Pocket ObGyn – Menopause
See Abbreviations
Definitions and Epidemiology (Fertil Steril 2012;97(4):843)
- Final menstrual period (FMP) defined by 12 mo of amenorrhea from a loss of ovarian Perimenopausal transition: Wide fluctuation in hormonal profiles; irreg cycle length; quantitative FSH of >25 IU/mL on a random bld sample.
- FMP at <40 y = premature menopause (~1%)
- Growing number of menopausal 37.9 million over 55 yo (2010) ® 45.9 M (2020).
- Median age 4 y (Am J Epidemiol 2001;153:865). Gaussian distribution of 40–58 y.
- Leading cause of mortality is cardiovascular dz related (45%) > stroke >
Figure 5.5 Stages of reproductive aging
| Stage | –5 | –4 | –3b | –3a | –2 | –1 | +1a | +1b | +1c | +2 |
| Terminology | REPRODUCTIVE | MENOPAUSAL
TRANSITION |
POSTMENOPAUSE | |||||||
| Early | Peak | Late | Early | Late | Early | Late | ||||
| Perimenopause | ||||||||||
| Duration | Variable | Variable | 1–3 yr | 2 yr
(1+1) |
3–6 yr | Remaining
lifespan |
||||
| PRINCIPAL CRITERIA | ||||||||||
| Menstrual cycle | Variable to regular | Regular | Regular | Subtle changes in flow/ Length | Variable length persistent
≥7-day difference in length of consecutive cycles |
Interval of amenorrhea of >–60 days | ||||
| SUPPORTIVE CRITERIA | ||||||||||
| Endocrine FSH AMH
inhibin B |
Low Low |
Variable* Low Low |
Variable* Low Low |
>25 IU/L** Low Low |
Variable* Low Low |
Stabilizes Very Low Very Low |
||||
| Antral follicle
count |
Low | Low | Low | Low | Very Low | Very Low | ||||
| DESCRIPTIVE CHARACTERISTICS | ||||||||||
| Symptoms | Vasomotor symptoms
Likely |
Vasomotor symptoms
Most likely |
Increasing
symptoms of urogenital atrophy |
|||||||
*Blood draw on cycle days 2–5 – elevated
**Approximate expected level based on assays using current international pituitary standard
(From Harlow SD, Gass M, Hall JE, et al. Executive summary of the stages of reproductive aging workshop + 10: Addressing the unfinished agenda of staging reproductive aging. Fertil Steril. 2012;97(4):843–851)
Etiology
- Reproductive axis is a negative neuroendocrine feedback loop. Reduced quality & quantity of aging follicles ® ¯ inhibin & ¯ ovarian estrogen ® FSH ® accelerated loss of ovarian follicles ® depleted ovarian follicle supply® ovarian senescence
- a- & b-estrogen receptors are located throughout the body; ¯ estrogen ®
Clinical Manifestations
- Vasomotor instability: Hot flushes & night sweats (~75%); most common during late menopausal transition (Stage –1) through early postmenopausal period (Stage
+1). Self-limited w/ resolution in 1st 5 postmenopausal years; 25% symptomatic >5 y; high variability among individuals & cx.
- Urogenital atrophy: Pruritus, recurrent UTI, vaginal neuropathy in the distribution of pudendal nerve, sexual dysfxn, dyspareunia (up to 75%); most common during late postmenopause (Stage +2)
- Alterations in menstrual patterns: Chronic anovulation ® heavy dysfunctional bleeding during late reproductive stage (Stage –3a) & menopausal transition (Stages –2, –1)
- Infertility secondary to oocyte depletion
- Increased cardiovascular dz risk: total cholesterol, markedly LDL-C.
- Accelerated bone loss: Spine bone density ¯ by 15–30% in 1st 5–7 postmenopausal Thereafter, it is 1–2% per year as compared to premenopausal bone loss rate of 13% per year. The effect is predominantly on trabecular bone (Hormone Therapy 2010;115(4):844).
- Decreased collagen support: ¯ skin collagen by 30% in 1st 5 years after There is an ~2% ¯ per year for the 1st 10 y after established menopause.
- Increased endometrial & breast cancer risk d/t unopposed endogenous estrogen production
Physical Exam
- Habitus, race, serial Pelvic exam:Vagina may appear thin, pale, dry, inflamed, lack rugae, petechial hemorrhages, cervical atrophy, narrowed or shortened vagina is a possibility; urethral caruncle may be present.
Diagnostic Workup/Studies
- Clinical dx from longitudinal assessment of absence of menses over 12
- Risk assessment for CVD (lifestyle, FHx, lipid profile) & DEXA scan of the hip & vertebrae w/ resultant T-score (1–2% accuracy & precision). BMD may be used to diagnose osteoporosis, predict fracture risk & identify who would benefit from therapy. See Chap. 1 Osteoporosis.
Treatment and Medications
- Perimenopausal transition: Prolonged maximal physical energy, social & mental
- VMSx classified mild (transient heat), mod (heat + sweating + permits continuation of activity), sev (heat + sweating + discontinuation of activity). Mod–sev VMSx = 7 hot flashes/d or 50–60 per HRT most effective for VMSx therapy (see section below).
- Mild urogenital atrophic sx, vaginal moisturizing agents on a regular basis before bedtime several times weekly & lubricants during intercourse, regular sexual
- Urogenital atrophy: Systemic ET is the most effective for mod–sev sx; local vaginal Est Rx (rings, creams, tablets) w/ minimal systemic absorp & increased safety up to 1 Long-term effects lacking (Obstet Gynecol 2010;115(4):843).
| Treatment for menopausal atrophic vaginal/genitourinary symptoms | |
| Vaginal estrogen preparations | Regimen |
| Vaginal ring with estrogen sustained- release 07.5 mg/d | Replace ring q90d |
| Vaginal tablet 10–25 mg | Insert 1 tablet daily ´ 2 w, then twice weekly |
| Vaginal cream 0.5 mg conj estrogen/g of cream | 0.5 g of cream twice weekly |
- Sexual dysfxn: Local estrogen for lubrication by increasing bld flow & sensation of vaginal Oral systemic ET is approved for rx of dyspareunia.
- Urinary sx: Vaginal ET Est Rx (in RCT ¯ risk of recurrent UTI) (Am J Obstet Gynecol
1999;180:1072)
- See Chap. 1 for osteoporosis
- Primary & secondary prevention of CHD, stroke,VTE, Recommend modifiable lifestyle change for primary & secondary prevention: Smoking cessation; control of HTN, dyslipidemia, & DM. Calcium suppl (1200–1500 mg daily),Vit D suppl (800 IU daily).