Elsevier

The Lancet

Volume 371, Issue 9614, 1–7 March 2008, Pages 760-770
The Lancet

Seminar
Menopause

https://doi.org/10.1016/S0140-6736(08)60346-3Get rights and content

Summary

Menopause is the time of life when menstrual cycles cease, and is caused by reduced secretion of the ovarian hormones oestrogen and progesterone. Although menopause is a normal event for women, individual experiences vary, and some women seek medical advice for the management of symptoms. Many symptoms have been attributed to menopause, but only vasomotor dysfunction and vaginal dryness are consistently associated with this time of life in epidemiological studies. Other common symptoms such as mood changes, sleep disturbances, urinary incontinence, cognitive changes, somatic complaints, sexual dysfunction, and reduced quality of life may be secondary to other symptoms, or related to other causes. Trials of therapies for vasomotor dysfunction have shown improvements with oestrogen, gabapentin, paroxetine, and clonidine, but little or no benefit with other agents; adverse effects of these treatments must also be considered. Many questions about menopausal transition and its effects on health have not been adequately addressed.

Introduction

The transition to menopause is a complex physiological process, often accompanied by the additional effects of ageing and social adjustment. Historically, much medical knowledge of menopause drew on convention rather than on rigorously designed studies, which led to inappropriate care. Moreover, at times serious symptoms were regarded as normal concomitants of the time of life and not addressed further, and mild symptoms were overmedicalised.

Menopause results from reduced secretion of the ovarian hormones oestrogen and progesterone, which takes place as the finite store of ovarian follicles is depleted. Natural menopause is diagnosed after 12 months of amenorrhoea not associated with a pathological cause. Menopause can also be induced by surgery, chemotherapy, or radiation. Initially, the menstrual cycle lengths become irregular, and follicle-stimulating hormone (FSH) concentrations rise in response to decreased concentrations of ovarian hormones. As the menopausal transition progresses, menstrual cycles are missed and ultimately stop, as does ovulation. For some women, 3 consecutive months of amenorrhoea, or mean cycle lengths longer than 42 days, are predictors of impending menopause.2, 3

Several terms have been used to describe the events that take place during the menopausal transition. A model developed at the Stages of Reproductive Aging Workshop (STRAW)4 described seven stages of reproductive ageing (figure 1), which were subdivided into reproductive stages, characterised by regular menstrual cycles; menopausal transition stages, with variable menstrual cycles and high FSH values; and postmenopause stages, beginning with the final menstrual period, and lasting until the end of life. Definitions and models continue to be assessed and refined for clinical and research applications.5, 6, 7 Although models are useful to describe the general progression of events leading to menopause, substantial individual variation exists, including skipping stages and moving back and forth between stages.8

The menopausal transition usually begins when women are in their mid-to-late 40s, and can last several years, most commonly 4–5 years.9 The final menstrual period generally happens when women are between 40 and 58 years old,9 and a final menstrual period before 40 years of age is regarded as premature. Population studies suggest that smoking and low socioeconomic status are associated with premature final menstrual periods.10 Other factors can affect the age at which women have their final menstrual period, including age at menarche, parity, previous oral contraceptive use, body-mass index, ethnic origin, and family history.11 The age at which women have their final menstrual period varies across large surveys done in different countries. Mean ages of 50–51 years were reported in Italy, Iran, Slovenia,11 and the USA;12 and of 47–50 years in Korea, Lebanon, Singapore, Greece, Morocco, Mexico, Taiwan, and Turkey.11

Section snippets

Clinical manifestations

Many clinical manifestations have been attributed to menopause. Vasomotor episodes manifest as spontaneous sensations of warmth, usually felt on the chest, neck and face, and often associated with perspiration, palpitations, and anxiety. These episodes are described as hot flushes, hot flashes, and night sweats. The term “hot flush” indicates the sensation of heat; “hot flash” describes episodes with sweating, sometimes followed by a chill; however, the terms are often used interchangeably.

Management and treatment

Many questions about the menopausal transition and its effects on health have not yet been adequately answered. Considerable differences exist between individuals from different countries. Even in homogeneous populations, individual experiences of menopause vary, as do experiences of pregnancy. The best possible approach to the management of menopausal symptoms is to address each woman's unique needs.

Surveys in the USA indicate that physicians underestimate their patients' concerns about

Conclusions

Menopause is an expected life event for midlife women. Most women have transient symptoms that are manageable with self-care approaches, such as wearing layers of clothing, and lowering stress. Some women ask health providers for help to manage menopausal symptoms, especially frequent and severe vasomotor symptoms and vaginal dryness, that interfere with healthy living. Coexistent health concerns can complicate the presentation, and require independent assessment. Social changes that are common

Search strategy and selection criteria

Relevant studies were identified from comprehensive searches of MedLine (1966 to December, 2006) and the Cochrane database of systematic reviews and controlled trials (last accessed December, 2006). Search strategies focused on menopausal symptoms and therapies for symptoms using the terms climacteric and menopause with terms depression, depressive disorder, affect, mood disorders, quality of life, sex disorders or dysfunction, sleep disorder, urination disorder, vasomotor symptom,

References (126)

  • LW Maartens et al.

    Menopausal transition and increased depressive symptomatology: a community based prospective study

    Maturitas

    (2002)
  • M Sherburn et al.

    Is incontinence associated with menopause?

    Obstet Gynecol

    (2001)
  • L Dennerstein et al.

