Basic: Module 2

Menopause - Definitions, Diagnosis

Agenda

• Define menopause

• Types of menopause

• Diagnosis of menopause

• Staging of menopause

• Initial assessment at menopause

• Classifying women to plan management

Transition In Women’s Life

• Menarche

• Pregnancy

• Menopause
Definition Of Menopause

• 12 months of amenorrhea
• Retrospective diagnosis
• Depletion of ovarian follicles
• Diminution of ovarian hormones
• No independent biological marker
• Objective sensitive marker—Irregular cycles
No need to conduct tests routinely to diagnose menopause
Diagnosis Of Menopause
• History - Symptoms

• Signs - Vaginal pH

Lateral vaginal smear

• Trial of Medication - Progesterone withdrawal

Response to HT
Diagnosis Of Menopause
• Laboratory
Tests

Tests Results

Serum FSH > 40 mlu/ml

Serum Estradiol < 20 pg/ml

AMH, Inhibin B Low

US < Antral Follicular Count

Markers for diagnosis of menopause are preferably restricted for

use in special situations and for fertility issues
Definitions

• Premenopause - Reproductive period prior to menopause

• Perimenopause - 3-5 years before and one year after menopause

• Menopause Transition - Disturbed menstrual cycle, endocrine

changes
Postmenopause And Senescence

• Postmenopause

It is the span of time dating from the final menstrual period,

regardless of whether menopause was spontaneous or iatrogenic

• Senescence

It is the period after the age of 60 years

Premature Menopause

• Spontaneous menopause occurring two standard deviations below the

mean estimated age for the reference population

• Traditionally, considered to be below the age of 40 years- we may

consider it as occurring below 38 years*

* We need population-based studies to derive at the cut off values

Clinical Practice Guidelines on Menopause 2012, updated 2015, Indian Menopause Society
Early And Delayed Menopause

• Early menopause: It is the time span between the spontaneous or iatrogenic

menopause occurring between the age of 40 years and the accepted typical

age of menopause for a given population

• Delayed menopause: It is not defined but may be important in terms of the

increased problems associated with the hyperestrogenism. It is two standard

deviations above from the natural average age of menopause in a given

population. We may consider it to be beyond 54 years

Induced And Temporary Menopause

• Induced menopause: Cessation of menstruation that follows bilateral

oophorectomy or iatrogenic ablation of ovarian function

• Temporary menopause: It is a term preferably not to be used, since

definition of menopause is complete cessation of menstruation.

Rarely, ovarian function is interrupted for a period of time and later

resumes
Postmenopausal Bleeding

• Postmenopausal bleeding is the occurrence of vaginal bleeding

following a woman’s final menstrual cycle and is not on cyclical

hormone therapy

• But, vaginal bleeding that occurs six months after amenorrhea

should be considered suspicious and warrants investigation

Age At Natural Menopause

• Estimated mean age of menopause is 46 years in India, and is lower

than that of the Caucasians

Clinical Practice Guidelines on Menopause 2012, updated 2015, Indian Menopause Society
Etiology Of Common Symptoms Of

Midlife Women: Aging Vs Menopause

• General aging

• Midlife – society, culture, life events

• Ovarian aging: perimenopause and postmenopause

Staging Systems: 

IMS Consensus Group

• Both modified classification of Anklesaria’s staging & stages of

reproductive aging workshop (STRAW) classifications, may be utilized

for Clinical Purposes and Treatment of Menopause

 Modified Anklesaria’s IMS Consensus 

Group Staging

Menopause
Stage I Stage II A Stage II B Stage III
Roughly 2 years before 1 year after last Up to 5 years after From 5 years postmenopausal
menopause period menopause till Late (postmenopausal )
Early (Premenopausal Atrophic changes Intermediate complications:
symptoms): IA Genitourinary (postmenopausal Residual changes from stage
Vasomotor instability IB Vasomotor symptoms): Late II
Early psychosomatic Weight gain psychosomatic and genital Ischemic heart changes
symptoms Osteopenia symptoms Other late complications,
Menstrual problems Sexual disorders e.g. Alzheimer’s disease,
Residual changes from stage Osteoporosis
II A osteopenia or
osteoporosis
PREVENT TREAT TREAT PALLIATE

Window of Opportunity
When Is Medical Intervention 

Required?
Changes At Menopause Transition
Who Manages Menopause?
Menopause Clinic
• Minimum Basic Requirement

