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  • Perimenopause begins with the onset of menstrual irregularity and ends 12 months after the last menstrual period, which marks the beginning of menopause. Menopause is the permanent cessation of menses caused by the loss of ovarian follicular activity. Women spend about 40% of their lives in postmenopause.


  • The hypothalamic−pituitary−ovarian axis controls reproductive physiology. Follicle-stimulating hormone (FSH) and luteinizing hormone (LH), produced by the pituitary in response to gonadotropin-releasing hormone from the hypothalamus, regulate ovarian function. Gonadotropins are also influenced by negative feedback from the sex steroids estradiol (produced by the dominant follicle) and progesterone (produced by the corpus luteum). Other sex steroids are androgens, primarily testosterone and androstenedione, secreted by the ovarian stroma.

  • As women age, circulating FSH progressively rises, and ovarian inhibin-B and anti-Mullerian hormone declines. In menopause, there is a 10- to 15-fold increase in circulating FSH, a 4- to 5-fold increase in LH, and a greater than 90% decrease in circulating estradiol concentrations.


  • Symptoms of perimenopause and menopause include vasomotor symptoms (hot flushes and night sweats), sleep disturbances, depression, anxiety, poor concentration and memory, vaginal dryness and dyspareunia, headache, sexual dysfunction, and arthralgia.

  • Signs include urogenital atrophy in menopause and dysfunctional uterine bleeding in perimenopause. Other potential causes of dysfunctional uterine bleeding should be ruled out.

  • Additionally, loss of estrogen production results in metabolic changes; increase in central abdominal fat; and effects on lipids, vascular function, and bone metabolism.


  • Menopause is determined retrospectively after 12 consecutive months of amenorrhea. FSH on day 2 or 3 of the menstrual cycle greater than 10−12 IU/L indicates diminished ovarian reserve.

  • The diagnosis of menopause should include a comprehensive medical history and physical examination, complete blood count, and measurement of serum FSH. When ovarian function has ceased, serum FSH concentrations exceed 40 IU/L. Altered thyroid function and pregnancy must be excluded.


  • Goals of Treatment: The goals are to relieve symptoms, improve quality of life, and minimize medication adverse effects.

Nonpharmacologic Therapy

  • Mild vasomotor and/or vaginal symptoms can often be alleviated by lowering the room temperature; decreasing intake of caffeine, spicy foods, and hot beverages; smoking cessation; exercise; and a healthy diet.

  • Mild vaginal dryness can sometimes be relieved by nonestrogenic vaginal creams, but significant vaginal dryness often requires local or systemic estrogen therapy.

Pharmacologic Therapy

  • Figure 31-1 outlines the pharmacologic treatment of women with menopausal symptoms. Food and Drug Administration (FDA)-approved indications and contraindications for menopausal hormone therapy (MHT) are shown in Table 31-1.

  • The decision to use MHT and the type of formulation used must be individualized based on several factors, including personal preference, age, menopause onset, the severity of menopausal symptoms, and MHT-associated risks.

  • Combined ...

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