Key Points
- Menopausal hormone therapy (MHT) is the most effective treatment for vasomotor symptoms and other symptoms of the climacteric.
- Benefits may exceed risks for the majority of symptomatic postmenopausal women who are under age 60 or less than 10 years since the onset of menopause.
- Health care professionals should individualize therapy based on clinical factors and patient preference.
- Before initiating MHT, clinicians should screen women for cardiovascular and breast cancer risk and recommend the most appropriate therapy depending on risk/benefit considerations.
- Current evidence does not justify the use of MHT to prevent coronary heart disease, breast cancer, or dementia.
- Other options are available for those with vasomotor symptoms who prefer not to use MHT or who have contraindications because these patients should not use MHT.
- Low-dose vaginal estrogen and ospemifene provide effective therapy for the genitourinary syndrome of menopause, and vaginal moisturizers and lubricants are available for those not choosing hormonal therapy.
- All postmenopausal women should embrace appropriate lifestyle measures.
Diagnosis
Diagnosis and Symptoms of Menopause
- The Endocrine Society (ES) suggests diagnosing menopause based on the clinical menstrual cycle criteria. (2|⊕⊕oo)
- If establishing a diagnosis of menopause is necessary for patient management in women having undergone a hysterectomy without bilateral oophorectomy or presenting with a menstrual history that is inadequate to ascertain menopausal status, ES suggests making a presumptive diagnosis of menopause based on the presence of vasomotor symptoms (VMS) and, when indicated, laboratory testing that includes replicate measures of follicle-stimulating hormone (FSH) and serum estradiol. (2|⊕⊕oo)
Health Considerations for All Menopausal Women
- When women present during the menopausal transition, ES suggests using this opportunity to address bone health, smoking cessation, alcohol use, cardiovascular risk assessment and management, and cancer screening and prevention. (US)
Table 1. Definitions of Spectrum of Menopause
Term and Definition
- Menopause
- Clinical status after the final menstrual period, diagnosed retrospectively after cessation of menses for 12 mo in a previously cycling woman and reflecting complete or nearly complete permanent cessation of ovarian function and fertility.
- Spontaneous menopause
- Cessation of menses that occurs at an average age of 51 y in the absence of surgery or medication.
- Menopausal transition (or perimenopause)
- An interval preceding the menopause characterized by variations in menstrual cycle length and bleeding pattern, mood shifts, vasomotor and vaginal symptoms and with rising FSH levels and falling anti-Mullerian hormone and inhibin B levels, which starts during the late reproductive stage and progresses during the menopause transition.
- Climacteric
- The phase in the aging of women marking the transition from the reproductive phase to the nonreproductive state. This phase incorporates the perimenopause by extending for a longer variable period before and after the perimenopause.
- Climacteric syndrome
- When the climacteric is associated with symptomatology.
- Menopause after hysterectomy without oophorectomy
- Spontaneous cessation of ovarian function without the clinical signal of cessation of menses.
- Induced menopause
- Cessation of ovarian function induced by chemotherapy, radiotherapy, or bilateral oophorectomy.
- Early menopause
- Cessation of ovarian function occurring between ages 40 and 45 in the absence of other etiologies for secondary amenorrhea (pregnancy, hyperprolactinemia, and thyroid disorders).
- Primary ovarian insufficiency (POI)
- Loss of ovarian function before the age of 40 y with waxing and waning course and potential resumption of menses, conception, and pregnancy. The prevalence of POI is approximately 1% and is differentiated into idiopathic, autoimmune (associated with polyglandular autoimmune syndromes), metabolic disorders, and genetic abnormalities (including fragile x premutation).
Table 2. Conditions That May Cause or Mimic Vasomotor Events and That Can Be Distinguished From Menopausal Symptoms by History, Examination, and Investigations, as Indicated
Hormone excess
- Thyroid hormone excess
- Carcinoid syndrome (flushing without sweating)
- Pheochromocytoma (hypertension, flushing, and profuse sweating)
Dietary factors
- Alcohol
- Spicy food
- Food additives (e.g., monosodium glutamate, sulfites)
Pharmaceuticals
- Chronic opioid use
- Opiate withdrawal
- Selective serotonin reuptake inhibitors (SSRIs) (may cause sweats)
- Nicotinic acid (intense warmth, itching lasting ≤30 min)
- Calcium channel blockers
- Medications that block estrogen action or biosynthesis
Chronic infection (increased body temperature)
Other medical conditions
- Postgastric surgery dumping syndrome
- Mastocytosis and mast cell disorders (usually with gastrointestinal symptoms)
- Some cancers: medullary carcinoma of the thyroid, pancreatic islet-cell tumors, renal cell carcinoma, lymphoma
- Anxiety disorders
Table 3. Genitourinary Syndrome of Menopause
Symptoms
- Vulvar pain, burning, or itching
- Vaginal dryness
- Vaginal discharge
- Dyspareunia
- Spotting or bleeding after intercourse
- Dysuria, urinary frequency, urgency
- Recurrent urinary tract infections
Signs – external genitalia
- Decreased labial size
- Loss of vulvar fat pads
- Vulvar fissures
- Receded or phimotic clitoris
- Prominent urethra with mucosal eversion or prolapse
Signs – vagina
- Introital narrowing
- Loss of elasticity with constriction
- Thin vaginal epithelial lining
- Loss of mature squamous epithelium
- Pale or erythematous appearance
- Petechiae, ulcerations, or tears
- Alkaline pH (>5.5)
- Infection (yellow or greenish discharge)
Derived from D. J. Portman et al: Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women’s Sexual Health and the North American Menopause Society. Menopause. 2014;21:1063–1068, with permission.
