Gab Kovacs1 and Paula Briggs2
(1)
Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
(2)
Sexual and Reproductive Health, Southport and Ormskirk Hospital, Southport, UK
Definitions
Incidence
Aetilogy and Pathogenesis
Clinical Assessment
History
Examination
Investigations
Treatment
Medical
Complications
Prognosis
Definitions
Menopause is the cessation of ovarian function. A woman is “post menopausal” 12 months after her last menstrual period. Ovarian function declines in the 5 years running up to menopause, and this is known as the “perimenopause” or the “menopause transition”. “Premature menopause”, now known as “premature ovarian insufficiency” (POI), occurs when a woman’s ovaries cease functioning under the age of 40.
Incidence
Menopause affects 100 % of women, usually between the ages of 45–55.
Aetilogy and Pathogenesis
During reproductive life, in regularly ovulating women, the menstrual cycle occurs repeatedly every 4 weeks. As described in Chap. 1, the cycle commences with a batch of follicles starting to develop, and during the follicular phase, oestrogen is secreted, resulting in endometrial proliferation. One follicle becomes the leading follicle, and in an ovulatory cycle, ovulates and then becomes the corpus luteum (CL), which produces progesterone as well as oestrogen. The CL has an inherent life span of about 2 weeks, when, in the absence of a pregnancy it succumbs, resulting in a drop in oestrogen and progesterone levels, which causes in the endometrium to slough (menstrual period). During the menopause transition, a woman has cycles where she makes follicles, but does not ovulate; the follicle still secretes oestrogen which causes endometrial proliferation, and when the follicle undergoes atresia, then oestrogen secretion ceases, and the endometrium is lost – still resulting in menstruation (although in an anovulatory cycle). Once ovarian function totally ceases, there is no folliculogenesis, no oestrogen secreted, no endometrial proliferation or shedding, and amenorrhoea results.
Clinical Assessment
History
The symptoms of the menopause/perimenopause can be divided into those due to hormonal fluctuation and those resulting due to the long term consequences of oestrogen deficiency. As these symptoms and signs are usually reported as a continuum, they are considered together, and classified into five types:
1.
2.
3.
4.
5.
Examination
A general examination including blood pressure, breast examination and bimanual examination including a cervical smear (if indicated) should be undertaken. Clinical signs are unlikely to be found, although signs of vaginal atrophy due to lack of oestrogen may be detected.
Investigations
Hormone Tests
These offer little benefit and can be confusing.
· FSH. FSH >30 MiU/ml suggests menopause. However, during the menopause transition the level of FSH can oscillate significantly. Therefore, one cannot diagnose a woman as “post menopausal” on a single FSH level.
· Anti Mullerian Hormone (AMH) – There is no place for measuring this in a woman who is thought to be menopausal. Its value is in predicting ovarian reserve in younger woman, but once in the perimenopause, AMH will always be low, and knowing its value does not change patient management.
· Oestrogen. Measuring oestrogen in a perimenopausal/post menopausal woman is of little benefit. The level of oestrogen does not reflect the degree of symptoms, nor does it help with assessing the effect of hormone replacement therapy (HRT).
· Thyroid Function Tests (TFTs) or fasting glucose or HbA1c should only be measured if medically indicated.
· Bone mineral density- Once a woman becomes post menopausal, she loses about 1 % of her bone mass per year. As osteoporosis is a significant problem in postmenopausal women, prevention is important. Knowing the baseline bone mineral density is useful.
Treatment
Medical
Hormonal
Menopausal women are oestrogen deficient. Hormonal treatment necessitates replacement of oestrogen. This can be oral, transdermal, vaginal or by subcutaneous implant.
Women who have a uterus need endometrial protection. This is provided by using a progestin which can be oral, transdermal or intrauterine (Mirena®). Progestin therapy can be provided either sequentially or continuously.
Other Medical
Some women do not want to take oestrogen, whilst for others, oestrogen replacement is contra-indicated. For these women it is possible to provide symptomatic treatment with various degrees of success. These treatments include the use of antidepressants in the SSRI group, gabapentin and clonidine.
Complications
These are either the consequences of oestrogen deficiency if HRT is not taken, or the complications of HRT- abnormal bleeding, hormonal side effects, venous thromboembolism, and possibly a small increase in the risk of some cancers (such as breast).
Prognosis
The severity of symptoms is very variable. Some women experience virtually no symptoms, whilst other women find their symptoms debilitating.
Symptoms of the peri-menopause may last 5–10 years, during which time hot flushes decrease in frequency and severity.
If the symptoms are due to chronic oestrogen deficiency, they will be life-long eg atrophic vaginitis.