Menopause

Menopause means permanent cessation of menstruation at the end of reproductive life due to loss of ovarian follicular activity. It is the point of time when last and final menstruation occurs. The clinical diagnosis is confirmed following stoppage of menstruation (amenorrhea) for twelve consecutive months without any other pathology. As such, a woman is declared to have attained menopause only retrospectively. Premenopause refers to the period prior to menopause, postmenopause to the period after menopause and perimenopause to the period around menopause (40–55 years).

Climacteric is the period of time during which a woman passes from the reproductive to the nonreproductive stage. This phase covers 5–10 years on either side of menopause.

Perimenopause is the part of the climacteric when the menstrual cycle is likely to be irregular.

Postmenopause is the phase of life that comes after the menopause.

Age at which menopause occurs is genetically predetermined. The age of menopause is not related to age of menarche or age at last pregnancy. It is also not related to number of pregnancy, lactation, use of oral pill, socioeconomic condition, race, height or weight. Thinner women have early menopause. However, cigarette smoking and severe malnutrition may cause early menopause. The age of menopause ranges between 45–55 years, average being 50 years.

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Few years prior to menopause, along with depletion of the ovarian follicles, the follicles become resistant to pituitary gonadotropins. As a result, effective folliculogenesis is impaired with diminished estradiol production. There is a significant fall in the level of serum estradiol from 50–300 pg/mL before menopause to 10–20 pg/mL after menopause. This decreases the negative feedback effect on hypothalamopituitary axis resulting in increase in FSH. The increase in FSH is also due to diminished inhibin. Inhibin, a peptide, is secreted by the granulosa cells of the ovarian follicle. The increase of LH occurs subsequently.

Disturbed folliculogenesis during this period may result in anovulation, oligo-ovulation, premature corpus luteum or corpus luteal insufficiency. The sustained level of estrogens may even cause endometrial hyperplasia and clinical manifestation of menstrual abnormalities prior to menopause. The mean cycle length is significantly shorter. This is due to shortening of the follicular phase of the cycle.

Luteal phase length remaining constant. Ultimately, no more follicles are available and even some exist, they are resistant to gonadotropins Estradiol production drops down to the optimal level of 20 pg/mL → no endometrial growth → absence of menstruation.

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Following menopause, the predominant estrogen is estrone and to a lesser extent estradiol. Serum level of estrone (30–70 pg/mL) is higher than that of estradiol (10–20 pg/mL). The major source of estrone is peripheral conversion (aromatization) of androgens from adrenals (mainly) and ovaries. The aromatization occurs at the level of muscle and adipose tissue. The trace amount of estradiol is derived from peripheral conversion of estrone and androgens. Compared to estradiol, estrone is biologically less (about one-tenth) potent.

With times, the sources fail to supply the precursors of estrogen and about 5–10 years after menopause, there is a sharp fall in estrogen and also the trophic hormones. The woman is said to be in a state of true menopause.