Menopause

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chapter 53 Menopause

DEFINING THE MENOPAUSE TRANSITION

Over the past two decades there has been much discussion about defining the terminology surrounding the last period. Sherry Sherman has aptly summarised some of the terminology, drawing together the WHO and International Menopause Society (IMS) recommendations (Box 53.1).1

BOX 53.1 Menopause terminology

Source: adapted from Sherman 20051

EPIDEMIOLOGY

In Western countries, the average age at FMP is 51 years, with a normal range of 40–60 years.2 The four or five years leading up to the FMP are characterised by menstrual irregularity, often initially cycle shortening, followed by cycle lengthening, although there is much normal variability. There are some minor variations in cycle patterns across different cultures but, as will be discussed later, quite marked differences in the symptoms are experienced across the menopause transition.

SYMPTOMS

Some of the symptoms experienced by women in the menopause transition are listed in Box 53.2.

The Melbourne Women’s Midlife Health Project is a prospective, longitudinal study of healthy women passing through the menopause transition.3 The study began in 1991 and used random telephone dialling to recruit Australian-born women aged 45 to 55 years. One hundred and seventy-two women were premenopausal at the time at baseline, and by the end of the seventh year of annual follow-up had advanced to the peri- or postmenopausal interval.

By the postmenopausal period, almost all had recorded at least one symptom—the most common being hot flushes. As women transited from the premenopausal to the postmenopausal phase, they noted significantly less breast pain, but significantly more hot flushes, night sweats and vaginal dryness.

CULTURAL DIFFERENCES

There appear to be marked cultural differences in attitudes to menopause. In a study of Sydney women, Asian women generally appeared to view menopause in a more favourable light than Western women, who linked menopause with ‘getting older’. Asian women were also less likely to admit to a healthcare professional that they were suffering from vaginal dryness, but if a doctor raised the issue, they were very grateful.4,5

Among Indian women, only 34% complained of hot flushes; more were concerned about depression and memory loss.6 Unemployment was associated with more flushing and depression. Lebanese Muslim women reported high rates of feeling tired and worn out, as well as aches and pains, as they went through the menopause transition.7 Sixty-three per cent reported hot flushes and more than half had noticed vaginal dryness during intercourse.

Chinese women largely see menopause as a natural process.8 A group of Sydney-based Chinese women had more vasomotor symptoms (34%) than those women who live in mainland China (10.5%) or in Hong Kong (10–20%). The top three symptoms reported by Sydney-based Chinese women were poor memory (76.4%), dry skin (69.1%) and aching in muscles and joints (68.3%). Some told the interviewers that their vaginal dryness problem was so severe that they had given their husbands permission to have sex with someone else.

Among Greek women, most were more concerned about back pain, aches, pains and fatigue than about hot flushes.9 Seventy-nine per cent of the postmenopausal Greek women had vaginal dryness, and there was a high rate of sexual problems.

THE MENOPAUSE CONSULTATION

HISTORY

The initial menopause consultation is a long session and often takes at least 30 minutes. It might be facilitated by some pre-reading and by using one of the many menopause-scoring charts that are available, such as the MENQOL (Menopause-specific Quality of Life Questionnaire, Table 53.1).10

The following should be particularly considered while taking a ‘menopause’ history:

TESTS

A woman aged in her forties with amenorrhoea or slight periods should be tested for pregnancy. If a woman has ‘hot flushes’ and her blood pressure is elevated, a 24-hour ambulatory blood pressure monitor will reveal whether the flushes are symptomatic of hypertension.

All that flushes is not menopause. Consider the differential diagnosis of ‘night sweats’ (see below) including viral infection, tuberculosis, neoplasm, hyperthyroidism, sleep apnoea, gastro-oesophageal reflux disease, alcohol excess and hypoglycaemia.12

There is no place for the routine measurement of hormone levels (e.g. FSH and oestradiol (E2)). During the normal menstrual cycle, E2 levels fluctuate from very low (below 100 pmol/L) to 500–1000 pmol/L at ovulation. FSH levels more than 20 U/L suggest that the patient is perimenopausal. The problem is that perimenopausal women can have even more variation than usual. It is not unusual for E2 levels to be greater than 2000 pmol/L and FSH levels can vary from less than 10 U/L to more than 40 U/L. The typical patient who is over 40 years of age with irregular periods and typical symptoms does not need her FSH and E2 measured.

If early menopause is suspected in a woman under 30 years of age, it might be prudent to measure her FSH levels three times over 2–3 months. In this way, the diagnosis is usually readily confirmed. Antimüllerian hormone (AMH) is a relatively new blood test that may give some information on ovarian reserve.

Use this opportunity to check the results of her last Pap smear, mammogram, bone density, lipids and blood glucose measurement, and ensure that a regular testing protocol is established for the perimenopause and postmenopausal phase.

MANAGING MENOPAUSE

There are a number of important issues for a woman and her doctor to be mindful of in managing the menopause but there are also a wide range of options available to a woman in managing those issues. The management objectives include ameliorating symptoms associated with menopause as well as making efforts to minimise the risk of other illnesses that become more common after menopause, such as heart disease, cancer and osteoporosis. The management approaches outlined below focus on lifestyle issues and specific medical and complementary therapies.

LIFESTYLE ISSUES: THE ESSENCE MODEL

MANAGING HOT FLUSHES

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