Menopause Disease

BASICS

DESCRIPTION

The cessation of spontaneous menstrual cycles

Perimenopause: Period of time where there is a decline in ovarian function. Although a woman may continue to have periodic uterine bleeding, such cycles may be anovulatory. During this time estrogen production diminishes and a woman may experience early signs of estrogen deficiency.
Postmenopause: The period after menopause usually accounting for more than a third of a woman's total life.
Premature menopause: occurring before age 30 and may be associated with sex chromosome abnormalities.
System(s) affected: Reproductive, Endocrine/Metabolic, Musculoskeletal, Cardiovascular
Genetics: N/A
Incidence/Prevalence in USA: Increasingly common as life span increases - currently affects over 30 million women
Predominant age:
- Average age is 51 in the U.S. (unrelated to the age of menarche) and virtually all women postmenopausal by age 58.
Predominant sex: Female only

SIGNS AND SYMPTOMS

Cessation of menses - either abruptly or preceded by a period of irregular cycles and/or diminished bleeding
Vasomotor symptoms - hot flashes, sweating (85%)
Psychologic symptoms - depression, nervousness, insomnia
Vaginal atrophy - dyspareunia
Urinary tract atrophy - stress or urge urinary incontinence
Skin atrophy - wrinkles
Osteoporosis - fractures (20% by age 85)
Arteriosclerosis - coronary artery disease

CAUSES

Physiologic - when due to depletion of oocytes
Surgical - when due to removal of functioning ovaries because of disease or incidental to hysterectomy
Medical - as a result of treatment of endometriosis (danazol [Danocrine] or GnRH analogues) or of breast cancer (antiestrogens). This etiology is reversible. May occur after cancer chemotherapy and be permanent or reversible.

RISK FACTORS

Increasing age
Pelvic surgery
Sex chromosome abnormalities

DIAGNOSIS

LABORATORY

Usually none is required because patient's age and symptoms readily establish the diagnosis
If the diagnosis is questionable in a young patient, an elevated serum FSH indicates ovarian failure (FSH greater than 40 mIU/mL [100 IU/L]). Measurement of LH is not necessary. Estradiol (E2) levels will be less than 30 pg/mL.
Peripheral blood karyotype if age < 30

Drugs that may alter lab results:

Estrogens
Androgens
Hormonal contraceptives

Disorders that may alter lab results: Temporary, reversible cessation of ovarian function, e.g., during chemotherapy

PATHOLOGICAL FINDINGS

Atrophy of endometrium – virtually 100% if untreated. The uterus may seem smaller on bimanual examination.
Atrophy of vagina – loss of rugae, appearance of petechiae; virtually 100% after several years if untreated.
Atrophy of urethra.
Osteoporosis – approximately 2% loss of bone mass per year. Most common in Caucasians and Orientals, least common in African-Americans.
Arteriosclerosis.
Ovarian stroma only – or only a few inactive oocytes.

SPECIAL TESTS

Endometrial biopsy and/or D&C in patients who have intermenstrual or postmenopausal bleeding – may be accompanied by hysteroscopy. Investigation for endometrial cancer is necessary even in the presence of an atrophic vagina (usually the cause of the bleeding).
Bleeding may also be evaluated by vaginal sonography; if double wall thickness of endometrial stripe is less than 5 mm, endometrial carcinoma is highly unlikely.

IMAGING

None for physiologic menopause
MRI scan of head if pituitary tumor suspected

DIAGNOSTIC PROCEDURES

Endometrial sampling if intermenstrual or postmenopausal bleeding occurs
Pap smear
Bimanual pelvic examination
Mammography annually
Bone density determination

TREATMENT

APPROPRIATE HEALTH CARE

Periodic office visits

GENERAL MEASURES

To retard development of osteoporosis: adequate calcium intake - at least 1500 mg elemental calcium/day; exercise; avoid smoking, avoid excessive alcohol or caffeine intake
ERT for prophylaxis against osteoporosis and coronary artery disease, relief of vasomotor symptoms and urogenital atrophy. Exceptions are women with contraindications to therapy and obese women (who usually have sufficient endogenous estrogens produced by peripheral conversion of androgens by adipose tissue)
ERT has a favorable effect on lipoproteins; elevates HDL and may retard progression of Alzheimer's disease (no proof for prevention)

SURGICAL MEASURES

N/A

ACTIVITY

Active, weight-bearing exercise.

DIET

Increased calcium intake, adequate Vitamin D, high fiber, low fat

PATIENT EDUCATION

American College of Obstetricians and Gynecologists (ACOG), 409 12th St. S.W., Washington, D.C. 20024, (800)673-8444
For a listing of sources for patient education materials favorably reviewed on this topic, physicians may contact: American Academy of Family Physicians Foundation, P.O. Box 8418, Kansas City, MO 64114, (800)274-2237, ext. 4400
www.Menopause.com

FOLLOW UP

PREVENTION/AVOIDANCE

Menopause is a physiological process. It cannot be avoided, but the untoward effects can be moderated or eliminated by ERT.

POSSIBLE COMPLICATIONS

Vasomotor symptoms
Uncomfortable psychologic symptoms
Vaginal atrophy
Skin wrinkles
Osteoporosis
Arteriosclerosis
The estrogen dosage recommended is very low and is unlikely to cause some of the complications associated with higher doses of estrogen, including hypercoagulability, breast tenderness, gall bladder disease and hypertension. The possible relationship to breast cancer is controversial.

EXPECTED COURSE AND PROGNOSIS

If untreated
- Ultimate disappearance of vasomotor symptoms - usually takes several years
- Urogenital atrophy
- Osteoporosis - possible fractures especially of the hip, vertebrae and wrists. Mortality associated with hip fractures is 15%.
- Coronary artery disease
If treated
- Minimal effects of estrogen deprivation
- Slower bone loss and reduced incidence of coronary artery disease. Delayed appearance of Alzheimer's disease
- Therapy may be continued indefinitely if no contraindications appear since osteoporosis will rapidly occur after stopping therapy
- If existent, increased risk for breast cancer from estrogen is minimal

MISCELLANEOUS

ASSOCIATED CONDITIONS

Any medical problems that may occur with increasing age, especially osteoporosis

AGE-RELATED FACTORS

Pediatric: N/A
Geriatric: N/A
Others: N/A

PREGNANCY

Mutually exclusive

OTHER NOTES

Estrogen replacement therapy is especially important in women having an early menopause, either spontaneous or surgical because of their long expected life without endogenous estrogens. Without such therapy, they may be at a significantly increased risk for osteoporosis and its life threatening or debilitating effects.
Following surgical menopause, vasomotor symptoms often appear very rapidly. Estrogen replacement therapy may be started in the early postoperative period.
In perimenopausal women bothered by severe vasomotor symptoms, cyclic estrogen and progestogen therapy may be started even though the patient is still having periodic uterine bleeding.

ABBREVIATIONS

ERT = estrogen replacement therapy
HRT = hormone replacement therapy

Clinical Investigations

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