Menopause is technically the last menstrual period and can only be identified retrospectively. Menopause transition is a more helpful concept, describing the time from onset of menstrual irregularity to one year after the last period, when the woman becomes postmenopausal. The change is driven by the depletion of functional oocytes.
Age at the last spontaneous period is about 51.5 years in the developed world. This occurs earlier in less developed nations through the influence of disease and poor nutrition.
Infection, autoimmune disease, vascular compromise, drugs, chemotherapy, radiotherapy and surgery may influence and result in earlier cessation of ovarian function.
Menopausal symptoms are attributed to tissue sensitivity to lower estrogen levels. This primarily affects the estrogen receptors in the brain. Vasomotor symptoms of hot flushes and night sweats are attributed to a loss of homeostasis by the central thermoregulatory centre, which subsequently over-reacts to small changes in core body temperature. Sleep disturbance, mood change, concentration and word finding difficulty are also brain-mediated effects.
The experience of women varies widely, with some being debilitated and others unaffected by their symptoms. Some women experience symptoms while still menstruating and others not until a year or more after their last bleed.
Urogenital symptoms arise directly from loss of the trophic effect of estrogen. Vaginal dryness, loss of elasticity, poor sexual response and painful penetration may lead to aversion to intercourse, with relationship consequences.
Urinary frequency, nocturia, bladder irritability and an increased tendency to urinary infection are also described, but not nearly often enough. Research shows that urogenital atrophy is significantly under-reported and undertreated. Symptoms may not be problematic until five to 10 years postmenopause and should not automatically be attributed to the woman's age.
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Diagnosis, which is primarily clinical, is based on the menstrual pattern and symptoms described. Although gonadotrophin measurement can support a clinical hypothesis, this is not diagnostic.
Serum FSH >30IU/L is taken as significant although it can occur at ovulation in a normal cycle. Simultaneous estradiol will help to distinguish between these situations. A single sample provides little information about ovarian status or menopausal stage - a minimum of two consistent results taken four to six weeks apart is needed to indicate sustained ovarian unresponsiveness.
Such serial testing may be helpful when the bleeding pattern is obscured, such as after hysterectomy or with a levonorgestrel intrauterine system (LNG-IUS) in place. Contraceptive methods that block the FSH rise, such as combined hormones or depot medroxyprogesterone acetate, render this test useless.
3. Initial advice
Women should receive sufficient information to help them understand what is happening and allow them to make informed decisions.
Menopause marks the end of the reproductive phase and is a clear biological marker. It is an ideal opportunity to review health status and make lifestyle changes to reduce the risks of malignant and degenerative diseases in subsequent years.
Weight loss, an increase in exercise, a healthy diet, stopping smoking and reduced alcohol and caffeine intake can mitigate the symptoms of menopause, but may do much more and are to be encouraged.
4. Herbal products
A variety of 'natural' products promise salvation from menopause but the evidence base for these is poor.
Black cohosh may provide some relief in flushes and sweats but the effect is not maintained to 12 months.
Red clover contains phytoestrogens (low-potency plant-derived estrogenic compounds) and hence low-grade improvement may occur. There can be a significant placebo response.
If one patient reports complete resolution with a particular product, it will not necessarily work for another.
5. Hormone replacement
Women who have significant symptoms or are prematurely menopausal should be made aware of the option of hormone therapy. Estrogen replacement remains the most effective means to reduce symptoms attributable to deficiency; it also prevents and reverses bone loss and offers a variety of other benefits. Improved quality of life and ability to cope may not be easy to measure, but are important outcomes.
Estrogen can be either oral or transdermal; the choice about which to use should follow discussion of the patient's profile and preferences.
Where it is important to avoid hepatic first pass metabolism or direct gut effects, or to keep thrombotic influence to a minimum, the transdermal route is preferred. Generally, a low dose is given initially, with upward titration to the lowest effective dose.
Women who still have their uterus (even after endometrial ablation) need additional progestogen to prevent hyperplasia and malignant transformation. If starting within a year of the last bleed, a cyclical regimen should be used. Later initiation should be continuous to give best endometrial protection.
Review after three months allows adjustment of the treatment regimen if indicated.
Annual review is the minimum recommended. This should include review of residual symptoms, background health status and developments to the evidence base.
It is recommended that cyclical regimens should be changed to continuous within five years. An LNG-IUS provides adequate opposition at all stages of menopause. Low-potency vaginal estrogens can be used unopposed to relieve symptoms of urogenital atrophy. Allow three months for symptom relief, by which point serum levels are within postmenopausal norms.
It is preferable to use these products continuously. Stopping and starting not only allows symptoms to return, but also results in higher levels of absorption through an atrophic vaginal epithelium. They can be used in addition to systemic therapy if the latter fails to relieve the patient's bladder or vaginal symptoms.
Women should be offered the opportunity to discuss their menopausal experience and balance the risks and benefits of all available options before any decision is made about therapy.
- Dr Gray is a GPSI in women's health in Truro, Cornwall.