Chapter 105

### Introduction

Every woman should use what Mother Nature gave her before Father Time takes it away.

Laurence J Peter 1977

### Definitions

The menopause is the permanent cessation of menstruation in a non-hysterectomised woman. In most Western women it occurs between the ages of 45 and 55 years, with an average age of 51.5 years.1 Premature menopause is menopause occurring before age 40.

The WHO has defined the menopause as signifying the permanent cessation of menstruation, resulting from the loss of ovarian follicular activity.2 However, the term is used in a broader sense to include the perimenopausal phase when ovarian function waxes and wanes and the periods become irregular. This may last 2–5 years and sometimes longer and involves the premenopausal and menopausal phases.

The postmenopause is the period following the menopause but cannot be defined until after 12 months of spontaneous amenorrhoea, except in women who have had an oophorectomy.

Surgical menopause is known as bilateral oophorectomy.

#### Summary

The climacteric can be subdivided into four phases:

Phase 1 Premenopausal: up to 5 years before the last menstrual period.

Phase 2 Perimenopausal: the presence of early menopausal symptoms with vaginal bleeding (usually irregular).

Phase 3 Menopausal: the last menstrual period.

Phase 4 Postmenopausal: the phase beginning

12 months after the last menstrual cycle.

#### Osteoporosis

Osteoporosis, which literally means porous bone, is reduced bone mass per unit volume. Osteoporosis is usually addressed in the context of the menopause because it is found mainly in postmenopausal middle-aged and elderly women and can be largely prevented by correcting oestrogen deficiency.

### Physiology of the menopause

FIGURE 105.1 provides an overview of how menopausal symptoms are related to ovarian follicular activity and hormonal activity.

###### FIGURE 105.1

Schematic representation of some clinical, biological and endocrinological features of the perimenopausal and postmenopausal phases

Source: After Burger3

The number of ovarian primary follicles declines rapidly as the menopause approaches, with few if any being identifiable following the cessation of menstruation. In the postmenopause phase, FSH rises to levels 10–15 times that of the follicular phase of the cycle while LH levels rise about threefold. The ovary secretes minimal oestrogen but continues to secrete significant amounts of androgens.

An uncomfortable effect of oestrogen withdrawal, often not appreciated by medical practitioners, involves urogenital problems where the epithelium of the vagina, vulva, urethra and the base of the bladder becomes thin and dry, leading possibly to dysuria and frequency, itching, dyspareunia and atrophic bleeding. Hormone replacement therapy (HRT) can ameliorate these urogenital symptoms.

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