Perimenopause and Menopause

Perimenopause and Menopause

• Perimenopause begins with menstrual irregularity and ends 12 months after the last menstrual period, marking the beginning of menopause.
• Menopause is the permanent cessation of menses caused by the loss of ovarian follicular activity.

Clinical Presentation

• Symptoms of perimenopause and menopause include:
  • Vasomotor symptoms (hot flushes and night sweats)
  • Sleep disturbances
  • Depression
  • Anxiety
  • Poor concentration and memory
  • Vaginal dryness and dyspareunia
  • Headache
  • Sexual dysfunction
  • Arthralgia
  • Urogenital atrophy in menopause and dysfunctional uterine bleeding
• Metabolic changes occur due to the loss of estrogen production, including:
  • Increase in central abdominal fat
  • Effects on lipids, vascular function, and bone metabolism

Pathophysiology

• The hypothalamic−pituitary−ovarian axis controls reproductive physiology.
• Follicle stimulating hormone (FSH) and luteinizing hormone (LH) regulate ovarian function.
• Gonadotropins are influenced by negative feedback from sex steroids.
• As females age, circulating FSH progressively rises, and ovarian inhibin-B and anti-Mullerian hormone decline.
• In menopause, there is a 10-to-15-fold increase in circulating FSH, a 4-to-5-fold increase in LH, and a greater than 90% decrease in circulating estradiol concentrations.

Diagnosis

• Menopause is determined retrospectively after 12 consecutive months of amenorrhea.
• FSH on day 2 or 3 of the menstrual cycle greater than 10−12 IU/L indicates diminished ovarian reserve.
• Altered thyroid function and pregnancy must be excluded.

Treatment

• Goals of treatment include relieving symptoms, improving quality of life, and minimizing medication adverse effects.

Non-Pharmacologic Therapy

• Mild vasomotor and/or vaginal symptoms can be alleviated by:
  • Lowering the room temperature
  • Decreasing intake of caffeine, spicy foods, and hot beverages
  • Smoking cessation
  • Exercise
  • A healthy diet
• Mild vaginal dryness can be relieved by non-estrogenic vaginal creams or local/systemic estrogen therapy.

Pharmacologic Therapy

• Combined hormonal contraceptives (CHCs) provide contraception and vasomotor symptom relief but have contraindications.
• Hormone replacement therapy (HRT) is the most effective treatment for moderate and severe vasomotor symptoms, impaired sleep quality, and vulvovaginal symptoms of menopause.
• Estrogen-only therapy may decrease heart disease and all-cause mortality in 50- to 59-year-old women with a history of hysterectomy.
• HRT is effective for prevention of osteoporosis-related fractures in recently menopausal women at risk.
• In women with an intact uterus, HRT consists of an estrogen plus a progestogen.