Key Feature 1: In any woman of menopausal age, screen for symptoms of menopause and (ex: hot flashes, changes in libido, vaginal dryness, incontinence, and psychological changes).
Skill: Clinical Reasoning, Patient Centered
Phase: History, Hypothesis generation
Key Feature 2: In a patient with typical symptoms suggestive of menopause, make the diagnosis without ordering any tests. (This diagnosis is clinical and tests are not required.)
Skill: Clinical Reasoning
Key Feature 3: In a patient with atypical symptoms of menopause (ex: weight loss, blood in stools), rule out serious pathology through the history and selective use of tests, before diagnosing menopause.
Phase: Hypothesis generation, History
Key Feature 4: In a patient who presents with symptoms of menopause but whose test results may not support the diagnosis, do not eliminate the possibility of menopause solely because of these results.
Skill: Clinical Reasoning
Key Feature 7: In a menopausal or perimenopausal women, provide counselling about preventive health measures (ex: osteoporosis testing, mammography).
Skill: Clinical Reasoning
Key Feature 4: In menopausal or perimenopausal women, provide advice about fracture prevention that includes improving their physical fitness, reducing alcohol, smoking cessation, risks of physical abuse, and environmental factors that may contribute to falls (ex: don’t stop at suggesting calcium and vitamin D).
Skill: Clinical Reasoning, Communication
Phase: Treatment, Hypothesis generation
Women have reached menopause once they've gone a whole year without having a menstrual period. The average age at which women start to go through the menopausal transition - when the changes secondary to fluctuating estrogen levels begin to occur - is on average around 47 years. This natural cluster bomb of erratic menstrual cycles and hot flashes, with a domino effect of other symptoms such as poor sleep, difficulty concentrating, and decreased mood, is a natural process, not a disease, although for some women it may certainly feel like something is very wrong. Indeed, there is a range of severity of menopausal symptoms that affect different women differently, and for those who are suffering, there are ways that modern medicine can help to alleviate some of the distress. So that is why we are trained to ask about the menopausal transition. Asking may lead to disclosure of symptoms a woman may perceive as par for the course that in fact don't have to be. Imagine shooting 18 holes carrying your own bag vs hopping in a golf cart. You still have to get through it, but it doesn't have to be such an arduous process. You may get your ball stuck in a few sandpits on the way, but with the right pitching wedge, you can avoid a lot of unnecessary frustration.
Besides the utility of knowing about menopausal symptoms in order to reduce these and improve quality of life in the here and now, knowing that a women is perimenopausal is useful in order to practice preventative medicine. When it comes to screening for disease, although some women are candidates for screening interventions just based on age alone and not menopausal status [ex: mammography, colorectal cancer screening, screening for diabetes], screening guidelines for osteoporosis include candidacy for bone mineral density based on menopausal status. It's also an opportunity to discuss with the patient that the menopausal transition increases their risk for osteoporosis, and that there are lifestyle interventions that can reduce their risk, including supplementation with vitamin D (approximately 800 units daily) and calcium (aiming for 1200 mg daily, no more than 500 mg from supplementation), regular exercise aiming to include resistance training at least 2-3 times per week, and avoiding excess substance use (tobacco cessation, no more than one drink of alcohol daily).
It is not uncommon to hear women present to clinic asking to have their hormones tested to see if they're going through menopause. However, in a women who is older than 45 years old with the symptoms of menopause, testing is simply unnecessary. At least in a women with symptoms that are classic menopausal symptoms, without atypical features, the chances of the symptoms being attributed to some other endocrine disturbance is just so small, probably like getting a whole in one on the first time playing a course. As well, not only is it unnecessary, it may be downright misleading. Hormones, especially early in the menopausal transition, fluctuate immensely, such that if a hormone level is in the normal range for a premenopausal woman, this absolutely doesn't rule out menopause. So hormones can be ordered, but in a women who is of the right age and with the classic presentation, testing for them adds little value, wastes a lot of money on the grand scheme of things, and is time better spent delving into the options to actually improve the symptoms that are causing the burden in the first place. If a women is presenting with features not quite in keeping with menopause, and in whom you do think you should investigate for the possibility of other things going on, FSH can be ordered to look for evidence of menopause. If FSH is >15, it suggests the patient is indeed in the menopausal transition. This doesn't mean something else isn't going on. As well, if the FSH is <15, this doesn't necessarily exclude menopause since the FSH level can be pretty all over the place earlier on in the menopausal transition. So, it is something that can be used to help with figuring out in a patient who presents with atypical features of menopause, but by no means is it a definitive diagnostic test.
To be confident at reassuring women that their symptoms are truly normal menopausal symptoms, it takes knowing the spectrum of normal in menopause. Classic symptoms of menopause are as follows, in order of usual appearance:
In a women who indeed is having menopausal symptoms, we know that hormone replacement therapy works to treat the hot flashes and other sequelae. But what are the risks? Cardiovascular, breast cancer, and clotting. UpToDate provides a table to assess the cardiovascular risks and whether the risk of HRT outweighs the benefits:
To assess breast cancer risk, check out this tool: https://bcrisktool.cancer.gov
And last but not least, consider whether a patient has other risk factors (apart from HRT if initiated) for developing a blood clot, according to the following table from UpToDate. If so, it is best to provide transdermal HRT.