Menopause Overview

Menopause refers to the condition when a woman’s ovaries stop producing eggs and female hormones due to age. This causes an end to menstrual cycles. For some women the menopause can produce uncomfortable symptoms such as hot flushes, night sweats, vaginal dryness, and thinning of the vaginal mucosa. The average age of menopause in the United States is 53 years old. Symptoms can start years before menopause is complete and last for years after. Menopause can usually be diagnosed simply from symptoms. An FSH level is a blood test that can be used to diagnose menopause if there is any question based on the symptoms.

150 years ago the life expectancy was only about 35 years old. Menopause was much less of a problem because most women did not live long enough to experience it. The life expectancy for women in the US was 81 years old in 2011. Menopause has become a much bigger issue because most women are living long enough to go through this change.

The ovaries’ primary functions are to produce eggs for reproduction and to make the hormones estrogen and progesterone. The ovaries do not function forever. At around 53, the ovaries stop functioning; this is the cause of menopause. The most obvious change is an end to the menstrual cycle, women stop having periods after menopause. The decrease in hormones can cause symptoms in some women. These include “vasomotor symptoms” like hot flushes and night sweats, thinning of the vaginal mucosa, and vaginal dryness. The degree that women experience these symptoms is extremely variable from one woman to the next. For some women these symptoms can be extreme and significantly impact the quality of life, for others the symptoms are non-existent.

Vasomotor symptoms are caused by the rapid changes in hormone levels, particularly estrogen. These changes effect neurotransmitters in the brain and cause hot flushes and night sweats. A hot flush, also called hot flash, is a sensation of warmth radiating throughout the body. It can be accompanied by redness of the skin and sweating. This usually lasts a short period of time and then goes away. For some women these can be infrequent and not bothersome, for others hot flushes can occur multiple times per day and cause significant problems with normal activities. Night sweats is essentially a hot flash during the night while sleeping. Women who experience night sweats often report waking up with the sheets soaked from sweat. For some women this can occur multiple times in the night and can significantly impact sleep cycle. Vasomotor symptoms typically go away several years after the menopause. It is thought that the body eventually adjusts to the decrease in estrogen levels and is able to thermo-regulate normally.

The skin and especially the covering of the vagina (vaginal mucosa) is sensitive to estrogen levels. As the estrogen levels decrease after the menopause, the vaginal mucosa tends to thin. In addition, the glands of the vagina make less discharge with less estrogen. This can lead to vaginal dryness, itching, and pain with intercourse. Unlike vasomotor symptoms, this tends to worsen over time throughout the life of the postmenopausal woman.

The diagnoses of menopause can usually be made by symptoms and lab tests are usually not necessary. If things are not completely clear by symptoms, an FSH level can be obtained. FSH is a hormone that the brain makes that instructs the ovary to make more hormones. If the brain is seeing a decrease in hormone levels it will produce more FSH to signal the ovary that it is not doing its job. In menopause, the FSH will be elevated because the ovary is incapable of producing estrogen no matter how hard the brain pushes it with FSH. The FSH begins to rise before the menopause is complete as the ovary becomes less efficient prior to completely shutting down. An FSH level is often done prior to menopause to check for fertility and the Peri-menopausal state, the time around menopause. In a non-menopausal women FSH levels to spike to menopausal levels in the days just prior to ovulation. This FSH spike is a signal the brain uses to induce ovulation. For this reason it is important to time the FSH with the menstrual cycle to be sure a high FSH is due to menopause and not this pre-ovulatory spike. I usually order FSH levels on cycle day 3 for this reason. Some doctors order estradiol levels as well as FSH levels. In my opinion this is not usually helpful as the FSH level generally gives the information needed to diagnose menopause.