Perimenopause, menopause, and primary ovarian insufficiency: Clinical sciences

Menopause is defined as the cessation of menses due to loss of ovarian function. The diagnosis is made once menses have been absent for twelve months and, on average, occurs around age fifty-one. However, it can occur as early as between 40 and 45 years, in which case it’s called early menopause. Moreover, if menopausal symptoms and cessation of menses occur prior to the age of 40, that’s called premature ovarian insufficiency. Finally, perimenopause, or the menopause transition, defines the period of time between the onset of menopausal symptoms and one year after cessation of menses, regardless of age.

When a patient presents with a chief concern suggesting perimenopause menopause, or primary ovarian insufficiency… your first step should be a focused history and physical examination. The history might include abnormal uterine bleeding, amenorrhea, vasomotor symptoms such as hot flashes or night sweats, vaginal or vulvar dryness and itching and dyspareunia; as well as sleep disturbances.

Other reported symptoms might include changes in mood, weight gain, headaches, decreased libido, and cognitive changes. Of note, there’s high individual variability as to how long these symptoms last, for some women lasting up to 12 years!

Now, on the physical exam, you might find evidence of vaginal and vulvar atrophy. If you see these findings, your next step is to assess the patient’s menstrual status.

Here’s a high-yield fact! Genitourinary syndrome of menopause, or GSM, refers to a group of symptoms that are related to decreased estrogen levels at the genital epithelium. These symptoms include vaginal and vulvar dryness, burning, and irritation; dyspareunia; urinary urgency and frequency; and frequent urinary tract infections.

Let’s begin with patients who have had menstrual bleeding within the past twelve months. They might report fluctuations in bleeding patterns such as shortened cycle length, oligomenorrhea, or heavy bleeding. Bear in mind that bleeding patterns can also be affected by hormonal medications such as oral contraceptive pills, as well as intrauterine devices, endometrial ablation procedures, and hysterectomy. So if your patient is on hormone based medication, menopause assessment can be inconclusive.

Now, in the presence of menopausal symptoms, the first step is ruling out other causes of abnormal bleeding. So you should obtain thyroid stimulating hormone, or TSH; prolactin; human chorionic gonadotropin, or hCG;levels; and order a pelvic ultrasound. If TSH and prolactin levels are abnormal, if hCG is positive, or if the pelvic ultrasound demonstrates abnormal findings, consider an alternative diagnosis for abnormal bleeding. On the other hand, if TSH and prolactin are normal, the hCG is negative, and the ultrasound is normal, you can diagnose perimenopause.

When treating perimenopause, remember that symptoms vary in type and severity. Therefore, management is tailored to individual needs.

Counsel all patients regarding lifestyle modifications such as exercise, sleep hygiene, and stress management. Discuss expectations for future symptoms, the timeline of the menopausal transition, and the final menstrual period.

Consider hormonal management with systemic therapy such as combined oral contraceptives or progestins, which can regulate bleeding patterns and improve vasomotor symptoms. A progestin containing IUD, on the other hand, can manage abnormal bleeding, but doesn’t address systemic symptoms. Topical vaginal estrogen therapy can be used to treat symptoms of genitourinary syndrome of menopause.

Also consider non-hormonal therapy, including selective serotonin uptake inhibitors, SSRIs, which treat hot flashes as well as symptoms of anxiety or depression. Gabapentin can also help manage hot flashes. Finally, endometrial ablation is a surgical option to manage abnormal uterine bleeding, but it also won’t help with systemic symptoms.

Let’s switch gears and talk about patients whose menses have been absent for more than 12 months. First, if the patient is under the age of 40, suspect primary ovarian insufficiency. Then, obtain labs including an FSH, estradiol, TSH, prolactin, and hCG. If the FSH is less than or equal to 20 and serum estradiol levels are normal, it’s unlikely that the patient has primary ovarian insufficiency. Your other labs might be normal, but any abnormal value can point you to an alternative diagnosis for secondary amenorrhea.

On the other hand, if FSH is greater than 20, estradiol is low, TSH and prolactin are normal, and hCG is negative, the diagnosis is primary ovarian insufficiency, or POI. To confirm this diagnosis, repeat FSH and estradiol 4 weeks later.

Management begins with counseling. Discuss lifestyle modifications like exercise, sleep hygiene, and stress management. Depending upon the age at diagnosis, patients may need psychosocial support as they navigate issues of fertility and self-image. Of note, some patients may ovulate after the diagnosis is made, and a small percentage of them can conceive spontaneously. If pregnancy is undesired, contraceptive counseling is indicated.