Menopause, Normal

Key Features

Essentials of Diagnosis

• Menopause is a retrospective diagnosis after 12 months of amenorrhea

• Approximately 80% of women experience hot flushes and night sweats

• High FSH and low estradiol help confirm the diagnosis

General Considerations

• Normal menopause refers to primary ovarian failure that occurs after age 45

• "Climacteric"

  • Defined as the period of natural physiologic decline in ovarian function, generally occurring over about 10 years

  • Estradiol levels may actually rise during early climacteric

• 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

• The normal age for menopause in the United States ranges between 48 and 55 years, with an average of about 51.5 years

Clinical Findings

• Cessation of menstruation

  • Menstrual cycles generally become irregular as menopause approaches

  • 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++

• Vasomotor symptoms

  • Hot flushes (feelings of intense heat over the trunk and face, with flushing of the skin and sweating) occur in > 80% of women as a result of the decrease in ovarian hormones

  • Vasomotor symptoms last more than 7 years in > 50% of women

  • Black American women report the longest duration of vasomotor symptoms

• Genitourinary syndrome of menopause (GSM)++

  • Dryness, dyspareunia, burning, and pruritus

  • Urinary frequency, urgency, dysuria, and an increased risk of urinary tract infections

  • GSM does not tend to improve over time, in contrast to menopausal hot flushes

  • Pelvic examination reveals

    • Pale, smooth vaginal mucosa

    • Small cervix and uterus

    • Ovaries are not normally palpable after menopause

• Other menopausal manifestations

  • Over 60% of women experience cognitive problems, particularly during the menopausal transition

  • Most commonly, perimenopausal women complain of difficulty retrieving words and short-term forgetfulness (such as not remembering why they entered a room or misplacing keys or glasses)

  • There is an increased incidence of sleep disturbance and mood changes

  • Postmenopausal osteoporosis presents later in menopause with fragility fractures of long bones and vertebrae

Diagnosis

• No laboratory testing is required

• An elevated serum FSH with a low or low-normal serum estradiol helps confirm the diagnosis

• A vaginal cytologic examination will show a low estrogen effect with predominantly parabasal cells, indicating lack of epithelial maturation due to hypoestrogenism

Treatment

Non-estrogen treatments

• Women with night sweats should sleep in a cool room and avoid the use of down comforters

• Eliminating triggers for hot flushes, such as smoking, alcohol, caffeine, and hot spicy foods, may be helpful

• Slow, deep breathing can ameliorate hot ...