Small clinical trials of evening primrose, dong quai, ginseng, and wild yam do not support use for relief of hot flashes.
Weight-bearing exercise >30 minutes, 3 times weekly
Healthy diet to maintain appropriate weight
Avoid excess alcohol.
Address cardiovascular risk factor modification.
Ultimate disappearance of vasomotor symptoms
Worsening of vaginal/vulvar atrophy
Osteoporosis: possible fractures of the hip, vertebrae, and wrists
Osteoporosis: At menopause, women have accelerated bone loss up to 3-5% per year for 5 to 7 years.
Increased risk of CVD following menopause
ACOG Practice bulletin no. 141: management of menopausal symptoms. Obstet Gynecol. 2014;123(1):202–216.
Grady D. Clinical practice. Management of menopausal symptoms. N Engl J Med. 2006;355(22):2338–2347.
Mørch LS, Løkkegaard E, Andreasen AH, et al. Hormone therapy and ovarian cancer. JAMA. 2009;302(3):298–305.
National Guideline Clearinghouse. Menopause. http://www.guideline.gov
Nelson HD. Commonly used types of postmenopausal estrogen for treatment of hot flashes: scientific review. JAMA. 2004;291(13):1610–1620.
North American Menopause Society. The 2012 hormone therapy position statement of the North American Menopause Society. Menopause. 2012;19(3):257–271.
U.S. Preventive Services Task Force. Screening for breast cancer, topic page. http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm. Accessed December 7, 2016.
E28.310 Symptomatic premature menopause
N95.1 Menopausal and female climacteric states
Z78.0 Asymptomatic menopausal state
E89.40 Asymptomatic postprocedural ovarian failure
E28.319 Asymptomatic premature menopause
E89.41 Symptomatic postprocedural ovarian failure
627.2 Symptomatic menopausal or female climacteric states
256.31 Premature menopause
627.4 Symptomatic states associated with artificial menopause
256.2 Postablative ovarian failure
289903006 Menopause present (finding)
237123000 Normal menopause (finding)
373717006 Premature menopause (finding)
21801002 menopausal symptom (finding)
278063007 Post-hysterectomy menopause (disorder)
278064001 Post-radiation menopause (disorder)
371036001 Postsurgical menopause (disorder)
123756000 Menopausal syndrome (disorder)
Menopause is usually diagnosed by history alone.
HT can be used short term for relief of moderate to severe vasomotor symptoms but should not be used for long-term prevention of CVD.