Menopause is defined as the permanent cessation of menstruation after 12 months without a period. The average age of menopause in North America is 51. During perimenopause, the years leading up to menopause, women experience fluctuations in hormone levels including rising FSH and decreasing estrogen and progesterone. Common symptoms include hot flashes, night sweats, vaginal dryness, sleep disturbances, and mood changes. Estrogen deficiency after menopause can also lead to increased risks of bone loss, cardiovascular disease, and skin aging over the long term.

1. Menopause
STEPHANIE CUMMINGS, MD

2. Menopause
 Defined as the permanent cessation of menstruation
 Menopause is complete after one year without a
menstrual period

Postmenopausal
 The average age of menopause in North America is 51

Affected by genetics and smoking
 Serum follicle stimulating hormone (FSH) levels: 70-100

3. Late Reproductive Years
 Typically women in their 40’s
 Menstrual cycles are still ovulatory, but the follicular
phase begins to shorten

Shorter interval between menstrual periods
 FSH begins to rise, but estradiol levels are still
preserved

4. Perimenopause
 Menopausal Transition
 The years before menopause characterized by the
physiologic changes associated with menopause
 Fluctuations are seen in blood hormone levels

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Follicle stimulating hormone (FSH) rises
Estradiol and progesterone decrease
 Begins on average 4 years before the final menstrual
period

5. Perimenopause
 The intermenstrual interval begins to lengthen
 Normal: 25-35 days
 Perimenopause: 40-50 days
 The early follicular FSH levels continue to rise
 Changes in the menstrual cycle become more
pronounced
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Skipped cycles
Episodes of amenorrhea
Increased frequency of anovulatory cycles

6. Perimenopause
 During this time, some women experience heavy or
prolonged bleeding

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Anovulatory cycles
Prolonged exposure to unopposed estrogen
 These symptoms are more common in women with
fibroids and obese women

7. Menopausal Symptoms
 Vasomotor symptoms
 Hot flashes/night sweats
 Vaginal symptoms
 Vaginal dryness
 Vaginal atrophy
 Sleep Disturbances
 Mood disorders

8. Vasomotor Symptoms
 Hot flashes are the hallmark symptom
 The sudden sensation of extreme heat in the upper
body that last 1-5 minutes

Typically the neck, face, and chest
 They occur several times per day, but can be as
frequent as several times per hour
 More commonly occur at night

Night sweats
 Associated with perspiration, flushing, clamminess,
chills, anxiety, and at times palpitations

9. Vasomotor Symptoms
 80% of women experience hot flashes
 Only 20-30% seek treatment
 More than 80% of women who experience hot
flashes will have them for more than one year

Most will spontaneously resolve within 4-5 years

10. Physiology of Hot Flashes
 Multifactorial
 Due to changes in reproductive hormones
 Estrogen allow the body to tolerate a wider range of
temperature changes without becoming symptomatic (the
thermoregulatory zone)
 During the menopausal transition, the body becomes
more sensitive to subtle changes in core temperature

11. Sleep Disturbances
 Many times due to vasomotor symptoms occurring at
night
 During the menopausal transition, new onset mood
disorders can also contribute to insomnia

Depression/anxiety
 Also consider primary sleep disorders


Sleep apnea
Restless leg syndrome
 Correcting vasomotor symptoms may not completely
resolve sleep disturbances

12. Vaginal Symptoms
 Vaginal dryness, atrophy, and itching
 The cells lining the vagina and urethra are estrogen-
dependent

Estrogen deficiency leads to the thinning of the vaginal
epithelium
 Loss of elasticity in the vagina leads to a shortening
and narrowing of the vagina

The tissues also become more fragile and may tear
 Loss of subcutaneous fat in the labia may result in
narrowing of the introitus

13. Vaginal Symptoms
 Vaginal pH becomes more alkaline
 Increased risk of urinary tract infections
 Vaginal secretions may decrease
 May cause pain with intercourse
 In the early menopause transition, a slight decrease in
lubrication may be the first sign of decreasing levels of
estrogen
 May progress to vaginal dryness during daily activities

14. Long Term Effects of Estrogen Deficiency
 Bone loss and osteoporosis
 Cardiovascular disease and changes to the lipid
profile
 Skin changes
 Limited data regarding dementia, arthritis, and
balance

15. Bone Loss
 Begins during the menopausal transition
 Rates of bone loss appear to be the highest during the one
year before through two years after the final menstrual period
 Bone density screening should begin at age 65 unless a
woman has significant risk factors
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History of a fragility fracture
Weight less than 127 pounds
Medical causes of bone loss (medications, diseases)
Current smoker
Alcoholism
Parental medical history of a hip fracture
Rheumatoid arthritis

16. Bone Loss
 FRAX score


Can be used in women under 65 to assess risk for fracture
If risk of osteoporotic fracture is 9.3% (similar to a 65 year old
woman), a bone density scan is reasonable to order
 Routine screening of newly menopausal women is not
recommended
 If treatment is started, a repeat scan should be done in 2
years
 For women with normal testing at 65, a screening
interval of 15 years is suggested

17. Cardiovascular Disease
 Lipid profiles begin to change during the
menopausal transition



LDL levels increase
HDL levels remain similar, but the protective effect may
decrease
Triglycerides increase
 Risk of cardiovascular disease increases after
menopause

Similar risk to males

18. Skin Changes
 Collagen content of skin and bones is decreased due
to lack of estrogen
 Decreased collagen may lead to increased aging as
well as wrinkling of the skin

19. References
 The American College of Obstetricians and Gynecologists.
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Management of menopausal symptoms. Practice Bulletin 141.
January 2014.
The American College of Obstetricians and Gynecologists.
Osteoporosis. Practice Bulletin 129. September 2012.
Grady D. Clinical practice. Management of menopausal
symptoms. N Engl J Med 2006;355:2338–47.
Freedman RR. Physiology of hot flashes. Am J Hum Biol
2001;13:453–64.
Casper R. Clinical manifestations and diagnosis of
menopause. UpToDate. February 4, 2014
Casper F. Santen R. Menopausal hot flashes. UpToDate.
January 2014.