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What is menopause?
Menopause is the time in a woman's life when the ovaries stop producing estrogen.
Menopause is usually recognized by the cessation of menstrual periods. Other
symptoms of menopause include flashes, mood changes, difficulty sleeping, and vaginal
dryness. If a woman is not menstruating because she has had a hysterectomy or
endometrial ablation, other symptoms of menopause often alert her that menopause is
starting.
When does menopause start?
The average age of the onset of menopause is 51 years, and it is most commonly occurs
from age 47 to 53. Perimenopause
is the period immediately before and after the onset of menopause, and averages 4 years.
How is menopause diagnosed?
A simple blood test measuring follicle
stimulating hormone (FSH) is usually all that is needed to diagnose
menopause.
What happens to periods during
menopause?
Although some women may abruptly stop
having menstrual periods, many women will notice that their periods space
out for months to years before bleeding stops permanently. Although
pregnancy is unlikely in this age group, it is essential to do a pregnancy
test to be absolutely sure.
Why is bleeding irregular in perimenopause?
Regular periods are the result of a precise hormone balance causing regular ovulation.
In perimenopause changes in hormone levels interfere with ovulation. If ovulation does not occur, the ovary will continue making estrogen, causing the
endometrium to keep thickening. This often leads to a late menstrual period followed
by irregular bleeding and spotting. This can also result in endometrial
polyps, a greater thickening called "hyperplasia," or in extreme
long-standing cases, cancer of the lining of the uterus.
How do I know if my bleeding is abnormal?
It is not unusual to have irregular bleeding for up to 6 months before
menstrual periods stop completely. Unless the bleeding is excessive, or
a woman it at high
risk for uterine cancer, this is generally not of concern.
I tell my
patients to notify me if they have:
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Bleeding that
requires the use of a pad every hour
for over 24 hours
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Bleeding that
lasts more than 2 weeks
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Any
bleeding after bleeding has be absent for
over 6 months.
(An exception is women who just has
started estrogen replacement therapy.)
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How is abnormal uterine bleeding
in menopause or perimenopause evaluated?
Traditionally, an endometrial biopsy, or sampling of the lining of the uterus
is done. This is a simple office procedure to rule out cancer or pre-cancer.
It is not accurate for diagnosing
polyps or
fibroids. Vaginal probe ultrasound is a quick and painless screening exam and
has frequently made endometrial biopsy unnecessary. It is also possible to look
directly into the uterus using a thin telescope called a hysteroscope.
Hysteroscopy is usually a simple office procedure that gives
far more information than endometrial biopsy alone.
Click here
to
learn more about hysteroscopy. While D&C (dilation and curettage) may
be used in an emergency to stop extremely heavy bleeding, I feel that as a diagnostic tool
it is obsolete and should be replaced by hysteroscopy with endometrial sampling.
How is abnormal uterine bleeding
in menopause or perimenopause treated?
As
in all women, the cause of the
abnormal bleeding first needs to be determined.
If the bleeding is caused by lack of ovulation, cycling with progesterone will
usually control the problem.
For
some women, surgery is the another alternative. Many women think that
hysterectomy is the only choice left, but many alternatives to hysterectomy
are available. Before deciding on any surgical treatment, it is
important to understand what alternatives to hysterectomy are available.
The
large number of surgical possibilities may at first seem confusing. Many
have fancy names and may be promoted as being the latest and the greatest.
It is easier to understand these surgical procedures when you realize that all
of them fall into one or more of the following categories:
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Removing the
uterus (hysterectomy) |
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Removing fibroids through an incision in the
abdomen or through a laparoscope
(myomectomy) |
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Removing fibroids or polyps through the
cervix
using a
resectoscope |
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Removing or destroying the lining of the
uterus
(endometrial
ablation) |
Most polyps
can be removed with the resectoscope. If I do this, I will usually
suggest doing an endometrial ablation at the same time to decrease the
risk that polyps will regrow. Endometrial ablation in a menopausal
woman takes quite a bit of skill, as the walls of the uterus are thin, but
in skilled hands the procedure is often an excellent alternative for
bleeding that would otherwise require hysterectomy.
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