Despite modern advances, the age at which menopause takes place has not changed, approximately age 51. However, women are now living to the average age of 81 years, spending roughly one-third of their lives post-menopause. The physiologic and psychological impact of this duration of time, which includes the transition leading up to menopause, can be enormous.

At 20 weeks of gestation, female fetuses have the maximum number of eggs they can have over their lifespan. From birth onward, this number decreases, either through atresia or ovulation, until the onset of menopause. Much of this journey is dictated by the interaction of a few key hormones.

At puberty, follicle stimulating hormone (FSH) from the pituitary stimulates the ovary to develop a follicle in preparation for ovulation. As the follicle develops, it secretes estrogen. This estrogen thickens the uterine lining, maintains vaginal blood flow and lubrication, and causes skin thickness and elasticity. As estrogen levels increase, it results in a surge of FSH and luteinizing hormone (LH, also from the pituitary), all leading to ovulation (i.e. release of the egg from the ovary). The remaining cells of the follicle in the ovary produce progesterone, which in turn further thickens and prepares the lining of the uterus for possible fertilization. If the egg is not fertilized, progesterone levels fall, resulting in menstruation. This pathway is called the hypothalamic-pituitary-ovary axis.

As a woman ages through late reproductive age, the number of follicles diminish. As the follicle supply diminishes, there is a surge of FSH in an attempt to recruit more follicles. This leads to earlier follicle recruitment, and shorter cycles. As follicle recruitment is hastened, the cyclical spikes in estrogen levels begin to mimic more of a sustained increased plateau. This in turn can increase the heaviness of the flow and exacerbate estrogen-dominant symptoms, such as increased PMS-like symptoms and agitation.

The early phases of the menopause-transition are characterized by relative hyper-estrogenism and hypo-progesteronism (resulting in lighter, more frequent bleeds as the elevated estrogen causes thickening of the uterine lining that cannot be maintained for a significant duration given the lack of a corresponding increase in progesterone levels).

Hypo-estrogenism dominates later phases, resulting in less frequent bleeds. At the average age of 51, a woman has her final menstrual period (FMP). At this stage, follicles are no longer being released and very little estrogen is produced. After 1 year without menstruation, the patient has officially entered stage menopause.

The variable secretion of estrogen as well as the overall declining amount being produced in the menopausal transition causes many of the first, and often most bothersome symptoms of the menopausal transition: hot flushes and night sweats. These symptoms are caused by the fluctuations in estrogen and the variable dilation of the blood vessels, resulting in unexpected and sudden increases of blood flow, often to the chest, face, and neck, which in turn can produce profuse sweating, heart palpitations, anxiety, and flushing. These symptoms can last anywhere from 1 to 5 minutes and can occur at night. The “night sweats” often lead to poor and disrupted sleep patterns and can lead to downstream consequences of being overtired and more prone to depression. Lack of circulating estrogen can cause other symptoms including vaginal dryness and atrophy, weight gain, bone loss, increased risk of osteoporosis, increased risk of heart disease, skin dryness and wrinkles, and increased risk for bladder infections.

The most effective therapy for hot flushes is estrogen. By increasing circulating estrogen, the thermoneutral zone is restored. The current recommendation remains “to use the lowest effective dose for the shortest duration” for the woman who decides that the benefits of therapy outweigh the risks. In general, patients should be started on a lower dose of estrogen and titrated upwards until the desired reduction in symptoms is achieved.

Progestogen refers to the class of both natural progesterone and the synthetic hormones usually derived from testosterone that mimic progesterone. Progestogen is a necessary adjuvant treatment for endometrial protection when the patient retains her uterus or has a history of endometriosis and is using estrogen. In order to prevent growth of the endometrial lining that can lead to endometrial hyperplasia and cancer, a minimum of 10–14 days of progestogen therapy should be given per month. Additionally, there is evidence that a more extended cycle of 14 days every 3 months can be used and that the levonorgestrel-intrauterine device (IUD) may be effective.

At RMRM, we’d be happy to devise a therapeutic plan that fits your needs exactly and alter it along the way to best suit your evolving health condition.