Menopause

Aka: Menopause, Perimenopause, Postmenopause

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II. Definitions

  1. Menopause
    1. Physiologic transition to cessation of Ovulation and Menstruation, and reduced ovarian endocrine function

III. 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)
    1. Worse with higher BMI, Tobacco use and black race
    2. Gold (2006) Am J Public Health 96(7): 1226-35 [PubMed]
  3. Atrophic Genitourinary Symptoms (50% of women)
    1. Vaginal Mucosa (Atrophic Vaginitis)
      1. Vaginal Dryness
      2. Vaginitis or vaginal Pruritus
      3. 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 [PubMed]
    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

IV. Labs

  1. See Markers of Ovarian Reserve
  2. Anti-Mullerian Hormone
  3. 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
  4. Thyroid Stimulating Hormone (TSH)
    1. Consider for atypical or young presentation
    2. Vasomotor (hot flash) symptoms predominate
  5. 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 [PubMed]

V. Differential Diagnosis

  1. See Hot Flushes
  2. See Secondary Amenorrhea
  3. See Anovulatory Bleeding
  4. See Vaginal Dryness

VI. 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

VII. Management: General Approach

  1. See Health Concerns in the Elderly
  2. See symptom management below for Menopause and Perimenopause
  3. Osteoporosis Prevention
    1. See Osteoporosis and Osteoporosis Management
    2. See Fall Prevention in the Elderly
    3. Calcium Supplementation at 1200 mg per day
    4. Vitamin D Supplementation 800-1000 IU per day
  4. Cardiovascular Disease Prevention
    1. Postmenopausal women have a higher Incidence of Angina and worse CAD outcomes than men
    2. Postmenopausal women have a higher Incidence of Heart Failure with Preserved Ejection Fraction (HFpEF)
    3. Reduce CVA, HFpEF and CAD Risk
      1. Control Hypertension, Atrial Fibrillation, Diabetes Mellitus, Tobacco Abuse, Obesity
    4. See Cardiac Risk Management
    5. See Exercise in the Elderly
    6. Tobacco Cessation
  5. Cerebrovascular Disease Prevention
    1. Manage Hypertension
      1. See Hypertension in the Elderly
    2. Manage Atrial Fibrillation
      1. See CHADS2-VASc Score
  6. Cancer Prevention
    1. Breast Cancer Screening
    2. Cervical Cancer Screening
    3. Colorectal Cancer Screening
  7. Immunizations
    1. Influenza Vaccine annually
    2. Herpes Zoster Vaccine for 1 dose routinely at age 60 years
    3. Pneumococcal Vaccine routinely at age 65 years (e.g. PCV21)
    4. Tetanus Vaccine (Tdap for at least 1 dose after age 19, then Td every 10 years)
  8. Sexual health
    1. Women are sexually active at least once weekly in >65% of cases
      1. Sherman (2005) J Women Aging 17(3): 41-55 [PubMed]
    2. Sexually Transmitted Infection occurs in at least 1% of women over age 65 years
      1. Smith (2009) Am J Public Health 99(11): 2055-62 [PubMed]
  9. Psychosocial Concerns
    1. See Depression in Older Adults
    2. See Alcohol Abuse
    3. See Intimate Partner Violence

VIII. Management: Menopausal Symptom Management (and Osteoporosis Prevention)

  1. Predominant Genitourinary Symptoms (e.g. Vaginal Dryness)
    1. See Atrophic Vaginitis
  2. Predominant Vasomotor Symptoms (e.g. Hot Flushes)
    1. See Vasomotor Symptoms of Menopause
  3. Estrogen Replacement Therapy (Hormone Replacement Therapy, HRT)
    1. Weigh risks (CAD, DVT, CVA, Breast Cancer) versus benefits (Osteoporosis, Hot Flashes)
      1. Consider for women under age 60 years old or within 10 years of Last Menstrual Period
        1. All cause mortality (including CAD risk) is not increased with HRT
          1. Manson (2017) JAMA 318(10): 927-38 [PubMed]
        2. Over age 60 years, HRT risks of CVA, MI, Dementia outweigh benefits
      2. Avoid when contraindicated
        1. Estrogen sensitive Breast Cancer
        2. Cardiovascular disease (CVA, CAD)
        3. Venous Thromboembolism history or Thrombophilia risk
        4. Unexaplained Vaginal Bleeding
    2. See Cardiac Risk Management
    3. See Estrogen Replacement for a general overview of risks, benefits and protocols
      1. Estrogen Replacement is recommended only for symptom control (e.g. Hot Flushes)
      2. ACOG and AAFP do not recommend Hormone Replacement for chronic disease prevention
      3. (2013) Obstet Gynecol 121(6): 1407-10 [PubMed]
      4. Manson (2013) 310(13): 1353-68 +PMID:24084921 [PubMed]
    4. See Specific Estrogen Replacement Options
      1. Continuous Estrogen Replacement
      2. Sequential Estrogen Replacement
      3. Vaginal Estrogen
      4. Transdermal Estrogen

