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 (Prevnar 13 and after 1 year, Pneumovax 23)
    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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