Menopause: Definition, Symptoms, and Management
Menopause is defined as the permanent cessation of menses for 12 months in the absence of prior chemotherapy or tamoxifen use, or no menses after surgical removal of all ovarian tissue, and includes a profound and permanent decrease in ovarian estrogen synthesis. 1
Definition and Physiology
- Menopause typically occurs between ages 45-56 years, with a mean age of 51 years, when 95% of women reach menopause between ages 45-55 years 1
- The perimenopause is a transitional period preceding final menses by several years, characterized by changing ovarian function and fluctuating hormone levels 2
- Menopause results from declining ovarian follicular activity, with a profound decline in follicle numbers leading to decreased production of estrogen, progesterone, and testosterone 3
- Follicle-stimulating hormone (FSH) levels increase as inhibin B levels decline, reflecting the fall in ovarian follicle numbers 3
Diagnostic Criteria
Reasonable criteria for determining menopause include any of the following:
- Prior bilateral oophorectomy 1
- Age ≥60 years 1
- Age <60 years and amenorrheic for 12 or more months in the absence of chemotherapy, tamoxifen, toremifene, or ovarian suppression with FSH and estradiol in the postmenopausal range 1
- If taking tamoxifen or toremifene, and age <60 years, then FSH and plasma estradiol levels in postmenopausal ranges 1
Common Symptoms
- Vasomotor symptoms (hot flashes/night sweats) affect approximately 50-75% of women during the menopausal transition 4
- Genitourinary syndrome of menopause (GSM) affects more than 50% of women 4
- Other symptoms include:
Management Options
Hormone Replacement Therapy (HRT)
For women with bothersome menopausal symptoms, hormone replacement therapy is the most effective treatment option, reducing vasomotor symptoms by approximately 75%. 4
- Estrogen replacement therapy with progestin protection is indicated if the uterus is intact 5
- Transdermal estrogen is preferred due to lower risk of venous thromboembolism compared to oral formulations 5
- Typical regimens:
Risks of Hormone Therapy
- Women's Health Initiative (WHI) study showed increased risks with combined estrogen plus progestin therapy 6:
- Increased risk of breast cancer (8 more cases per 10,000 women-years) 6
- Increased risk of stroke (8 more cases per 10,000 women-years) 6
- Increased risk of pulmonary embolism (10 more cases per 10,000 women-years) 6
- Increased risk of dementia in women over 65 years (23 more cases per 10,000 women-years) 6
Contraindications to HRT
Absolute contraindications include:
- History of breast cancer 5
- Active venous thromboembolism 5
- Active liver disease 5
- Unexplained vaginal bleeding 6
Non-Hormonal Options
For women who cannot or choose not to use HRT:
- SSRIs/SNRIs (citalopram, desvenlafaxine, escitalopram, paroxetine, venlafaxine) reduce vasomotor symptoms by 40-65% 4
- Gabapentin is effective for vasomotor symptoms 4
- For genitourinary symptoms:
Special Considerations
Bone Health
- Menopause accelerates bone loss, with approximately 2% decrease in bone density annually for the first 5 years after menopause 1
- Consider bone density testing for women at risk of osteoporosis 5
- For women with osteopenia or osteoporosis, bisphosphonates (oral or IV) or denosumab are recommended 1
Chemotherapy-Induced Ovarian Failure (CIOF)
- CIOF can occur as early as 6 months after initiating adjuvant chemotherapy 1
- Risk factors include:
- Important to distinguish between transient amenorrhea and permanent ovarian failure 1
- Women who experience transient amenorrhea with bone loss at 6 months may recover bone density by 12 months 1
Monitoring
- Clinical evaluation at 3-6 month intervals initially, then annually 5
- Annual mammography for women over 50 years 5
- Bone mineral density assessment should not be conducted more than annually 1