26-36: Normal Menopause

ESSENTIALS OF DIAGNOSIS

GENERAL CONSIDERATIONS

Normal menopause refers to primary ovarian failure that occurs after age 45. “Climacteric” is defined as the period of natural physiologic decline in ovarian function, generally occurring over about 10 years. By about age 40 years, the remaining ovarian follicles are those that are the least sensitive to gonadotropins. Increasing titers of FSH are required to stimulate estradiol secretion. Estradiol levels may actually rise during early climacteric.

The normal age for menopause in the United States ranges between 48 and 55 years, with an average of about 51.5 years. Serum estradiol levels fall and the remaining estrogen after menopause is estrone, derived mainly from peripheral aromatization of adrenal androstenedione. Such peripheral production of estrone is enhanced by obesity and liver disease. Individual differences in estrone levels partly explain why the symptoms noted above may be minimal in some women but severe in others.

CLINICAL FINDINGS

A. Symptoms and Signs

1. Cessation of menstruation

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 from the cessation of menses warrants investigation by endometrial curettage or aspiration to rule out endometrial cancer.

2. Vasomotor symptoms

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. Black American women report the longest duration of vasomotor symptoms. Hot flushes occur more frequently at night, causing sweating and insomnia that result in fatigue on the following day.

3. Genitourinary syndrome of menopause (GSM)

Decreased estrogen secretion results in less vaginal lubrication and vulvovaginal atrophy with dryness, dyspareunia, burning, and pruritus. Estrogen deficiency also causes urinary frequency, urgency, dysuria, and an increased risk of UTIs. GSM does not improve over time, in contrast to hot flushes. Pelvic examination reveals pale, smooth vaginal mucosa and a small cervix and uterus. The ovaries ...