Menopause

DEFINITION

• Stages of Reproductive Aging Workshop (STRAW) Staging System 2001

• 1) Menopausal transition: a) Variation in menstrual cycle ( > 7 d different from normal) and ≥2 skipped cycles and >=60 d amenorrhea; b) FSH
• 2) Perimenopause: Starts at the time of the menopausal transition ( see above) and ends 12 months after last menstrual period
• 3) Menopause: 12 months of amenorrhea after final menses
• 4) Postmenopause: Stage 1 is the first 5 years after menopause – women have bone loss and hot flashes. Stage 2 is 5 yrs after the last menstrual period until death.

Etiology/Endocrinology

• • Menopause occurs due to programmed loss of ovarian follicles
• • During perimenopause inhibin B falls due to decline in follicular number and FSH rises, estradiol preserved, low progesterone
• • In late menopausal transition, FSH and estradiol fluctuate
• • After menopause, ovary no longer secretes estradiol, however produces androgens under the stimulation of LH

EPIDEMIOLOGY

• • Average age of menopause is app. 51.4 years; menopause prior to age 40 is premature ovarian failure
• • Age of menopause reduced in smokers
• • Ethnicity and race may influence menopause, earlier age among Hispanic women and later in Japanese-American women when c/w Caucasian
• • Important to assess family history of early menopause

CLINICAL MENIFESTETION

• • Hot flashes- Etiology unknown. Thermoregulatory dysfunction. Self limited to 1-5 yrs. Variable among cultures – 75% US women complain of hot flashes, 20% seek therapy.
• • Irregular bleeding patterns- if heavy bleeding should perform endometrial surveillance given period of unopposed estrogen exposure
• • Sleep disturbance – Hot flashes can arouse from sleep and primary sleep disorders more common
• • Vaginal dryness – Estrogen deficiency leads to thinning of epithelium – > vaginal atrophy ( loss of rugae, pale, pH inc to > 6.0)
• • Sexual dysfunction – decrease in blood flow to vagina/vulva -> decreased lubrication; dyspareunia
• • Urinary sx – low estrogen results in atrophy of urethral epithelium and predispose to stress/urge urinary incontinence
• • Depression – Overall studies support an association between menopause and mood changes such as irritability/nervousness; controversial if related to true depression
• • Bone loss – secondary to estrogen def
• • Breast pain – Common in early menopausal transition
• • Skin changes – estrogen def -> reduced collagen content of the skin/bones

THERAPEUTICS

moderate/severe vasomotor sx only

• • Estrogen – most effective; po or transdermal; if women has uterus give in conjunction with progesterone; short term therapy; taper to end
• • Behavioral changes – keeping temp cool, regular exercise, relaxation therapy
• • SSRIs – One of first choices if not taking HRT. RCT’s have shown benefit
• • Gabapentin- suggested for nocturnal hot flashes
• • Progestins – Megestrol acetate, norethindrone acetate, high dose DMPA shown to be effective
• • Clonidine – effective in some trials; try transdermal; may be good in women with HTN
• • Phytoestrogens – NO more effective than placebo; concern is that they are SERMS
• • Herbal/Black Cohosh – No more effective than placebo; may have estrogenic effect on breast