Menopausal syndrome

Definition

• Menopause: last bleeding after 12 months of amenorrhoea.
• Average age in Germany: around 51 years.
• Perimenopause: period before and 1 year after menopause.
• Premature menopause (climacterium praecox): cessation of ovarian function before age 40.
• The underlying hormonal basis: depleted follicle reserve, oestradiol ↓, FSH ↑.

• The climacteric is the transition from the reproductive phase of life to the cessation of ovarian function; perimenopause covers the years before and the first year after the final menstrual period and is usually the most symptomatic phase.
• Menopause is the permanent cessation of menstruation due to loss of ovarian follicular function and is determined retrospectively after 12 months of amenorrhoea.

Classification

• Staging follows STRAW+10; the key criterion is menstrual cycle regularity, while FSH, AMH, inhibin B and the antral follicle count serve only as supportive criteria.
• The early menopausal transition is defined by a persistent difference in cycle length of at least 7 days, the late transition by intervals of amenorrhoea of at least 60 days.
• Early menopause occurs between 40 and 45 years; non-iatrogenic loss of ovarian function before the age of 40 corresponds to premature ovarian insufficiency.

Occurrence & epidemiology

Epidemiology

• Natural menopause usually occurs between 45 and 55 years, at an average age of 51 in the United States; smoking, living at high altitude and undernutrition may bring it forward.
• Hot flushes and night sweats affect the majority of women (reported figures 50–85%), usually begin before menses stop and last on average about 7 years, sometimes more than 10 years.
• Vulvovaginal atrophy, as part of the genitourinary syndrome of menopause, affects about 40% of postmenopausal women.

Aetiopathogenesis

Aetiology and pathogenesis

• The cause is the progressive decline in viable follicles; as ovarian inhibin and oestrogen levels fall, negative feedback on the pituitary is lost and FSH and LH rise substantially.
• Initially the follicular phase shortens, with shorter, less regular cycles, fewer ovulations and decreased progesterone production; markedly fluctuating oestrogen levels may cause breast tenderness, changes in menstrual flow and mood swings.
• Hot flushes result from changes in hypothalamic thermoregulation: as oestradiol falls, kisspeptin–neurokinin B–dynorphin (KNDy) neurons in the arcuate nucleus become hyperactive and trigger heat loss via the preoptic area.

Clinical features

Symptoms

• Cardinal symptom: hot flushes and sweating, i.e. vasomotor symptoms.
• Other common complaints: sleep disorders, mood swings, loss of libido.
• The genitourinary syndrome: vaginal dryness, dyspareunia, recurrent UTIs.
• What affects almost everyone, but is noticed late: accelerated bone loss.

More facts from the study questions

• The diagnosis is based on the clinical assessment of age, menstrual history and typical symptoms.
• Instrumental or laboratory diagnostics are not primarily necessary.
• Hormone testing is usually unnecessary with a typical clinical picture, as hormone levels can fluctuate widely.
• An indication exists, for example, if premature ovarian insufficiency is suspected.
• The term climacterium praecox describes the premature failure of ovarian function before the age of 40.

• Vasomotor symptoms: episodic hot flushes lasting 30 seconds to 5 minutes with a feeling of warmth, flushing of the face, head and neck and sweating, often followed by chills, and at night as night sweats with disrupted sleep.
• Poor concentration, forgetfulness, low mood and anxiety may transiently accompany perimenopause; a direct link with menopause is not established, but sleep disrupted by night sweats can contribute to fatigue and irritability.
• Genitourinary syndrome of menopause comprises vaginal dryness, irritation, itching, dyspareunia, urinary urgency, dysuria and recurrent urinary tract infections or vaginitis; unlike vasomotor symptoms, it progresses with age.
• Joint aches are less common; after menopause, LDL cholesterol rises and coronary artery disease becomes more common.
• Up to 20% of bone density is lost during the first 5 years after menopause; thereafter, the age-related rate of bone loss is similar to that in men.

Diagnosis

Diagnostics

• How the diagnosis is made: clinically: age, cycle, symptoms.
• The value of hormone testing: mostly unnecessary.
• What always requires investigation: any postmenopausal bleeding.

• The diagnosis is clinical; in women in their 40s with typical symptoms, perimenopause is likely.
• FSH is measured only rarely, for example in women without a uterus or in younger women; because of fluctuations during the transition a single value is of limited use, whereas consistently elevated levels confirm menopause.
• Examination shows vulvovaginal atrophy with thin, dry, friable mucosa and loss of rugae; vaginal pH rises, and a pH above 5 indicates an increased proportion of parabasal cells.

Keep learning in the app

Further reading (selection)

1. MSD Manual Professional: Menopause
2. Effects of menopause on temperature regulation (Temperature (Austin) 2025, PubMed Central)
3. DocCheck Flexikon, Klimakterium

Cross-references