- Core team- Gynecologist, Nurse, Receptionist

- Secondary team of visiting consultants

• Equipment

-Examination table with lithotomy position, Measuring tape,

Weighing machine, BP Apparatus, Speculums, Pap’s smear kits,
Laboratory/ Collection centre

• Stationary
 Menopause Performa

access-wwwindianmenopausesociety.org-domain Clinical practice guidelines on

menopause
Physician’s Role And Approach

Menopause + Aging

Symptomatic Preventive health Asymptomatic

Physician’s Role
• Assessment of symptoms

• Physical Examination

• Investigation

• Management - Group 1- Women without menopausal symptoms

Group 2- Women with menopausal symptoms

Physician’s Role

• Each group, is sub-classified

- Healthy with no co-morbidities, Healthy with significant risk factors,

Healthy with latent disease, Medically compromised

• Lifestyle management

• Pharmacotherapy after risk/benefit analysis

Menopause Clinic

• A young woman is a gift of nature

but an old woman is a work of art
 Is This Woman Pre/Peri/

Postmenopausal
When was your last period?

Less than 3 months Less than 12 months More than 12 months

ago Regular ago Irregular ago
Bleeding Bleeding
Natural Menopause
Premenopausal Perimenopausal
Removal of both ovaries?
Yes

Surgical
menopause
 Assessment History

Full assessment required irrespective of presenting reason of midlife

woman
Medical History
Menopausal symptoms Risk assessment of: Family History:
Gynaecological facts: Diabetes Cardio/cerebrovascular disease
Bleeding pattern or LMP Hypertension Osteoporosis/fractures
Past surgery (eg: hysterectomy/ Deep vein thrombosis, Dementia
oophorectomy) Thyroid dysfunction Cancer
Current use of hormonal therapy Liver disease
+/- contraceptive needs Osteoporosis, Current medication including OTC
Dietary History Arthritis, medications
Sleep History Climacteric depression
Sexual History Dementia
PMS, Postnatal depression, Cancers in general, breast, Social & Personal history
cervical , endometrial, Tobacco/alcohol use
ovarian
Calcium Calculator -Diet
• Quick dietary calcium assessment chart: A tool for a quick
assessment of total dietary calcium intake

Source Calcium (in mg)* No. Of Total Calcium

Servings (mg)
Dietary 300/1glass milk X
-
300/2 katori curds
Non-dietary 200–300 X
-
 Risk Factors – Osteoporosis

Modifiable Non-modifiable Environmental Factors

• Low BMI • Gender • Nutrition (calcium intake
• Smoking and • Advancing age using the quick dietary
• More than 3 drinks • Pr i o r f r a g i l i t y calculator, protein)
of alcohol per day fracture, or • Physical activity
(Grade A) • Family history of • Sunlight exposure which
fracture are important modifiable
risk factors in India
• Relevance of risk of
falling increases with
ageing (Grade A)
 Risk Factors – 

Cardiovascular Disease (CVD)
Modifiable Additional risk factors for
• Diabetes Non-modifiable
• Hypertension • Age more than 55 yrs stroke
• High LDL Cholesterol • Premature menopause < • Atrial fibrillation
• Low HDL Cholesterol
(<35mg/dl) 40 yrs • Asymptomatic carotid
• Elevated Triglycerides • Family history of CHD < stenosis
• Physical Inactivity
• Cigarette smoking 65 yrs
(current)
• Obesity
• Homocystenemia
• Lipoprotein(a),
• High risk CRP
Risk Factors – Deep Vein Thrombosis

• Personal or family history of clot, if so, when?

- While on Prolonged immobilization/surgery/ or while pregnant or

on the contraceptive pills

- Were tests performed to confirm the history/treatment with

anticoagulants for the clot?

Risk Factors – Diabetes Mellitus

Modifiable Non-modifiable

• Hypertension • Advancing age

• Family history
• Dyslipidemia
• Personal history of gestational
• Polycystic ovary syndrome
diabetes mellitus or impaired
• Physical inactivity
glucose tolerance
• Obesity
• Polycystic ovary syndrome
 Risk Factors – Alzheimer's Disease
Modifiable Non-modifiable
• Physical inactivity • Age

• Diabetes • Family history

• Hypertension • Genetic factor apolipoprotein APOE,

• • Auto-immune diseases
Dyslipidaemia
• Head trauma
• Smoking
• Traumatic brain injury
• Obesity
• Depression
• Stress & Social engagement
• Diet

