LINDA FRENCH, MD East Lansing, Michigan From the Department of Family Practice, Michigan State University, East Lansing. The author reports no competing interests. Reprint requests should be addressed to Linda French, MD, Associate Professor, Department of Family Practice, Michigan State University, B101 Clinical Center, East Lansing, MI 48824. E-mail: Linda.French@ht.msu.edu. (J Fam Pract 2002; 51:271-276)
Laboratory testing is not indicated to initiate treatment of perimenopausal symptoms.
While estrogens are the best established of the options to treat vasomotor symptoms at perimenopause, they are not a proven treatment for major depression or poor libido.
Little evidence exists regarding the benefits and risks of androgens for perimenopausal women, suggesting a cautious approach to their use.
Routine use of hormone replacement therapy, especially beyond 5 years’ duration, is not recommended because of uncertainties regarding risks and benefits.
Menopause has been successfully promoted as an estrogen-deficient state. Prescriptions in the United States for noncontraceptive estrogen formulations increased from 16 million to 39 million between 1982 and 1992; progestin sales reached 4.7 million by 1992 after their introduction in 1986.1 A condition for which half of the population becomes eligible for pharmacologic treatment for 30 years or more of their life spans is worthy of family physicians’ attention. Counseling of women regarding menopause has also been incorporated into the Health Employer Data Information Set (HEDIS) for measuring the quality of care provided by health care plans.
The women of the generation born from 1946 to 1965 are now 36 to 55 years old. About half will at some time seek medical attention for relief of symptoms believed to be related to the menopausal transition.2 The clinical picture, however, can be confusing: women at midlife are susceptible to diseases that may affect or be affected by the menopausal transition. Life cycle changes can also provoke dysphoric symptoms similar to those of menopause or aggravate symptoms that already exist.
Natural history
A woman’s hormonal rhythm changes gradually, usually in the early to middle forties. Ovarian mass decreases progressively; production of ovarian hormones decreases as well. The menstrual cycles tend to be somewhat shorter. Follicle-stimulating hormone (FSH) and estrogen levels fluctuate. Estrogen levels may be transiently higher than in former years in response to higher FSH levels, recruiting more ovarian follicles. Anovulatory cycles are more frequent. Perimenopausal menstrual irregularity typically lasts for approximately 4 years; the large majority of women experience such irregularity for 1 to 7 years.2 For 10% of women, menses simply cease without prior menstrual irregularity.
The best estimate of mean age at menopause in the United States, based on a cohort of primarily Caucasian women, is 51.3 years.2 Smokers experience menopause 1.8 years earlier than nonsmokers (50.2 versus 52.0 years). Less than 10% of women reach menopause before age 46, while approximately 30% do so before age 50.2 A recent review3 concluded that the lifetime number of ovulatory cycles is predictive of age at menopause: earlier for women with shorter cycles and nulliparous women, later for multigravid women and those with a history of oral contraceptive use. A familial tendency toward similarity in age at menopause has been noted.
Premature menopause or premature ovarian failure is defined as cessation of menstrual periods before 40 years of age. The prevalence of premature ovarian failure is approximately 1% by age 40 and 0.1% by 30 years of age.4 Premature ovarian failure is frequently an autoimmune disorder.5
Diagnosis of menopause
The gold standard for diagnosing menopause is to do so retrospectively, 1 year after the last menstrual period. In general, a diagnosis of menopause based on menstrual history or hormone levels is not considered necessary to begin treatment for perimenopausal symptoms, which often begin several years before the onset of menopause.
Laboratory diagnosis
The extent to which FSH or other serologic markers can be used to diagnose menopause is controversial. The most important clinical reason to do so is to discontinue contraceptive methods safely. Some consider an FSH level greater than 40 mIU/mL to be diagnostic. This value was chosen because it is about 2 standard deviations above the periovulatory peak in FSH levels in regularly cycling women. However, longitudinal studies6,7 during the perimenopausal years have demonstrated that hormonal patterns that include FSH values greater than 40 mIU/mL often abruptly revert to premenopausal patterns and are accompanied by ovulatory cycles. For the individual patient, hormone levels do not appear to rule out fertility reliably.8 Studies defining test characteristics (sensitivity, specificity, likelihood ratios) of hormone assays for the diagnosis of menopause are needed.
History and physical examination
A large population-based survey of Swedish women9 found that the most common climacteric symptoms are, in order of frequency, vasomotor symptoms (hot flashes), mood disturbances, sleep disturbances, decreased libido, and vaginal dryness. Several observational studies10-13 have shown that vasomotor symptoms have the clearest temporal association with the menstrual cycle changes of the climacteric. These symptoms result from a sudden change in the hypothalamic control of temperature regulation,14 although the precise triggers have not been elucidated. Hot flashes occur commonly among women in their late thirties and forties who have regular menstrual cycles.15 Several studies2,10,13,16 have shown that the prevalence of hot flashes peaks in the year immediately following the final menstrual period. A typical pattern prevalence of hot flashes is 25% in premenopausal women, 69% in perimenopausal women, and 39% in late-postmenopausal women (more than 4.5 years).17 Fifteen years after menopause, 10% of women may continue to have moderate to severe hot flashes,18 which can be lifelong.
