• 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.


  • • 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


  • • 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

      • • 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


      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
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