Polypharmacy and thyroid disease are 2 examples of reversible causes of memory loss in older adults
Risk Factors – Breast Caner
Modifiable Non-modifiable
• Age at First Child • Age & Gender
• Breastfeeding • Benign Breast Disease
• BMI • Family History
• Alcohol • BRCA1 & BRCA2
• Hormone Therapy? • Menstrual History: Ages at
Menarche and Menopause
• Breast Density on Mammogram
• Medical History of Hodgkin’s
Lymphoma
Risk Factors – Endometrium Cancer
Modifiable Non-modifiable
• Obesity • Advancing Age
• Diabetes • Endogenous Estrogens
• Hypertension • Late menopause
• Polycystic Ovarian • Nulliparity and Infertility
Syndrome
• Genetic factor
• Unopposed Estrogen
Therapy
Assessment – Clinical Examination

Full assessment required irrespective of presenting reason of midlife

woman

Examination

Height & Weight Waist Circumference

Blood Pressure & CVS Physical fitness
Pelvic examination Assessment of mood and cognition
(+/- Pap Smear) Eye check-up—intraocular pressures,
Breast examination refractive index, and retina
Thyroid Examination Dental check up
Assessment – Investigations
Full assessment required irrespective of presenting reason of midlife woman

Laboratory Tests
Complete blood picture
Urine test routine
Fasting blood glucose level
Lipid profile
Ideal
Serum thyroid stimulating hormone
Papanicolaou (PAP) smear
Transvaginal ultrasound
Mammogram
Further targeted investigations are done depending on the risks of a disease
suspected on history and clinical examination
Health Check At Menopause
Recommendations Of DXA Scan In 

Indian Females

• All women 5 years beyond the age of natural menopause

• Women less than 5 years since Menopause with a particular risk factor

• Women with fragility fractures

• Women in Menopause transition with secondary causes

• Radiological evidence of osteopenia & presence of vertebral

compression fractures

Clinical Practice Guidelines on Post Menopausal Osteoporosis 2012,Indian Menopause Society

Recommendations Of DXA Scan In 

Indian Females

• Before initiating pharmacotherapy for osteoporosis

• The Interval Testing should be based on calculated individual risk,

mostly be scheduled between 1 & 5 years later

Clinical Practice Guidelines on Post Menopausal Osteoporosis 2012,Indian Menopause Society

World Health Organization

Osteoporosis Diagnosis

Normal BMD T-score between -1

and +1 SD
Low BMD SD T-score between -1
(Osteopenia) and -2.5
Osteoporosis T-score between
-2.5SD or lower
Severe T-score of -2.5 or
Osteoporosis lower and fracture(s)
T-score * Measured at the hip, spine or
wrist
Assessment – Investigations

Premenopause Peri and Early Menopause Postmenopause

Therapeutic Lifestyle
Management
• Health concerns including family history
• General health/disease management (lifestyle
issues such as physical activity, diet, smoking,
alcohol, obesity)

Contraceptive needs AUB

Management of:
• Menopausal symptoms
• Vulvovaginal atrophy
• Prevention of osteoporosis
• Sexual dysfunction
Management Plan At Menopause


Group 1 – Women Without Menopausal Symptoms

Group 2 – Women With Menopausal Symptoms
Management Plan At Menopause 

Group 1 – Women Without Menopausal Symptoms

a. Healthy with no problems, no symptoms - Institute preventive and

promotive care

b.Healthy with risk factors for disease, no symptoms—Evaluate, institute

preventive health care

c.Women with latent disease(pre-disease), no symptoms- Evaluate, treat

the disease, institute individualized lifestyle health care,

d.Women with co-morbidities, no symptoms- Treat the disease,institute

individualized lifestyle health care,
Management Plan At Menopause 

Group 2 – Women With Menopausal Symptoms

a) Healthy with no problems, symptoms of menopause

• Institute preventive and promotive care health care, treat with

MHT

b) Healthy with risk factors for disease , symptoms of menopause

• Institute preventive health care risk benefit analysis before

therapeutic intervention
Management Plan At Menopause 

Group 2 – Women With Menopausal Symptoms

c) Women with latent diseases, symptoms of menopause

• Institute individualized lifestyle health care, risk benefit analysis

before therapeutic intervention

d) Women with co-morbidities, symptoms of menopause

• Institute individualized lifestyle health care, treat the disease,

risk benefit analysis before therapeutic intervention