What are the initial steps for testing and managing suspected menopause in women?

Initial Steps for Testing and Managing Suspected Menopause

The initial approach to testing and managing suspected menopause should include a thorough assessment of menopausal symptoms and their impact on quality of life, followed by appropriate laboratory evaluation and treatment options based on symptom severity. 1

Assessment of Menopausal Symptoms

• Evaluate the frequency and severity of vasomotor symptoms (hot flashes and night sweats), which occur in approximately 50-75% of women during menopausal transition 2
• Assess symptoms of atrophic vaginitis (vaginal dryness, dyspareunia, urinary urgency, and pruritus) and associated symptoms such as sexual dysfunction, reduced libido, and sleep disturbance 1
• Document other common menopausal symptoms including sleep disturbances and depression, which are consistently linked to the menopause transition 1
• Use standardized scales such as the Greene Scale to establish symptom range and severity, evaluate changes over time, and differentiate menopause symptoms from other pathologies 1
• Determine the impact of symptoms on activities of daily living and quality of life using menopause-specific tools like MENQOL 1

Laboratory Evaluation

• Laboratory testing should include estradiol, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and prolactin, as clinically indicated 1
• Important caveat: FSH is not a reliable marker of menopausal status in women with prior chemotherapy, pelvic radiation exposure, or those on tamoxifen 1
• For perimenopausal or premenopausal women who have become amenorrheic and later develop bleeding, serial estradiol levels can help determine return of ovarian function 1
• Additional markers such as anti-Mullerian hormone (AMH) and inhibin may provide supplementary information on ovarian status but alone are not reliable indicators of menopause 1

Establish Patient Expectations and Goals

• Determine what the patient wants from intervention - whether reduction in symptoms, information, or other outcomes 1
• Discuss realistic expectations regarding treatment efficacy - many women may be satisfied with a 50% reduction in symptom severity with non-hormonal treatments 1
• Provide high-quality, personalized information about menopause and treatment options, which may be sufficient for some women 1

Management Approach

Non-Pharmacological Interventions

• Identify and modify lifestyle and environmental factors that may exacerbate hot flashes, such as spicy food, overheating, and anxiety 1
• Recommend practical strategies like dressing in layers, avoiding overheating, wearing natural fibers, and using cold packs 1
• Consider lifestyle modifications including exercise, achieving a healthy weight, and smoking cessation, as hot flashes may be more severe in overweight women and smokers 1

Pharmacological Options

• For women with bothersome vasomotor symptoms, non-hormonal pharmacologic options include:

  • Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) 1
  • Anticonvulsants, neuropathic pain relievers, and certain antihypertensives 1
  • These medications can reduce frequency of vasomotor symptoms by approximately 40-65% 2

• For severe symptoms, menopausal hormone therapy (MHT) may be considered:

  • Combination estrogen and progestins for women with an intact uterus 1
  • Estrogen alone for women without a uterus 1
  • Systemic estrogen alone or combined with progestogen reduces frequency of vasomotor symptoms by approximately 75% 2

• Important cautions regarding hormone therapy:

  • Contraindicated in women with history of hormone-related cancers, abnormal vaginal bleeding, recent pregnancy, or active liver disease 1
  • Increased risk of stroke, venous thromboembolism, and breast cancer (with estrogen plus progestin) of approximately 1 excess event per 1000 person-years 3
  • Women using MHT should be monitored regularly to assess continued need for treatment 3

Special Considerations

• For women with complaints of vaginal dryness, a pelvic evaluation should be performed to assess for vaginal atrophy 1
• For genitourinary symptoms, low-dose vaginal estrogen is associated with 60-80% improvement in symptom severity 2
• Consider referral to a specialist menopause service, particularly one with multidisciplinary input, for complex cases or severe symptoms 1
• For younger women experiencing early menopause, additional considerations regarding bone health, cardiovascular risk, and psychological impact are important 4

Follow-up and Monitoring

• Periodically reassess the need for continued treatment of vasomotor symptoms, as they typically decrease in frequency and severity following 12 months of amenorrhea in spontaneous menopause 1
• Consider trying to discontinue treatments for hot flashes on an intermittent, perhaps annual basis to assess whether symptoms recur 1
• Monitor for side effects of medications and adjust treatment as needed 3

By following this structured approach to assessment and management, clinicians can effectively address menopausal symptoms and improve quality of life for women experiencing this transition.