Menopause and Climacteric: Definition and Diagnosis

Menopause and Climacteric

• Menopause: permanent cessation of menstruation due to failure of ovarian follicular development in the presence of adequate gonadotropins.
• Diagnosis of menopause is established when menstruation stops for 12 months in absence of an organic or a pathological cause.
• Climacteric: physiological period in a woman's life during which ovarian function regresses, characterized by endocrine, somatic, and psychological changes.

Hormonal Changes

• FSH and LH levels are elevated (>25 IU/L).
• Estrogen levels decrease.
• Progesterone and inhibin levels decrease.
• Testosterone levels are relatively increased.

Clinical Changes

Menstrual Changes

• Gradual tapering in both amount and duration of flow.
• A minority of women experience more frequent and heavier bleeding.
• Abrupt cessation of menses is rare.

Vasomotor Instability (Hot Flashes)

• Most common and troublesome symptoms for women at the climacteric.
• Obese women are less troubled by hot flashes than thin women.
• 75% of women experience hot flashes within 3 months of menopause.
• Hot flashes lessen in frequency and intensity with advancing age.

Cardiovascular Changes

• Estrogen is cardio-protective.
• Estrogen increases HDL and decreases LDL.
• Risk of cardiovascular disease increases after menopause.

Genitourinary Atrophy

• Vaginal walls become pale and thin due to diminished vascularity.
• Vaginal epithelial cells contain less glycogen, leading to loss of acidic pH and increased risk of infection and ulceration.
• Vagina loses its rugae and becomes shorter and inelastic.
• Symptoms: dyspareunia, vaginitis, vaginal dryness, dysuria, urgency, frequency of urination, and suprapubic pain.

Psychological Changes

• Irritability, anxiety, and depression.
• Lack of concentration.
• Change of libido.
• Increased risk of Alzheimer's disease.

Skin Collagen

• Up to 30% of skin collagen is lost during the first five years of menopause.
• Loss can be prevented and reversed with Estrogen Replacement Therapy (ERT).

Osteoporosis

• Reduction of bone mass density with micro-architectural alteration, leading to increased bone fragility.
• Imbalance between osteoclastic and osteoblastic activity (defective remodeling).
• Loss in total mineralized bone.
• Disruption of normal balance of bone breakdown and build-up.
• Major mechanisms: slow down of bone build-up, accelerated bone breakdown.
• Normal loss: 0.5% per year after peak in 20s.
• Up to 5% loss per year during first 5 years after menopause.

Risk Factors for Osteoporosis

Unchangeable Factors

• Gender
• Heredity
• Age
• Fracture history
• Medical conditions (e.g., hyperthyroidism, parathyroidism)
• Medications for chronic diseases (e.g., steroids)

Changeable Factors

• Calcium consumption
• Vitamin D intake
• Quit smoking or vaping
• Alcohol consumption
• Physical activity
• Posture
• Low body weight (BMI < 20)
• Some medications

Complications of Osteoporosis

• Fractures: most common sites are vertebrae, femur neck, and distal radius.
• One-third of women will suffer vertebral fracture after 65 years of age and hip fracture by age 90.