Gynecology Notes – Papadopoulos DAF

Menopause

In a Nutshell:

A. Menopause is the permanent end of menstrual periods and thus of fertility (amenorrhea)

B. Manifestations may include hot flushes and vulvovaginal atrophy

C. Diagnosis is clinical: absence of menses for 1 year

D. Manifestations may be treated (eg, with lifestyle modification, complementary and

alternative medicine, and/or hormone therapy).

A. Physiology

Menopause results from loss of ovarian sensitivity to gonadotropin stimulation (LH +

FSH)

1. Anovulatory cycles + LH surge failure

2. Less follicles and more Resistant follicles

3. FSH and LH levels increase => Stromal cells of Ovary stimulation => Increase in Estrone

4. 4 year Perimenopausal Period (2 before and 2 after) – Estradiol decline due to follicle
failure – Main estrogen is Estrone coming from by the aromatization of androgens
(androstenedione) in the ovarian stroma + estrogen production in extragonadal sites
(adipose tissue, muscle, liver, bone, bone marrow, fibroblasts, and hair roots)
(peripheral aromatization of androstenedione produced by adrenal glands)

5. Decreased estradiol + progesterone

6. A shorter menstrual cycle (< 25 days) is the most common change in menstrual cyclicity
that occurs during the MT (menopausal transition) in women who continue to be
ovulatory – shorter follicular phase with 14 day constant luteal phase

B. Symptoms and Signs

1. Changes in the menstrual cycle: A persistent difference in consecutive menstrual cycle

length of ≥ 7 days defines early menopausal transition. Skipping ≥ 2 cycles defines late
menopausal transition.

The marked fluctuations in estrogen levels may contribute to other perimenopausal symptoms
and signs such as

 Breast tenderness
 Changes in menstrual flow
Gynecology Notes – Papadopoulos DAF

 Moodiness
 Exacerbation of menstrual migraines

Symptoms can last from 6 mo to > 10 yr and range from nonexistent to severe.

2. Vasomotor

Hot flushes (hot flashes, night sweats) on skin, especially of the face, head, and neck, may
become red and warm. The episodic flush, which may last from 30 sec to 5 min, may be
followed by chills. Flushes may manifest during the night as night sweats. Reason hypothalamic.

3. Vaginal

These symptoms include dryness, dyspareunia, and occasionally irritation and itching

4. Vulvovaginal atrophy

5. Genitourinary syndrome of menopause: eg. frequent UTIs

6. Neuropsychiatric: mood, insomnia etc

C. Diagnosis

1. Age of patient must be considered – 45-48 years is the normal symptoms starting age

2. Confirmation comes after 12 months of amenorrhea

3. Increased FSH levels measured in 2-3 months intervals

4. Vulvovaginal atrophy + Menopausal symptoms confirm the diagnosis

D. Treatment

A. Lifestyle

1. Cool environment

2. Avoid a lot of Light

3. Vaginal lubrication + Sexual intercourse

4. Hormonal Th ( Estrogen + Progestin ) : Increase risk of Coronary events, cancers plus

other disorders esp estrogen

They must be used only symptomatically and low dosage ( Forms: per os, transdermal,
cream, vaginal tablets etc. )

Progesterone for hot flushes

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Gynecology Notes – Papadopoulos DAF

Estrogen more potent for hot flushes and for vaginal dryness and atrophy + anti -
Osteoporosis

5. Risks and adverse effects

Risks with estrogen therapy or combined estrogen /progestin therapy include

 Endometrial cancer, mainly if women who have a uterus take estrogen without a
progestin
 Deep vein thrombosis
 Pulmonary embolism
 Stroke
 Breast cancer
 Gallbladder disease
 Stress urinary incontinence

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