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Menopause

The reliability of ovarian function, both hormonally and reproductively peaks in the mid to late 20's. Beginning in the early thirties, there is epidemiologic evidence of a decline in fertility. By the mid thirties, there are subtle changes in the levels of FSH in the early follicular phase and become more marked in the 40's. These changes may not be reflected in clearly noticeable changes in the experience of an individual woman's menstrual cycle. As the mid 40s arrive, there may be a shortening of the length of the menstrual cycle which is a reflection of a declining pool of oocytes, declining inhibin, rising FSH and earlier efforts at recruitment and ovulation of the dominant follicle. The nature of these changes as perceived by an individual woman will be very different from person to person. The perimenopause is defined as that period around the menopause that is marked by unpredictable ovarian function and menstrual irregularity. Epidemiologic studies of normal women suggest that this is a period of about 4 years around the menopause although the variation from woman to woman is large. This time is marked by unpredictable ovulation and periods both higher and lower that usual estrogen levels. Uterine bleeding may be more or less than "usual" in flow and the timing of uterine bleeding is also unpredictable.

There are numerous physical and psychological phenomena attributed to this time of reproductive life (mood swings, vasomotor flushes, sleep disturbances, headaches, memory problems, decreased libido, urinary incontinence) but it is not clear which are related to fluctuations of ovarian function, which are related to aging, and which are psycho-social responses to mid-life which may vary from person to person and culture to culture.

The menopause is the retrospective diagnosis of the "final" spontaneous menstrual period. Usually a woman in her 50's who has not had a period for over a year may look back and note that her "menopause" was on a specific date of her last spontaneous period. The average age of menopause in American women is 51. Various inherited and environmental factors influence the age of menopause. Cigarette smoking, living at high altitude, exposure to some chemotherapeutic agents, and hysterectomy tend to slightly lower the age of menopause or final cessation of ovulation.

The climacteric is a term used for the transitional period including the perimenopause and the several years after the menopause. There are specific symptoms which some women may experience which are directly attributable to estrogen withdrawal (vasomotor flushes, urogenital atrophy) and there are some long-term aging and disease processes which are worsened by estrogen withdrawal such as osteoporosis. There are number of other symptoms of aging which may be worsened by estrogen withdrawal but the evidence is not so clear.

The post-menopausal ovary is still capable of producing substantial amount of weak androgens (ovarian stroma stimulated by menopausal levels of LH) which are peripherally converted to estrogens.

The eventual cessation of ovulation is a "normal" event in human development. Until the last several hundred years, human life span was usually less than 50 years of age. The existence of a population of women who predictably lived well beyond the age of reproduction is new in human history. Through epidemiologic studies in aging women, many who took estrogen hormones for the treatment of vasomotor flushes, it was noted that long term estrogen users had decreased incidence of complications of osteoporosis. The health benefits and risks of estrogen therapy after menopause have been continuously evaluated over the past 35 years and this therapy is now being subjected to prospective randomized trials. At present, estrogen therapy after menopause is recommended only to treat severe vasomotor symptoms and not for the prevention of cardiovascular disease. It use over five years may increase the risk of breast cancer, stroke and thromboembolic phenomenon. These risks should be assessed on an individual basis between the patient and her physician.

Observations from women who had a uterus and took only estrogen after menopause revealed an increased risk of uterine cancer. Unopposed estrogen stimulation of the uterus, whether due to endogenous estrogens or estrogen therapy, causes endometrial hyperplasia and potentially adenocarcinoma of the uterus. The intermittent addition of progestational agents for 12 days each month causing endometrial shedding eliminates this increased risk. For older women, the thought of monthly periods is unattractive and is one of the major reasons for lack of compliance in post- menopausal hormone therapy. Another concern is the possibility of a small increase in the risk of breast cancer in long-term estrogen users. Exogenous estrogens for the menopause may also have a very small increased risk of deep venous thrombosis and gall stone formation. Formulations for estrogens and progestins and combinations of both will be changing dramatically in the years to come as clinical research develops methods and formulations which alleviate hot flushes but do not stimulate the endometrium or breast.

It is recommended that you consult with your private physician regarding the risks and benefits of hormone replacement therapy in your individual situation.