What is the most likely diagnosis for a postmenopausal woman with amenorrhea, vaginal atrophy, and insomnia?

From the Guidelines

The correct answer is B. increased follicle-stimulating hormone level. This 52-year-old woman with 13 months of amenorrhea, vaginal dryness, pruritus, discomfort during intercourse, and sleep disturbances is experiencing menopause. During menopause, the ovaries stop responding to gonadotropins, leading to decreased estrogen production. Through negative feedback, this causes the pituitary to increase FSH secretion in an attempt to stimulate the ovaries. An elevated FSH level (typically >30-40 mIU/mL) is the most reliable laboratory indicator of menopause in a woman with appropriate symptoms and age, as supported by the most recent study 1.

The other options are incorrect because LH is typically elevated (not decreased) in menopause, hyperprolactinemia causes amenorrhea but wouldn't explain her other symptoms, hypothyroidism (increased TSH) can cause menstrual irregularities but is not the primary cause of menopause, and a progesterone challenge test would be negative in menopause due to atrophic endometrium from estrogen deficiency. The management of menopausal symptoms, including vaginal dryness and discomfort during intercourse, can be addressed with topical estrogen therapy or other treatments, as discussed in the guidelines 1.

Key points to consider in the management of this patient include:

• The use of vaginal moisturizers and lubricants to alleviate vaginal dryness and discomfort during intercourse, as recommended by the guidelines 1.
• The potential benefits and risks of hormone replacement therapy (HRT) in women with a history of cancer, as discussed in the guidelines 1.
• The importance of regular monitoring of bone health and preventive measures to reduce the risk of osteoporosis, as recommended by the guidelines 1.

Overall, the diagnosis and management of menopause in this patient should be guided by the most recent and highest-quality evidence, with a focus on alleviating symptoms and improving quality of life, as supported by the studies 1.

From the FDA Drug Label

CLINICAL PHARMACOLOGY Endogenous estrogens are largely responsible for the development and maintenance of the female reproductive system and secondary sexual characteristics Although circulating estrogens exist in a dynamic equilibrium of metabolic interconversions, estradiol is the principal intracellular human estrogen and is substantially more potent than its metabolites, estrone and estriol, at the receptor level The primary source of estrogen in normally cycling adult women is the ovarian follicle, which secretes 70 to 500 mcg of estradiol daily, depending on the phase of the menstrual cycle. After menopause, most endogenous estrogen is produced by conversion of androstenedione, secreted by the adrenal cortex, to estrone by peripheral tissues Thus, estrone and the sulfate conjugated form, estrone sulfate, are the most abundant circulating estrogens in postmenopausal women. Estrogens act through binding to nuclear receptors in estrogen-responsive tissues. To date, two estrogen receptors have been identified. These vary in proportion from tissue to tissue Circulating estrogens modulate the pituitary secretion of the gonadotropins, luteinizing hormone (LH) and follicle stimulating hormone (FSH), through a negative feedback mechanism. Estrogens act to reduce the elevated levels of these hormones seen in postmenopausal women

The patient's symptoms, such as amenorrhea, vaginal pruritus and dryness, and trouble sleeping, are consistent with menopause. The test result most likely to confirm this patient's diagnosis is

• B. increased follicle-stimulating hormone level, as estrogens act to reduce the elevated levels of FSH seen in postmenopausal women 2.

From the Research

Diagnosis of Menopause

The patient's symptoms, including a 13-month history of amenorrhea, vaginal pruritus and dryness, and sleep disturbances, are consistent with menopause. To confirm the diagnosis, laboratory tests can be used to evaluate hormone levels.

Laboratory Tests

• The test result most likely to confirm this patient's diagnosis is an increased follicle-stimulating hormone (FSH) level 3.
• FSH levels rise 10-15-fold after menopause, with low oestradiol and undetectable inhibin levels 3.
• While other tests, such as decreased luteinizing hormone level, increased prolactin level, and increased thyroid-stimulating hormone level, may be useful in certain situations, they are not the most likely to confirm a diagnosis of menopause in this patient.
• Vaginal bleeding with a progesterone challenge test may also be used to evaluate menstrual status, but it is not the most direct test for menopause.

Hormone Levels and Menopause

• Menopause is characterized by a chronic hypo-estrogenic state, which can cause a range of symptoms, including hot flashes, vaginal dryness, and sleep disturbances 4.
• Hormone replacement therapy (HRT) can be effective in managing menopausal symptoms and improving quality of life 5, 6.
• FSH has been shown to play a role in regulating bone mass, adipose tissue function, energy metabolism, and cholesterol production, and may be relevant to the pathogenesis of age-associated diseases 7.