Menopause

Description

• Natural menopause: 12 consecutive months of amenorrhea in a nonpregnant person with a uterus ≥40 years old; mean age of 51 years; resulting from loss of ovarian activity
• Perimenopause/menopausal transition (MT): the onset of irregular menses to the final menstrual cycle; begins on average 4 years before menopause; mean age of 47 years
• Postmenopause: usually >1/3 of a woman’s life
• Primary ovarian insufficiency: irregularity or cessation of ovulatory cycles before age 40 years
• Surgical menopause: removal of hormone-producing ovaries leading to immediate menopause

Epidemiology

• The median age of menopause is 51 years in the United States.
• 5% of people with a uterus undergo menopause after age 55 years; another 5% between ages 40 and 45 years
• Occurs earlier in Hispanic patients and later in Japanese American patients as compared with Caucasians

Incidence
In the United States, 1.3 million patients reach menopause annually.

Etiology and Pathophysiology

• As women age, the number of ovarian follicles decreases. Ovarian production of estrogen varies and then decreases. Follicle-stimulating hormone (FSH) production varies and then increases.
• Insufficient estradiol production leads to the absence of the luteinizing hormone (LH) surge, resulting in anovulation. Anovulation causes lack of progesterone production.
• Failure to produce estradiol leads to thinning of endometrial lining and eventually menstruation ceases.
• Estrone (produced by adipose tissue) becomes the dominant form of estrogen during menopause.

Risk Factors

Oophorectomy/hysterectomy; sex chromosome abnormalities (e.g., Turner syndrome and fragile X syndrome); family history of early menopause; smoking (earlier age of onset by 2 years); chemotherapy and/or pelvic radiation; low body mass index (BMI)

General Prevention

Menopause is a physiologic event and cannot be prevented. It is associated with increased risk of long-term medical issues, including cardiovascular disease (CVD) and osteoporotic fractures.

• Decrease risk of CVD by increasing exercise; maintaining healthy diet and a healthy weight; avoiding tobacco use; and treating hypertension, hyperlipidemia, and diabetes mellitus.
• Decrease risk of osteoporotic fractures with weight-bearing exercise and fall prevention, avoidance of smoking and excessive alcohol intake, dietary calcium of 1,200 mg/day, and adequate vitamin D intake.