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ESSENTIALS OF DIAGNOSIS
Menopause is a retrospective diagnosis after 12 months of amenorrhea.
Approximately 80% of women will experience hot flushes and night sweats.
Elevated follicle-stimulating hormone (FSH) and low estradiol can help confirm the diagnosis.
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GENERAL CONSIDERATIONS
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The term “menopause” denotes the final cessation of menstruation, either as a normal part of aging or as the result of surgical removal of both ovaries. In a broader sense, as the term is commonly used, it denotes a 1- to 3-year period during which a woman adjusts to a diminishing, and then absent, menstrual flow and the physiologic changes that may be associated with lowered estrogen levels—hot flushes, night sweats, and vaginal dryness.
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The average age at menopause in Western societies is 51 years. Premature menopause is defined as ovarian failure and menstrual cessation before age 40; this often has a genetic or autoimmune basis. Surgical menopause due to bilateral oophorectomy is common and can cause more severe symptoms owing to the sudden rapid drop in sex hormone levels.
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There is no objective evidence that cessation of ovarian function is associated with severe emotional disturbance or personality changes. However, mood changes toward depression and anxiety can occur at this time. Disruption of sleep patterns associated with the menopause can affect mood and concentration and cause fatigue. Furthermore, the time of menopause often coincides with other major life changes, such as departure of children from the home, a midlife identity crisis, or divorce.
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A. Symptoms and Signs
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1. Cessation of menstruation
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Menstrual cycles generally become irregular as menopause approaches. Anovulatory cycles occur more often, with irregular cycle length and occasional menorrhagia. Menstrual flow usually diminishes in amount owing to decreased estrogen secretion, resulting in less abundant endometrial growth. Finally, cycles become longer, with missed periods or episodes of spotting only. When no bleeding has occurred for 1 year, the menopausal transition can be said to have occurred. Any bleeding after 6 months of the cessation of menses warrants investigation by endometrial curettage or aspiration to rule out endometrial cancer.
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Hot flushes (feelings of intense heat over the trunk and face, with flushing of the skin and sweating) occur in over 80% of women as a result of the decrease in ovarian hormones. Hot flushes can begin before the cessation of menses. Menopausal vasomotor symptoms last longer than previously thought, and there are ethnic differences in the duration of symptoms. Vasomotor symptoms last more than 7 years in more than 50% of the women. African-American women report the longest duration of vasomotor symptoms. The etiology of hot flushes is unknown. Occurring at night, they often cause sweating and insomnia and result in fatigue on the following day.
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