Clinical features of the menopause transition

Denise is 47 years old. Recently her periods have become irregular and heavier. She is having hot flashes several times a day and she has been feeling tired and emotional, which she puts down to a poor sleep pattern. She has had to take time off work due to frequent migraine. She has four children and the youngest has just gone to university. She has been crying a lot. Her best friend has advised her to see her general practitioner as she thinks that Denise might be in “the change.” Before considering the various symptoms potentially attributable to the “menopause,” some of which Denise may be suffering from, a better understanding of the changes taking place can be gained by reviewing the physiology. This will help define the terminology. Whilst “menopause” means the “end of menstruation,” “menopausal symptoms” refer to a number of different symptoms associated with the climacteric, the transition from mature reproductive function, through the perimenopause to no ovarian follicular function. Postmenopause is the period a woman enters once she has not menstruated for at least 12 months. However, the hormonal changes leading up to this stage commence several years earlier, and this period is called the “perimenopause” or “menopause transition.” The physiological basis of these changes relates to the changes in a woman's ability to ovulate (Chapter 1). Normal ovulation is the culmination of a complex interaction between the various elements of the hypothalamic-pituitary-ovarian axis. Loss of regulation of these complex hormonal changes results in widely fluctuating levels of estrogen. The loss of a predictable cycle at this time is associated with the development of menopausal symptoms. Before menopause transition, estrogen and progesterone circulate throughout the body, and have many different effects on various systems, some of which we do not necessarily understand as yet. The development of the Graafian follicles with maturation of the oocyte, ovulation, and then subsequent formation of the corpus luteum is a complex process.