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 that typically presents with 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 experience atrophy of the genitourinary tract, resulting in vaginal dryness and pain with sexual intercourse (dyspareunia).
Vaginal dryness may increase the risk of urinary tract infection. Menopause is also an established risk factor for osteoporosis, which increases one’s risk for hip fracture.
When women reach menopause, they no longer experience the typical monthly hormone fluctuations that stimulate ovulation, estrogen production, and menstruation. Sufficient estrogen levels are important in the normal health and physiology of the vagina, including its mucous production and moisture. Estrogen also plays a role in body temperature regulation.
Consequently, decreased levels 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 and may result in fractures.
Menopause occurs in every woman with only the age of onset differing. The cessation of menses occurs at age 51 on average. 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 which menopause begins.
Not all women undergoing menopause experience the same symptoms. 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.
While all women differ in their presenting symptoms when entering menopause, the most common symptoms of perimenopause 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 typically most prominent during this period.
The diagnosis of menopause is only made in women over the age of 45. Under the age of 45 the signs and symptoms of menopause would lead to a diangosis of “early menopause.” The key diagnostic criteria is 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 to search for atypical causes of menopause-like symptoms. Women age <40 with these features should receive a comprehensive assessment for premature ovarian failure, which is beyond the scope of this article.
Menopausal hormone replacement therapy is primarily used 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, pulmonary embolism, deep vein thrombosis, and liver disease should generally avoid hormone replacement therapy. In these patients, hormone replacement may lead to the recurrence of cancer, increased risk of blood clots, or the worsening of chronic disease.
The most common first-line options for hormone replacement include:
- Transdermal 17-beta estradiol
- Oral estrogen is also safe and effective.
Women who continue to experience bothersome hot flash symptoms after discontinuing estrogen or would be at risk of complications from estrogen may benefit from non-hormonal drugs such as:
- Serotonin-norepinephrine reuptake inhibitors (SNRIs)
- Effexor (venlafaxine)
- Pristiq (desvenlafaxine)
- Selective serotonin reuptake inhibitors (SSRIs),
- Paxil (paroxetine)
- Celexa (citalopram)
- Lexapro (escitalopram)
- Neurontin (gabapentin)
The majority of women 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 for the prevention of 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