    Are changes in sexual functioning during midlife due to aging or menopause?

    Fertil Steril

    (2001)
  • L Dennerstein et al.

    Sexuality

    Am J Med

    (2005)
  • MJ Boulet et al.

    Climacteric and menopause in seven South-east Asian countries

    Maturitas

    (1994)
  • NE Avis et al.

    Is there a menopausal syndrome? Menopausal status and symptoms across racial/ethnic groups

    Soc Sci Med

    (2001)
  • CJ Haines et al.

    Prevalence of menopausal symptoms in different ethnic groups of Asian women and responsiveness to therapy with three doses of conjugated estrogens/medroxyprogesterone acetate: the Pan-Asia Menopause (PAM) study

    Maturitas

    (2005)
  • WA Ghali et al.

    Menopausal hormone therapy: physician awareness of patient attitudes

    Am J Med

    (1997)
  • D Grady et al.

    Discontinuation of postmenopausal hormone therapy

    Am J Med

    (2005)
  • HB Leonetti et al.

    Transdermal progesterone cream for vasomotor symptoms and postmenopausal bone loss

    Obstet Gynecol

    (1999)
  • H de Wit et al.

    Effects of acute progesterone administration in healthy postmenopausal women and normally-cycling women

    Psychoneuroendocrinology

    (2001)
  • JC Morrison et al.

    The use of medroxyprogesterone acetate for relief of climacteric symptoms

    Am J Obstet Gynecol

    (1980)
  • IB Meeuwsen et al.

    The influence of tibolone on quality of life in postmenopausal women

    Maturitas

    (2002)
  • MB Landgren et al.

    Tibolone relieves climacteric symptoms in highly symptomatic women with at least seven hot flushes and sweats per day

    Maturitas

    (2005)
  • A Baksu et al.

    Efficacy of tibolone and transdermal estrogen therapy on psychological symptoms in women following surgical menopause

    Int J Gynaecol Obstet

    (2005)
  • T Guttuso et al.

    Gabapentin's effects on hot flashes in postmenopausal women: a randomized controlled trial

    Obstet Gynecol

    (2003)
  • KJ Pandya et al.

    Gabapentin for hot flashes in 420 women with breast cancer: a randomised double-blind placebo-controlled trial

    Lancet

    (2005)
  • CL Loprinzi et al.

    Venlafaxine in management of hot flashes in survivors of breast cancer: a randomised controlled trial

    Lancet

    (2000)
  • MG Bergmans et al.

    Effect of Bellergal Retard on climacteric complaints: a double-blind, placebo-controlled study

    Maturitas

    (1987)
  • A Heyerick et al.

    A first prospective, randomized, double-blind, placebo-controlled study on the use of a standardized hop extract to alleviate menopausal discomforts

    Maturitas

    (2006)
  • W Wuttke et al.

    The Cimicifuga preparation BNO 1055 vs conjugated estrogens in a double-blind placebo-controlled study: effects on menopause symptoms and bone markers

    Maturitas

    (2003)
  • S Frei-Kleiner et al.

    Cimicifuga racemosa dried ethanolic extract in menopausal disorders: a double-blind placebo-controlled clinical trial

    Maturitas

    (2005)
  • H Nelson et al.

    Management of menopause-related symptoms. Evidence Report/Technology Assessment 120

    (2005)
  • EC Dudley et al.

    Using longitudinal data to define the perimenopause by menstrual cycle characteristics

    Climacteric

    (1998)
  • JR Taffe et al.

    Menstrual patterns leading to the final menstrual period

    Menopause

    (2002)
  • MR Soules et al.

    Executive Summary: stages of reproductive aging workshop (STRAW), Park City, Utah, July 2001

    Menopause

    (2001)
  • JM Johnston et al.

    Comparison of SWAN and WISE Menopausal Status Classification Algorithms

    J Women Health

    (2006)
  • SD Harlow et al.

    Evaluation of four proposed bleeding criteria for the onset of late menopausal transition

    J Clin Endocrinol Metab

    (2006)
  • JF Randolph et al.

    The value of follicle-stimulating hormone concentration and clinical findings as markers of the late menopausal transition

    J Clin Endocrinol Metab

    (2006)
  • Menopause Guidebook, 6th edn

  • EB Gold et al.

    Factors associated with age at natural menopause in a multiethnic sample of midlife women

    Am J Epidemiol

    (2001)
  • Melby MK, Lock M, Kaufert P. Culture and symptom reporting at menopause. Hum Reprod Update; 11:...
  • RF Casper et al.

    Neuroendocrinology of menopausal flushes: a hypothesis of flush mechanism

    Clin Endocrinol

    (1985)
  • RR Freedman et al.

    Core body temperature and circadian rhythm of hot flashes in menopausal women

    J Clin Endocrinol Metab

    (1995)
  • Assessing and improving measures of hot flashes: summary of an NIH workshop

    (Jan 20, 2004)
  • WJ Brown et al.

    Changes in physical symptoms during the menopause transition

    Int J Behav Med

    (2002)
  • A Koster et al.

    Anticipations and experiences of menopause in a Danish female general population cohort born in 1936

    Arch Womens Ment Health

    (2002)
  • SM McKinlay et al.

    The impact of menopause and social factors on health

  • NF Woods et al.

    Pathways to depressed mood for midlife women: observations from the Seattle Midlife Women's Health Study

    Res Nurs Health

    (1997)
  • Cited by (0)

    View full text