The Rational Clinical Examination
David L. Simel, Drummond Rennie
Menopause
Lori A. Bastian, Crystal M. Smith, Kavita Nanda
Inhibins
Topics Discussed:
depressed mood, diagnostic process, hot flashes, hysterectomy, irritable mood, menopause, night sweats, perimenopause, smoking, urinary incontinence, women's health
Excerpt:
"This evaluation can be divided into 5 basic categories: self-assessment,
symptoms, family and medical history, physical signs, and laboratory
tests.Clinicians can ask a woman whether she thinks she is starting
menopause. Women may base their perceptions of their menopausal
status on awareness of the subtle changes taking place in their bodies.10,11 In
a cross-sectional study by Garamszegi et al,10 self-reported
menopausal status was more correlated with symptoms than menstrual
cycle characteristics.Hot flashes are sudden sensations of heat, sweating, and flushing
that most often occur in the face, head, neck, and chest. Chills,
clamminess, and anxiety also may accompany hot flashes. They generally
last 1 to 5 minutes, though 6% of women experience hot
flashes lasting longer than 6 minutes.12 Most North
American, European, and Australian women report that they experience
hot flashes (50%-85%)9,12-14 and
that they occur periodically during a span of 1 to 5 years.15,16 There
appear to be cultural differences in the reporting or experiencing
of hot flashes. For example, only 10% to 20% of
Indonesian women17 and 10% to 25% of
Chinese women18 report experiencing them. The mechanism
triggering these episodes is thought to be a combination of fluctuating
estradiol levels and a narrowing of the thermoneutral zone.19Genetic factors seem to predispose women to menopause at an earlier
age.44,45 Torgerson et al44 reported
that women with premature (<40 years) and early (<45 years)
menopause report significantly younger maternal menopausal ages
than did women with normal menopausal ages. In a case-control study
of women from the greater Boston area, Cramer et al45 found
that women with a family history (eg, mother, sister, aunt, grandmother)
of menopause before age 46 years had a higher risk of early menopause
(odds ratio, 6.1; 95% confidence interval [CI],
3.9-9.4).One proposed assessment of vaginal estrogen deficiency is an
evaluation of the vaginal epithelium maturation index. This procedure
involves obtaining cells from the junction of the upper and middle third
of the lateral vaginal wall with a brush. These cells are prepared
on a slide with the Papanicolaou technique, and the percentages
of parabasal, intermediate, and superficial cells are counted.66 Although
the maturation index changes significantly after estrogen replacement
therapy, diagnostic studies have not compared the maturation index
with menstrual cycle characteristics.Measurement of FSH plasma levels has been used to try to identify
perimenopausal and postmenopausal women. High FSH levels indicate
that menopausal changes are occurring in the ovary. As the ovary
becomes less responsive to stimulation by FSH from the pituitary
gland (and produces less estrogen), the pituitary gland increases
production of FSH to try to stimulate the ovary to produce more
estrogen (Figure 31-1). However, some clinicians
and researchers doubt the clinical value of FSH measurements in
perimenopausal women because FSH levels fluctuate considerably each
month, depending on whether ovulation has occurred.2,69,70..."
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