IX. 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
      1. Risk of pregnancy (HRT doses are much lower than OCP doses and inadequate for Contraception)
  3. Evaluating end of Perimenopause for women on OCPs
    1. Identify when to switch to post-Menopause management
    2. Precaution
      1. Estrogen Replacement dosages are much lower than OCP doses and do NOT prevent pregnancy
      2. For women using OCPs for Contraception, transition to Estrogen Replacement should be carefully planned
    3. Protocol 1: Obtain Serum FSH on 6th day of OCPs Placebo pills
      1. Menopause suggested by FSH > 30 IU/L
    4. Protocol 2: Obtain Serum FSH and Estradiol level 2 weeks after stopping Oral Contraceptives
      1. Menopause suggested by a rise in FSH and no increase in Estradiol
      2. Castracane (1995) Contraception 52(6): 371-6 [PubMed]
    5. Protocol 3: Age based
      1. Likely safe to transition from OCP to Estrogen Replacement in mid-50s
      2. Allen (2013) CMAJ 185(7): 565-73 [PubMed]

X. Management: Adjunctive Therapy

  1. Precaution
    1. This is controversial and not generally recommended due to potential for adverse effects
  2. Estrogen Replacement does not improve the sexual negative effects of Menopause
    1. Testosterone Deficiency is associated with decreased Libido, sexual desire and orgasm
    2. DHEA-S Deficiency (as well as Hippocampus changes) are associated with decreased concentration and memory
  3. Consider Androgen Replacement in Women
    1. Testosterone Replacement in Women
    2. DHEA Replacement in Women
  4. 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

XI. Management: Other agents

  1. See Vasomotor Symptoms of Menopause
  2. New agents
    1. Amberen (not recommended)
      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

XII. References

  1. Shuer (2001) CMEA Medicine Lecture, San Diego
  2. Baill (2017) Am Fam Physician 95(9): 561-70 [PubMed]
  3. Chang (2023) Am Fam Physician 108(1): 28-39 [PubMed]
  4. Greenblatt (1972) J Am Geriatr Soc 20:49 [PubMed]
  5. Hill (2016) Am Fam Physician 94(11): 884-9 [PubMed]
  6. Orentreich (1984) J Clin Endocrinol Metab 59:551 [PubMed]
  7. Seeman (1997) Am J Psychiatry 154:1641-7 [PubMed]
  8. Shifren (2000) N Engl J Med 343:682-8 [PubMed]

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Related Studies

Ontology: Menopause (C0025320)

Definition (GO) Cessation of menstruation, occurring in (e.g.) the human female usually around the age of 50. [GOC:curators, PMID:18495681]
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 ovaries stop 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.

Dept. of Health and Human Services Office on Women's Health
Definition (NCI_CTCAE) 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 (NCI_NCI-GLOSS) 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 (NCI) The permanent cessation of menses, usually defined by 6 to 12 months of amenorrhea in a woman over 45 years of age.
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.
Concepts Physiologic Function (T039)
MSH D008593
SnomedCT 198435007, 161712005, 81785007, 138977003
English Menopausal, Change of Life, Female, Female climacteric state, function, Menopause, function, menopause (diagnosis), menopause, Menopause [Disease/Finding], change life, life change, changes life, menopausal state, female climacteric, female climacteric state, change of life, menopausal, climacteric, climacteric female, life changes, Menopause, Change of life, Change of Life, Menopause (finding), Menopause (observable entity), Female climacteric, Female climacteric state, Menopausal state, "Change of life", The change, Female climacteric state, function (observable entity), Menopause, function (observable entity), menopausal; state, state; menopausal, Menopause, NOS, Female climacteric state (qualifier value), Menopause (finding) [Ambiguous], Menopause (qualifier value)
Spanish menopausia, función, Menopaúsico, menopausia (hallazgo), estado climatérico femenino, climaterio femenino, climaterio, el cambio, estado menopáusico, menopausia (calificador), menopausia (concepto no activo), menopausia (entidad observable), 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
Norwegian Menopause, Kvinnens overgangsalder
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Postmenopause (C0206159)

Definition (MSH) The physiological period following the MENOPAUSE, the permanent cessation of the menstrual life.
Definition (CSP) period following menopause, permanent cessation of menstruation; often refers to women of late middle age or older.
Concepts Organism Function (T040)
MSH D017698
English Post-Menopause, Post-menopausal Period, Postmenopausal Period, Postmenopause, Period, Post-menopausal, Period, Postmenopausal, Post Menopause, Post menopausal Period, Post-Menopauses, postmenopause, post menopause, menopause post, Post-menopause, post menopausal period, post-menopause
Swedish Postmenopaus
Japanese ﾍｲｹｲｺﾞ, 閉経後
Czech postmenopauza, Postmenopauza
Finnish Tasannevuodet
French Post-ménopause, Postménopause, Période post-ménopausique, Période postménopausique
Russian POSTMENOPAUZA, POSTKLIMAKTERICHESKII PERIOD, ПОСТКЛИМАКТЕРИЧЕСКИЙ ПЕРИОД, ПОСТМЕНОПАУЗА
Italian Post-menopausa, Periodo postmenopausale, Postmenopausa
Croatian POSTMENOPAUZA
Polish Okres pomenopauzalny
Hungarian Posztmenopauza
Portuguese Pós-manopáusico, Pós-Menopausa
Spanish Postmenopausia, Posmenopausia
Dutch postmenopauze, Postmenopauze
German Postmenopause
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: 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
Derived from the NIH UMLS (Unified Medical Language System)

Related Topics in Endocrinology

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