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For further information, see CMDT Part 26-36: Normal Menopause

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


  • 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


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 ...

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