Curriculum · Gynecology / Women's Health / Infertility / Perinatal Care / Birth Spacing
Menopause and hormone therapy
What it is
Perimenopause is the transition phase of about 4 years before the final period, during which cycles become delayed, heavy and prolonged. Premature ovarian failure is menopause before the age of 40, confirmed with FSH above 30 mIU/L on 2 occasions at least 1 month apart. Menopause itself is the permanent cessation of menstruation resulting from loss of ovarian follicular activity, and it can only be determined after 12 months of spontaneous amenorrhea, so the diagnosis is retrospective. The average age is 51, and the determinants named are genetics, cigarette smoking, which brings it 2 years earlier, nulliparity, toxic chemicals, chemo, pelvic radiation, epilepsy and medically treated depression. Premature ovarian failure has a prevalence of 5%. Climacteric is the term for the gradual changes of ovarian function that start before the menopause and continue thereafter for a while.
How it presents
Hot flushes come in the first 2 years, several times an hour, over the face, neck and chest, and are worse at night. With them come mood changes, sleep disturbance and fatigue. The vaginal changes are atrophic: dryness, itchiness, dyspareunia and postcoital bleeding. On speculum the atrophic vagina is pale, dry, shiny and smooth with loss of rugation, and when inflammation is added there is patchy erythema, patechia, visible blood vessels and bleed. Bladder symptoms are urgency, frequency, UTI and stress incontinence. The risk of coronary artery disease rises, and osteoporosis and osteoarthritis follow. Hot flushes are the hallmark: a sudden sensation of extreme heat in the upper body that lasts 1-5 minutes, typically over the neck, face and chest, several times a day and as often as several times an hour, with perspiration, flushing, clamminess, chills, anxiety and at times palpitations. About 80% experience them but only 20-30% seek treatment, and most resolve spontaneously within 4-5 years; they are the commonest indication for hormonal therapy. Before the periods stop the intermenstrual interval lengthens from a normal 25-35 days to 40-50 days, with skipped cycles, episodes of amenorrhea and more anovulatory cycles, and the heavy or prolonged bleeding of this phase comes from those anovulatory cycles and from prolonged exposure to unopposed estrogen, so it is more common in women with fibroids and in obese women. Among 472 healthy Omani women aged 40 to 60, somatic and psychological symptoms occurred more frequently than urogenital ones at every stage, and the three most frequent were muscle and joint pain at 73.3%, mental and physical exhaustion at 47.2% and anxiety at 46.6%.