Gynecology Book

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Menopause

Aka: Menopause, Perimenopause
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  1. Symptoms: Perimenopause (lasts 3-8 years)
    1. Disturbance in menstrual pattern
      1. Shorter menstrual interval
      2. Heavier menstrual flow
    2. Hot Flashes (50-75% of women)
    3. Atrophic conditions (responds to Estrogen)
      1. Vaginal Mucosa (Atrophic Vaginitis)
        1. Vaginitis or vaginal Pruritus
        2. Dyspareunia
      2. Urethritis
        1. Dysuria, urgency, or urinary frequency
        2. Recurrent Urinary Tract Infection
    4. Neuropsychological changes
      1. Major Depression
        1. Estrogen Replacement efficacious as Antidepressant
        2. Soares (2001) Arch Gen Psychiatry 58:529-34
      2. Insomnia
      3. Hippocampus changes
        1. Decreased memory
        2. Decreased learning
        3. Decreased navigation or way finding
    5. Testosterone Deficiency (worse in surgical Menopause)
      1. Decreased energy and sense of well being
      2. Decreased sexual desire, arousability, and orgasm
        1. Decreased clitoral sensitivity
        2. Decreased nipple sensitivity
      3. Thinning of pubic hair
  2. Labs
    1. Follicle Stimulating Hormone (FSH)
      1. Not necessary to confirm diagnosis
      2. May be indicated for perimenopausal women age <45
      3. FSH >25 mIU/ml confirms Perimenopause or Menopause
        1. Measure on any day if patient is not having Menses
        2. Measure on Day 3 of cycle in menstruating women
        3. Measure Day 6-7 of Oral ContraceptivePlacebo week
          1. Confirms Birth Control no longer needed
    2. Thyroid Stimulating Hormone (TSH)
      1. Consider for atypical or young presentation
      2. Vasomotor (hot flash) symptoms predominate
    3. Vaginal pH
      1. pH > 4.5 indicates Menopause
        1. Women without Vaginitis and not receiving HRT
      2. pH <4.5
        1. Can be used to monitor for adequate HRT response
      3. References
        1. Roy (2004) Am J Obstet Gynecol 190:1272-7
  3. Diagnosis
    1. Serum FSH level are not necessary in age over 45 years
    2. Perimenopause: Hot Flashes and irregular Menses
    3. Menopause: Hot Flashes and no Menses for 6 months
  4. Management: General Approach
    1. See symptom management below for Menopause and Perimenopause
    2. Osteoporosis Prevention
      1. See Osteoporosis and Osteoporosis Management
      2. Calcium Supplementation at 1500 mg per day
      3. Vitamin D Supplementation 800-1000 IU per day
    3. Cardiovascular Disease Prevention
      1. See Cardiac Risk Management
      2. See Exercise in the Elderly
      3. Tobacco Cessation
    4. Cancer Prevention
      1. Breast Cancer Screening
      2. Cervical Cancer Screening
      3. Colorectal Cancer Screening
      4. Immunization
  5. Management: Menopausal Symptom Management (and Osteoporosis Prevention)
    1. See alternatives for Vasomotor Symptoms of Menopause
    2. Estrogen Replacement Therapy
      1. Weigh risks (CAD, DVT, CVA, Breast Cancer) versus benefits (Osteoporosis, Hot Flashes)
      2. See Cardiac Risk Management
      3. See Estrogen Replacement for a general overview of risks, benefits and protocols
      4. See Specific Estrogen Replacement Options
        1. Continuous Estrogen Replacement
        2. Sequential Estrogen Replacement
        3. Vaginal Estrogen
        4. Transdermal Estrogen
  6. Management: Perimenopausal Symptom management
    1. See Vasomotor Symptoms of Menopause
    2. Agents
      1. Provera 5-10 mg for 12 days per month
        1. Prevents Endometrial Hyperplasia
      2. Oral Contraceptives (OCP)
        1. Choose continuous low Estrogen option (e.g. Lo Loestrin Fe)
      3. Levonorgestrel IUD (Mirena)
        1. Stops Menstrual Bleeding but risk of atrophy
      4. Sequential Hormone Replacement
    3. Evaluating end of Perimenopause for women on OCPs
      1. Identify when to switch to postmenopause management
      2. Obtain Serum FSH on 6th day of OCPs Placebo pills
      3. Menopause suggested by FSH > 30 IU/L
  7. Management: Adjunctive Therapy
    1. Consider Androgen Replacement in Women
      1. Testosterone Replacement in Women
      2. DHEA Replacement in Women
    2. Combination Preparations
      1. E2P4T (Estrogen, Progesterone, Testosterone)
        1. Available from compounding pharmacies
      2. DHEA-S (see DHEA-S Replacement in Women)
        1. Used with the E2P4T
  8. Management: Other agents
    1. See Vasomotor Symptoms of Menopause
    2. Complimentary and Alternative Medicine (Variable efficacy)
      1. Phytoestrogens
      2. Dong Quai
      3. Yam extract
      4. Black Cohosh
    3. New agents
      1. Amberen
        1. Combination of multiple components (calcium, Magnesium, Vitamin E, Zinc, Ammonium Succinate)
        2. No evidence of benefit and expensive
        3. (2013) Presc Lett 20(2): 11
  9. References
    1. Greenblatt (1972) J Am Geriatr Soc 20:49
    2. Orentreich (1984) J Clin Endocrinol Metab 59:551
    3. Seeman (1997) Am J Psychiatry 154:1641-7
    4. Shifren (2000) N Engl J Med 343:682-8
    5. Shuer (2001) CMEA Medicine Lecture, San Diego

Menopause (C0025320)

Definition (NCI) A disorder characterized by the permanent cessation of menses, usually defined by 12 consecutive months of amenorrhea in a woman over 45 years of age.
Definition (MEDLINEPLUS)

Menopause is the time in a woman's life when her period stops. It usually occurs naturally, most often after age 45. Menopause happens because the woman's ovary stops producing the hormones estrogen and progesterone.

