Menopause

Menopausal symptoms can be very distressing and often affect a woman’s personal and social life

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Menopause is a non-pathologic condition involving the permanent cessation of menstruation for at least 12 months due to the loss of ovarian follicular activity.1

The transition from the reproductive period to the first year of postmenopause is called perimenopause. This transitional period occurs over several years and is associated with substantial biological changes.2

Perimenopause can be described according to the following stages (Figure 1):2

During this perimenopausal period, there are fluctuations in sex hormones which are more marked than the fluctuations which occur with a normal menstrual cycle and menopausal symptoms may appear during this time.2

In the postmenopausal period, there is a decrease in oestrogen production by the ovaries which leads to common menopausal symptoms such as hot flashes, vaginal dryness, and disrupted sleep (with or without associated night sweats).1

These symptoms typically begin between the ages of 51 and 52. However, about 5 % of women experience early menopause between the ages of 40 and 45.3

THE MENOPAUSE TRANSITION - EXPLAINED

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Figure 1:4

MENOPAUSE AND ITS SYMPTOMS

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Women are often puzzled by the changes in mood, sleep patterns, memory and body shape that occur, as well as the onset of vasomotor and urogenital symptoms (Figure 2).

As menopausal symptoms can be very distressing and often affect a woman’s personal and social life, healthcare providers caring for women at all levels of the healthcare system must be well prepared to guide patients through this transition and provide advice to improve quality of life.2

Vasomotor symptoms:
Vasomotor symptoms afflict most women during the menopausal transition, although their severity, frequency, and duration vary widely between women. Hot flashes are reported by up to 85 % of menopausal women.3,5

These symptoms are caused by resetting and narrowing of the thermoregulatory system in association with fluctuations in or loss of oestrogen production.5

Urogenital symptoms and Vulvovaginal atrophy:
Although they are not frequently reported, urogenital symptoms are often present after menopause.2 Urogenital tissues are extremely sensitive to oestrogen.5

The mucosal layer of the vagina begins to atrophy due to decreased oestrogen levels, which causes this cell layer to become drier and thinner.  As a result, the vaginal mucosa loses its elasticity and becomes fragile.3

Multiple population– and community-based studies confirm that 27 % – 60 % of women report moderate to severe symptoms of vaginal dryness or dyspareunia (genital pain before, during, or after intercourse) in association with menopause.5

Sleep disruption
Sleep difficulties, particularly night awakenings, are major complaints and are reported by 40 – 60% of menopausal women.2

 

Mood changes
Depressive symptoms may be worsened by lack of sleep and environmental stressors which are often prevalent during midlife.

Several large studies have shown an increased risk of depressed mood during the menopause transition and an approximately 3-fold risk for the development of a major depressive episode during perimenopause compared with premenopause.5

 

Cognitive changes
Perimenopausal women often report a decline in memory and concentration.2

 

Migraines
The prevalence of migraines during menopause ranges from 10 % to 29 %. It seems that women who are susceptible, particularly those with premenstrual migraines during fertile yearshave more migraine headaches as they transition through menopause.2

Weight and metabolic changes
One of the main complaints from women at midlife is increased weight. The prevalence of obesity is higher in postmenopausal women than in premenopausal women.2

 

Cardiovascular changes
Atherosclerosis and the risk of cardiovascular adverse events increase in women after menopause.2

 

Sexual dysfunction
Longitudinal and cross-sectional studies have reported that the menopausal transition is associated with a decrease in sexual desire, independent of ageing. Specifically, the menopausal transition is characterised by a change in hormone-driven sexual desire.2

 

Musculoskeletal symptoms
A major concern in menopausal women is a decline in bone health. Postmenopausal osteoporosis is a degenerative bone disorder characterised by reduced bone marrow density (BMD).2

 

Skin, mucosal and hair changes
Menopause reduces skin thicknesselasticity and hydration and leads to an increase in wrinkling.2

DIAGNOSIS

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Generally, no laboratory tests are required for the diagnosis of menopause. The diagnosis is clinically based on the patient’s age, symptoms, and ruling out other conditions for patients older than 45 years old.3,6

HORMONAL REPLACEMENT THERAPY

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Hormone Replacement Therapy (HRT) is considered to be the most effective way to relieve menopausal symptoms. It has been used in clinical practice for over 60 years since the 1960s; however, the benefits and risks of HRT have been controversial.1

In 2002, the Women’s Health Initiative (WHI) found that HRT increased the incidence of coronary heart disease and breast cancer, which led to a precipitous decline in the use of HRT.

Upon further analysis of the WHI data and with support from newer studies, international societies and organisations such as the International Menopause Society (IMS), the North American Menopause Society (NAMS), the European Menopause and Andropause Society (EMAS) have formulated guidelines and announced consensus opinions on the use of HRT.1

As understanding of HRT improves, studies have found that HRT is highly beneficial to symptomatic women who are younger than 60 years of age, within 10 years of menopause, and without contraindications such as active liver disease or thromboembolic disease.1




  1. Pan M, Pan X, Zhou J, et al. Update on hormone therapy for the management of postmenopausal women. Biosci Trends. 2022 Mar 11;16(1):46-57.
  2. Monteleone P, Mascagni G, Giannini A, et al. Symptoms of menopause – global prevalence, physiology and implications. Nat Rev Endocrinol. 2018 Apr;14(4):199-215.
  3. Tenny S, Boktor SW. Incidence. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430746/.
  4. https://drkathleenmahannah.com/blog/perimenopause.
  5. Santoro N, Epperson CN, Mathews SB. Menopausal Symptoms and Their Management. Endocrinol Metab Clin North Am. 2015 Sep;44(3):497-515.
  6. NICE. Menopause: diagnosis and management. NICE guideline. 2015. Available at: https://www.nice.org.uk/guidance/ng23.

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