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Source: Kalantaridou SN, Dang DK, Davis SR, Calis KA. Hormone Therapy in Women. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. Accessed June 8, 2012.

  • Climacteric
  • Change of life

  • Menopause is permanent cessation of menses after loss of ovarian follicular activity.

  • May be due to normal aging process, surgery (total abdominal hysterectomy, bilateral oophorectomy), medications (e.g., chemotherapy), or pelvic irradiation.

  • Loss of ovarian follicular activity; postmenopausal ovaries no longer primary site of estradiol or progesterone synthesis.
  • As women age, follicle-stimulating hormone (FSH) rises and ovarian inhibin declines. When ovarian function ceases, serum FSH concentrations are >40 IU/L. Menopause characterized by:
    • 10- to 15-fold increase in circulating FSH concentrations compared with concentrations of FSH in follicular phase
    • 4- to 5-fold increase in luteinizing hormone
    • >90% decrease in circulating estradiol concentrations

  • Median age at onset in United States: 51 years.
  • Cigarette smokers experience menopause 2 years earlier than nonsmokers.
  • Women who have undergone hysterectomy more likely to have earlier menopause.

Signs and Symptoms

  • Vasomotor symptoms (e.g., hot flushes and night sweats)
  • Vaginal dryness
  • Dyspareunia
  • Urogenital atrophy
  • Sleep disturbances
  • Sexual dysfunction
  • Impaired concentration and memory
  • Dysfunctional uterine bleeding may occur during perimenopause.

  • Complete medical history and physical examination.
  • Menopause determined retrospectively after 12 consecutive months of amenorrhea.

Laboratory Tests

  • Serum FSH levels exceed 40 IU/L when ovarian function has ceased.
  • Complete blood count (CBC)

Differential Diagnosis

  • Relieve symptoms.
  • Improve quality of life.
  • Minimize adverse effects.

  • Figure 1: Algorithm for pharmacotherapy of menopausal symptoms
  • Vasomotor symptoms usually require hormone treatment for <5 years.
    • Consider tapering and stopping hormone therapy after 2–3 years.
    • Without treatment, hot flushes usually disappear within 1–2 years.
  • Vaginal dryness because of vaginal atrophy often requires local or systemic estrogen therapy.
    • Topical estrogen cream, tablets, or vaginal ring
    • Vaginal estrogen may be more effective and avoids high circulating estrogen levels.

Figure 1.

Algorithm for pharmacologic management of menopause symptoms. a Tibolone is currently not approved for use in the United States. Reprinted with permission from Wells BG, DiPiro JT, Schwinghammer TL, et al. Pharmacotherapy Handbook. 8th ed. New York: McGraw-Hill, 2012.

  • Lifestyle modification, weight control, smoking cessation, exercise, and a healthy diet may improve mild vasomotor and/or vaginal symptoms.

  • Hormone Therapy
    • Estrogens
      • Most effective therapy for relieving vasomotor symptoms; different routes of systemic administration equally effective.
      • No increased risk of breast cancer if treatment stopped within 5 years.
      • Table 1: Preparations suitable for replacement therapy
      • Vaginal creams, tablets, and rings for treatment of vaginal atrophy
      • Table 2: Lower doses may effectively control postmenopausal symptoms.
      • Adverse effects:
        • Nausea
        • Headache
        • Breast tenderness
        • Heavy bleeding ...

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