A woman has reached menopause when she has not had a period for one year. Changes and symptoms can start several years earlier. They include

  • A change in periods - shorter or longer, lighter or heavier, with more or less time in between
  • Hot flashes and/or night sweats
  • Trouble sleeping
  • Vaginal dryness
  • Mood swings
  • Trouble focusing
  • Less hair on head, more on face

Some symptoms require treatment. Talk to your doctor about how to best manage menopause. Make sure the doctor knows your medical history and your family medical history. This includes whether you are at risk for heart disease, osteoporosis, or breast cancer.

National Women's Health Information Center
Definition (NCI) The time of life when a woman's ovaries stop producing hormones and menstrual periods stop. Natural menopause usually occurs around age 50. A woman is said to be in menopause when she hasn't had a period for 12 months in a row. Symptoms of menopause include hot flashes, mood swings, night sweats, vaginal dryness, trouble concentrating, and infertility.
Definition (GO) Cessation of menstruation, occurring in (e.g.) the human female usually around the age of 50. [GOC:curators, PMID:18495681]
Definition (MSH) The last menstrual period. Permanent cessation of menses (MENSTRUATION) is usually defined after 6 to 12 months of AMENORRHEA in a woman over 45 years of age. In the United States, menopause generally occurs in women between 48 and 55 years of age.
Definition (CSP) cessation of menstruation in the human female, usually occurring around the age of 50.
Definition (NCI) The permanent cessation of menses, usually defined by 6 to 12 months of amenorrhea in a woman over 45 years of age.
Concepts Physiologic Function (T039)
MSH D008593
SnomedCT 198435007, 161712005, 81785007, 138977003
English Climacteric, female, CLIMACTERIC, FEMALE, MENOPAUSE, Menopausal, Menopause, NOS, Change of Life, Female, Female climacteric state, function, Menopause, function, menopause (diagnosis), menopause, Menopause (finding), Menopause (observable entity), Change of life, MENOPAUSAL, Menopause [Disease/Finding], change life, life change, changes life, menopausal state, female climacteric, female climacteric state, change of life, climacteric, climacteric female, life changes, Change of Life, Menopause, Female climacteric, Female climacteric state, Menopausal state, "Change of life", The change, Female climacteric state, function (observable entity), Menopause, function (observable entity), menopausal; state, menopausal, state; menopausal, Female climacteric state (qualifier value), Menopause (finding) [Ambiguous], Menopause (qualifier value)
Spanish menopausia, función, Menopaúsico, Menopause, climaterio femenino, climaterio, el cambio, estado climatérico femenino, estado menopáusico, menopausia (calificador), menopausia (concepto no activo), menopausia (entidad observable), menopausia (hallazgo), menopausia, función (entidad observable), menopausia, perimenopausia (calificador), perimenopausia (entidad observable), perimenopausia, Menopausia, Cambio de Vida Femenina
Dutch menopauzaal, menopauze; toestand, toestand; menopauzaal, menopauze, Menopauze, Overgang
French Ménopausique, Ménopause
German menopausal, Menopause, Wechseljahre, weibliche
Italian Menopausale, Menopausa
Portuguese Menopáusico, Menopausa, Mudança de Vida Feminina
Swedish Menopaus
Japanese ﾍｲｹｲ, ﾍｲｹｲｷ, 閉経, 月経閉止, 閉経期
Czech menopauza, Menopauzální, Menopauza
Finnish Menopaussi
Russian MENOPAUZA, МЕНОПАУЗА
Croatian MENOPAUZA
Polish Menopauza, Zanik miesiączki, Ustanie miesiączkowania
Hungarian Menopauza
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Perimenopause (C0993589)

Definition (MSH) The transitional period before and after MENOPAUSE. Perimenopausal symptoms are associated with irregular MENSTRUAL CYCLE and widely fluctuated hormone levels. They may appear 6 years before menopause and subside 2 to 5 years after menopause.
Concepts Physiologic Function (T039)
MSH D047648
SnomedCT 198435007
Dutch perimenopauze, Perimenopauze
Japanese 閉経周辺期, ﾍｲｹｲｼｭｳﾍﾝｷ
Swedish Perimenopaus
Czech perimenopauza, Perimenopauza
Finnish Perimenopaussi
Russian PERIMENOPAUZA, ПЕРИМЕНОПАУЗА
English perimenopause (diagnosis), perimenopause, premenopause, Perimenopause
Polish Okres okołomenopauzalny
Hungarian Perimenopauza
French Périménopause
German Perimenopause
Italian Perimenopausa
Portuguese Perimenopausa
Spanish Perimenopausia
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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