STEPHANIE CUMMINGS, MD

Menopause

Menopause

Defined as the permanent cessation of menstruation

Menopause is complete after one year without a menstrual period Postmenopausal

The average age of menopause in North America is 51 Affected by genetics and smoking

Serum follicle stimulating hormone (FSH) levels: 70-100

Late Reproductive Years

Typically women in their 40’s

Menstrual cycles are still ovulatory, but the follicular phase begins to shorten Shorter interval between menstrual periods

FSH begins to rise, but estradiol levels are still preserved

Perimenopause

Menopausal Transition

The years before menopause characterized by the physiologic changes associated with menopause

Fluctuations are seen in blood hormone levels Follicle stimulating hormone (FSH) rises Estradiol and progesterone decrease

Begins on average 4 years before the final menstrual period

Perimenopause

The intermenstrual interval begins to lengthen Normal: 25-35 days Perimenopause: 40-50 days

The early follicular FSH levels continue to rise

Changes in the menstrual cycle become more pronounced Skipped cycles Episodes of amenorrhea Increased frequency of anovulatory cycles

Perimenopause

During this time, some women experience heavy or prolonged bleeding Anovulatory cycles Prolonged exposure to unopposed estrogen

These symptoms are more common in women with fibroids and obese women

Menopausal Symptoms

Vasomotor symptoms Hot flashes/night sweats

Vaginal symptoms Vaginal dryness Vaginal atrophy

Sleep DisturbancesMood disorders

Vasomotor Symptoms

Hot flashes are the hallmark symptomThe sudden sensation of extreme heat in the

upper body that last 1-5 minutes Typically the neck, face, and chest

They occur several times per day, but can be as frequent as several times per hour

More commonly occur at night Night sweats

Associated with perspiration, flushing, clamminess, chills, anxiety, and at times palpitations

Vasomotor Symptoms

80% of women experience hot flashes Only 20-30% seek treatment

More than 80% of women who experience hot flashes will have them for more than one year Most will spontaneously resolve within 4-5 years

Physiology of Hot Flashes

MultifactorialDue to changes in reproductive hormones

Estrogen allow the body to tolerate a wider range of temperature changes without becoming symptomatic (the thermoregulatory zone)

During the menopausal transition, the body becomes more sensitive to subtle changes in core temperature

Sleep Disturbances

Many times due to vasomotor symptoms occurring at night

During the menopausal transition, new onset mood disorders can also contribute to insomnia Depression/anxiety

Also consider primary sleep disorders Sleep apnea Restless leg syndrome

Correcting vasomotor symptoms may not completely resolve sleep disturbances

Vaginal Symptoms

Vaginal dryness, atrophy, and itching

The cells lining the vagina and urethra are estrogen-dependent Estrogen deficiency leads to the thinning of the vaginal

epitheliumLoss of elasticity in the vagina leads to a

shortening and narrowing of the vagina The tissues also become more fragile and may tear

Loss of subcutaneous fat in the labia may result in narrowing of the introitus

Vaginal Symptoms

Vaginal pH becomes more alkaline Increased risk of urinary tract infections

Vaginal secretions may decrease May cause pain with intercourse In the early menopause transition, a slight decrease in

lubrication may be the first sign of decreasing levels of estrogen

May progress to vaginal dryness during daily activities

Long Term Effects of Estrogen Deficiency

Bone loss and osteoporosis

Cardiovascular disease and changes to the lipid profile

Skin changes

Limited data regarding dementia, arthritis, and balance

Bone Loss

Begins during the menopausal transition

Rates of bone loss appear to be the highest during the one year before through two years after the final menstrual period

Bone density screening should begin at age 65 unless a woman has significant risk factors History of a fragility fracture Weight less than 127 pounds Medical causes of bone loss (medications, diseases) Current smoker Alcoholism Parental medical history of a hip fracture Rheumatoid arthritis

Bone Loss

FRAX score Can be used in women under 65 to assess risk for fracture If risk of osteoporotic fracture is 9.3% (similar to a 65 year old

woman), a bone density scan is reasonable to order

Routine screening of newly menopausal women is not recommended

If treatment is started, a repeat scan should be done in 2 years

For women with normal testing at 65, a screening interval of 15 years is suggested

Cardiovascular Disease

Lipid profiles begin to change during the menopausal transition LDL levels increase HDL levels remain similar, but the protective effect

may decrease Triglycerides increase

Risk of cardiovascular disease increases after menopause Similar risk to males

Skin Changes

Collagen content of skin and bones is decreased due to lack of estrogen

Decreased collagen may lead to increased aging as well as wrinkling of the skin

References

The American College of Obstetricians and Gynecologists. Management of menopausal symptoms. Practice Bulletin 141. January 2014.

The American College of Obstetricians and Gynecologists. Osteoporosis. Practice Bulletin 129. September 2012.

Grady D. Clinical practice. Management of menopausal symptoms. N Engl J Med 2006;355:2338–47.

Freedman RR. Physiology of hot flashes. Am J Hum Biol 2001;13:453–64.

Casper R. Clinical manifestations and diagnosis of menopause. UpToDate. February 4, 2014

Casper F. Santen R. Menopausal hot flashes. UpToDate. January 2014.