Menopause

September 17, 2011

The age at which 50% of the population will cease menstruation (menopause) is 51.3 years with about 8% of women ceasing menstruation before the age of 40. While the menopause represents the final menstrual period, the diagnosis is made retrospectively after loss of menstruation for 12 consecutive months.

Menopause occurs as a result of a decline in the total levels of circulating estrogen and progesterone, hormones which are produced by the ovary. The ovary is endowed with a finite number of eggs and the menopause represents the loss of any further eggs within the ovarian tissue.

The entire body may be affected by the altered and declining hormonal levels, particularly estrogen deficiency. Virtually all body tissues have estrogen receptors indicating that they are responsive to this hormone. Thus, the possible changes are listed in Table 1.

The immediate symptoms that may occur relate to the loss of menstruation, the onset of vasomotor symptoms (see entry Perimenopause), and the vaginal thinning which can increase susceptibility to infection, be associated with painful intercourse, or blood-stained vaginal discharge.

of great importance are the hidden potential effects of loss of ovarian activity. over time, multiple organ systems may be impacted increasing susceptibility to disease. Specifically, these include the cardiovascular system with an increased susceptibility to heart attack, loss of bone, which is accelerated with decline in estrogen and therefore increases susceptibility to bone fracture, and central nervous changes, with suggestion that there might be a relationship to the development of problems like Alzheimer’s disease. It should be emphasized that premature menopause, before the age of 40 years, is associated with an earlier increase in incidence of heart attacks, osteoporotic fractures, and Alzheimer’s disease.

With increasing life expectancy, menopause in a healthy 50-year-old woman would occur at less than two thirds into the life cycle. The menopause therefore serves as an ideal time to enter the health system for a comprehensive examination, based on screening for presence of risk factors for future disease or early evidence of current disease. Logically, the menopause then is also the ideal opportunity for the introduction of a comprehensive preventive health program.

CONFIRMING MENOPAUSE

Although menopause is defined as 12 months of amenorrhea (absence of a menstrual period), any woman with loss of menstruation of greater than 6 months and who is older than age 50 can be confidently diagnosed as being menopausal. It is extremely unusual for a breakthrough ovulation and potential pregnancy to occur in this instance. The diagnosis is more easily confirmed by the development of hot flashes, vaginal thinning, and night sweats.

Menopause can also be confirmed by administration of progestogenic medications (progesteronecontaining medications) in an attempt to induce a period. Failure to respond to progestogen indicates lack of the hormone estrogen. The blood level of folliclestimulating hormone, the brain-produced hormone that stimulates the ovary, can also be measured, but beyond age 50 need not be undertaken on a routine basis. The greatest value for this test is in younger women.

CLINICAL MANAGEMENT

There is a general consensus that the menopause is a normal physiological event occurring in the life cycle of all women. The concept of medicalization of the menopause has been debated. In view of the known effects of reduced ovarian sex steroids on body systems and potential health, there is a need to recognize the potential impact and possibilities for preventive health care.

It is generally recommended that the woman in perior postmenopause should have frequent, at least annual, medical checkups which include a comprehensive history and recommended laboratory testing such as routine blood screens, Pap smear, mammogram, stool guaiac (check for presence of blood) for colon cancer screening, blood lipid levels for cardiovascular screening, thyroid testing for coincidental hypothyroidism (underactive thyroid), and, when indicated, screens for sexually transmitted diseases.

There is a broad range of suggested modern therapies for preventive health beyond menopause. The concept of healthy living is of paramount importance and should be focused on healthy diet, including appropriate supplements as necessary, exercise, smoking cessation, moderation in the use of alcohol, avoidance of habit-forming drugs, seat belts, and safe sexual practices. Beyond that, pharmacologic preparations may be indicated dependent upon specific indications.

Recently, there has been considerable debate about the role of hormonal therapies beyond menopause. The situation is becoming clearer and the following is a summary. The use of estrogen alone in women who have undergone hysterectomy, or estrogen plus progestogen in women with an intact uterus can be considered under the following circumstances. It should be emphasized that there is a difference between utilization of these products for the treatment of specific menopause-related effects as opposed to the utilization of these hormones for potential prevention of future disease such as osteoporosis.

The hormonal products remain an essential component in the management of true menopause-related symptoms, most specifically, the vasomotor symptoms (changes in blood pressure), vaginal atrophy (change in the tissue lining the vagina), and night sweats. An additional indication would also be increased urinary frequency (increased need to urinate frequently). Under these circumstances, current recommendations are for the lowest dose products administered for the shortest period of time, consistent with management of symptoms. If symptoms recur upon drug cessation, restarting may be considered based on the risk-to-benefit profile for each individual woman.

Currently, the only preventive indication for hormonal therapy is reduction of bone loss and resultant osteoporosis and bone fracture. Hormones are highly effective for this problem. Use should be balanced for risk and benefit for each individual, and also take into consideration the use of alternate nonhormonal bone sparing products such as the bisphosphonates and the selective estrogen receptor modulators (SERMs). In general, up to 5 years of hormonal use in the younger periand postmenopausal women is quite safe, and longer term use needs a careful risk/benefit evaluation. Risks of hormone usage include a slight increase in the incidence of heart attack, blood clot, and stroke in the first year to 18 months of therapy, with no increase beyond that. There is also a slight increase in the diagnosis of breast cancer, but fortunately, there is currently no evidence to suggest an increase in mortality from breast cancer. Indeed, some studies suggest that women
on hormones at the time of diagnosis of breast cancer, have longer life expectancy than women who have never utilized these products.

When the only symptom relates to vaginal thinning or dryness, local use of estrogen is the preferred route of administration.

SEE ALSO: Menstrual cycle disorders, Menstruation

Suggested Reading

  • North American Menopause Society. (2002). Menopause core curriculum (2nd ed.). Cleveland, OH: Author.
  • Utian, W. H. (1980). Menopause in modern perspective. New York: Appleton Century Crofts.
  • Utian, W. H. (2003). Menopause. In R. E. Rakel & E. T. Bope (Eds.), Conn’s current therapy 2003 (pp. 1146—1149). Philadelphia: W. B. Saunders.

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