What is Menopause?
Menopause is a normal process characterized by the cessation of menstrual periods in women, which typically occurs after age 45. Perimenopause is a transition period that occurs approximately 4 years prior to menopause and is described by hormonal fluctuations and irregular menses. Women often develop vasomotor symptoms (e.g., hot flashes), problems sleeping, and altered sexual function. Hot flashes are the most common symptom in perimenopause and are often associated with sleep abnormalities. Patients frequently have atrophy of the genitourinary tract, resulting in vaginal dryness and pain with sexual intercourse (dyspareunia).
Vaginal dryness may increase the risk for urinary tract infection. Menopause is also an established risk factor for osteoporosis, which increases one’s risk for hip fracture.
What Causes Menopause?
When women reach menopause, they no longer go through the hormone fluctuations that stimulate ovulation, estrogen production, and menstruation. Estrogen is important for normal health and physiology of the vagina, including its mucous production and moisture. Estrogen also plays a role in body temperature regulation.
Consequently, lack of estrogen during menopause results in genitourinary atrophy and symptoms of dryness. Individuals also develop an impaired ability to regulate body temperature, leading to hot flashes and shivering. Additionally, estrogen is important for bone density and health – estrogen deficiency in menopause often leads to osteoporosis.
How Common is Menopause?
Symptoms of perimenopause and menopause are exceedingly common in the United States and responsible for a large number of primary care visits. Severe or complicated cases may require referral to a gynecology specialist.
The permanent cessation of menses occurs at age 51 on average in normal women. Approximately 5% of women begin menopause between age 40-45 and an additional 5% develop menopause after age 55. Factors such as genetics, ethnicity, smoking, and reproductive history can affect the age at menopause.
Vasomotor symptoms such as shivering and hot flashes occur in up to 80% of women during perimenopause. Vaginal dryness occurs in an estimated 21% of women in late perimenopause and 47% of women 3 years’ post-menopause. Only approximately 20%-30% of individuals see their healthcare provider for treatment of their symptoms.
Signs and Symptoms
Symptoms of perimenopause typically include:
- Alterations in the time interval between menstruation
- Vaginal dryness & itchiness
- Pain with sexual intercourse (dyspareunia)
- Sexual dysfunction
- Vasomotor symptoms – shivering and hot flashes
- Sleep disturbances
- Mood abnormalities such as major depression
Menopause is defined as the cessation of menstrual periods for 12 months. Vasomotor and genitourinary symptoms are prominent during this period.
The diagnosis of perimenopause in healthy women age >45 is based on irregular menstrual periods in the presence of vasomotor or genitourinary symptoms. Menopause is defined as amenorrhea (cessation of menstruation) for 12 months in the absence of other causes. It is often characterized by an elevated FSH level, but this is not required for the diagnosis. Women age 40-45 with irregular menstruation and menopausal symptoms generally receive an endocrine assessment by their doctor, which typically includes a pregnancy test (beta-hCG), prolactin, TSH, and FSH. Women age <40 with these features should receive a comprehensive assessment for premature ovarian failure, which is the beyond the scope of this article.
Menopause Medication and Treatment
Menopausal hormone replacement therapy is primary aimed to improve vasomotor symptoms such as hot flashes, although genitourinary, mood, and sleep-related symptoms also frequently respond to therapy. Healthy women age 50-60 have a very low risk of complications if they receive treatment for up to 5 years. Therapy should be started at the lowest dose possible and continued for the shortest duration of time.
Women with a history of breast cancer, coronary heart disease, stroke, or liver disease should generally avoid hormone replacement therapy.
The most common first-line options include:
- Transdermal 17-beta estradiol
- Oral estrogen is also safe and effective.
Women who experience bothersome hot flash symptoms after discontinuing estrogen may benefit from non-hormonal drugs such as:
- Serotonin-norepinephrine reuptake inhibitors (SNRIs)
- Selective serotonin reuptake inhibitors (SSRIs),
- Neurontin (gabapentin)
Women with normal functioning uterus who receive estrogen therapy must also receive progestin to prevent the development of endometrial hyperplasia and cancer. Your doctor may recommend Prometrium (micronized progesterone) because it is effective for endometrial hyperplasia and does not appear to increase the risk of breast cancer.
Vaginal estrogen can be beneficial in patients with primarily genitourinary findings such as vulvovaginal atrophy and dryness. Commonly prescribed agents include Estrace and Premarin cream. Hormone replacement therapy is not generally indicated to prevent osteoporosis, coronary artery disease, or dementia.
- Taffe JR, Dennerstein L. Menstrual patterns leading to the final menstrual period. Menopause 2002; 9:32. - https://www.ncbi.nlm.nih.gov/pubmed/11791084
- Marjoribanks J, Farquhar C, Roberts H, Lethaby A. Long term hormone therapy for perimenopausal and postmenopausal women. Cochrane Database Syst Rev 2012; :CD004143. - https://www.ncbi.nlm.nih.gov/pubmed/22786488
- North American Menopause Society. The 2012 hormone therapy position statement of: The North American Menopause Society. Menopause 2012; 19:257. - https://www.ncbi.nlm.nih.gov/pubmed/22367731
The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.