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Menopausal Transition

The transition towards the final menstrual period takes, on average, four years. This transitional period is characterized by irregular menstrual periods, hormonal imbalances, blood vessel related problems (hot flashes), sleep disturbances, and changes in sexual function.

In the early part of this transition, one notices a change in the gap between two periods.

Late transition has more dramatic menstrual cycle changes. Hot flashes are the most common symptom. Hot flashes are often associated with sleep disturbances.

Hot flashes

It is the most common symptom during the transition occurring in 80 percent women. Only 20 percent seek medical treatment. When hot flashes occur at night, they are described as "night sweats". They typically begin as a sudden sensation of heat centered on the upper chest and face that rapidly becomes generalized. Sensation of heat lasts from two to four minutes and is associated with profuse sweating and palpitations and sometimes followed by chills and shivering. They can occur several times in a day. Hot flashes are particularly common at night.

Genitourinary Symptoms

The surface cells of vagina require the hormone estrogen for normal functioning. During menopause, there is an estrogen-deficiency. Hence these tissues become thin. The tissue around the genitalia start to lose some mass, which gives rise to vaginal dryness, and painful sex. These are mostly seen in the later part of transition and also after menopause. Early in the transition, women might notice a slight decrease in vaginal lubrication upon sexual arousal, which is the first sign of estrogen deficiency.

Sexual Function

Estrogen deficiency leads to a decrease in blood flow to the vagina and vulva, which is the major cause of decreased lubrication. Symptoms related to genitourinary thinning are extremely responsive to estrogen therapy, in particular vaginal estrogen therapy.

Mood symptoms

Women in the transitional period, the perimenopause, have higher numbers of mood symptoms than women in whom menopause has set in or than in younger women.

Diagnosis

Clinically, menopausal transition is diagnosed in women over 45 years who have irregular periods as well as hot flashes, mood changes or sleep disturbances.

Menopause is diagnosed after 12 months of absence of periods in a woman of age 45 or older.

If a woman who is between 40 and 45 presents with irregular menstrual cycles and menopausal symptoms of hot flashes, mood changes and sleep disturbances, before she can be labelled as having menopausal transition, she should be evaluated by a gynecologist who should try to find other causes of irregular periods.

For women who are 40 years and below and who present with irregular menses and menopausal symptoms (hot flashes, sleep disturbances and mood changes), they need to be worked-up for the causes of premature ovarian failure.

Treatment:

  • The goal of menopausal hormone therapy(MHT) is to relieve menopausal symptoms, most importantly hot flashes. Other symptoms that respond to estrogen therapy include mood lability/depression, vaginal thinning and sleep disturbances.

  • Healthy symptomatic women in their 50s should know that the absolute risk of complications for healthy post-menopausal women taking hormonal therapy for five years is very low.

  • For peri and postmenopausal women in their 50s (or late 40s) with moderate-to-severe vasomotor symptoms, what is suggested is short-term HT as the treatment of choice. Exceptions include women with a history of breast cancer, coronary heart disease (CHD), a previous venous thromboembolic event or stroke (because of blood clotting), active liver disease, or those at high risk for these complications.

  • Transdermal i17-beta estradiol is recommended for most women starting MHT (Grade C-2). All types and routes of estrogen are equally effective for hot flashes, but transdermal preparations are associated with a lower risk of venous thromboembolism (VTE) and stroke (blood clots).

  • For women with an intact uterus who choose estrogen therapy, progestin therapy must be added to prevent endometrial hyperplasia and endometrial cancer(cancer of the inner lining of the uterus).

  • Micronized progestin (for above) is suggested.

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