Menopause Defined

A reader commented in my recent post that she was just a tad insulted when her doc implied that she was “in menopause”.

“Menopause! I had the period from HELL last week!”

She then goes on to wonder just what the difference is between menopause and peri-menopause, and asked that I address these definitions for her and her friends, because they are all a bit confused.

Happy to oblige, Sea Spray. The reason you’re confused is that it’s, well, confusing. Not to mention the fact that the terminology around menopause has recently changed.

But let’s see if I can make it simple.

Menopause

By definition, menopause is the date of the final menses. But you don’t get to call it your final menses until 12 months have passed with no intervening bleeding. Then, you get to look back and say “That was the date of my menopause!”. Of course, it’s a bit anti-climactic at that point…

If you have what you think is going to be your last period, and then you bleed again in the subsequent 12 months, then the clock resets at that new bleeding episode and we start the 12 month countdown all over again.

As to what to call yourself, you are not “menopausal”. You are either in your reproductive years, peri-menopausal or post-menopausal. The chart below may help you understand these terms.

Postmenopausal

Once it has been 12 months since your last menses, you are officially post-menopausal.

So what are you in that year while you are waiting to find out if that was your last period? You are peri-menopausal.

Perimenopausal

You are perimenopausal from the time from when you first start having variation in your menstrual cycle length to one year after the last menses. Other terms for the perimenopause are “menopause transition” or “climacteric”.

For some women, perimenopause is very short. For others, it encompasses a good deal of their forties and early fifties.

Hormonally, the perimenopause is characterized by fluctuating hormone levels and rising FSH levels. Cycles can range from textbook normal to skipping months at a time to occurring every few weeks. PMS can worsen. Periods can become very heavy and erratic. Mood swings can be problematic. Breast tenderness can be a bitch. And you can have hot flashes even while you are still having menses.

A simple way to remember the perimenopause is this – “Perimenopause is hell”.

Reproductive years

This one’s easy. It’s the years from menarche to the onset of the perimenopause.

The problem with this term is that it implies that the perimenopausal years are not reproductive. Tell that to the woman who gets pregnant in her perimenopause. Which definitely happens, by the way, so use birth control till you are post menopauseal.

What about the word Premenopausal ?

By definition, you are premenopausal for your whole reproductive life, until your final period.

Premenopausal is not really a helpful word, because it not distinguish the perimenopausal years. But it can occasionally be used to describe all those women out there who are still menstruating.

What about the word Menopausal?

When docs use that, they usually mean perimenopausal.

What does Menopause really mean?

The use of the last menstrual period as a defining moment in a women’s life is really an artificial construct based on the only outwardly measurable event we have marking the decline in ovarian function – the last episode of bleeding.

But it’s not like the ovaries give up the ghost at the final period. Many women’s ovaries keep chugging along for quite some time after the last menses, but in general cycling in an increasingly erratic fashion that is characterized by a lack of ovulation, absence of bleeding and lower and lower estrogen levels over time.

But this continuing ovarian function can make the perimenopause and early post-menopausal years a bit less predictable than some think. Not infrequently, my post-menopausal patients will complain of episodes of breast tenderness or PMS, and swear they are going to get a menses, but then nothing comes. And some women, even after 12months of amenorrhea, will occasionally have a full blown normal menses.

Take me, for example.

My Post-Menopausal Period

Just last month, a full 14 months since my last period, I had a miserable 3-4 weeks of bloating, breast tenderness, crankiness and a 5 pound weight gain, along with a pleasant little blip in libido, followed by a whopping migraine the likes of which I had not had for months, followed by a week long episode of vaginal bleeding.

Officially, this was an episode of post-menopausal bleeding. Not something to be ignored, since post-menopausal bleeding can be an early sign of uterine cancer. So I had a sonogram, which was normal. I didn’t have uterine cancer. It was, simply, a period. Just my ovaries popping up to say “We’re not dead yet!”

It’s all normal, because menopause is really a period of time, not a magic day. An episode of transition that can last for days, weeks, months and even years.

Which Reminds me of a Joke

A woman goes to her gynecologist for a check up. “Doctor”, she complains, “There are pennies coming out of my vagina.”

“Take this medicine”, says the doctor, “It should stop the problem.”

Two weeks later, the woman is back. “Well, the pennies stopped, but today I found a nickel.”

“Let’s increase the dose”, says the doctor, and writes her a new prescription.

Two weeks later, she’s back. “Now it’s dimes”, she complains.

The doctor reaches for his prescription pad.

“But doctor,” cries the woman. “What is wrong with me?”

“Nothing,” he says. “In fact, it’s completely natural. You’re just going through your change.”
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For information on Menopause, see

 

Cartoon copyrighted and used with permission from cartoonstock.com.

Chart from Straw (Stagng of reproductive aging workshop). J Clin Endocrinol Metab. 2007 Aug;92(8):3060-7. Epub 2007 Jun 5.

21 Responses to Menopause Defined

  1. Don’t ovaries continue to work post menopause? I was always of the belief that they didn’t die just went into gentle retirement after the hard slog of producing all those eggs!

  2. Thank you so much TBTAM for writing this. I am going to do another post about it linking to this post if alright with you. Finally…some straight information! I will also look up links when I have a chance.

    Great joke! 🙂

    I do have one question now.

    I understand that if you didn’t have your period for 14 months that means you were 14 months post menopausal. So during the last 2 months you should be able to go without birth control…right?

    BUT…does getting your period at that point technically mean that there is a possibility that you could get pregnant.

    I know the odds are unlikely but could you or anyone?

    I mean I am so ready to send up fireworks on the day I realize I am birth control free!! But the idea that there is even the remotest chance of becoming pregnant would be one bucket of ice water to my husband and really disappointing to me and worrisome.

    Say it ain’t so. 🙂

    Again…I truly appreciate this post and you are clarifying things for a lot of people.

    I have more comments and will come back later. Off to the races now! Where’s that cotton pony when you need it? Oh wait..wrong horse! 😉

  3. Seaspray,

    One word will put your mind at ease – vasectomy!

    This way you don’t have to put yourself into a category and worry about labels, timing, etc.

    TBTAM. It’s good to become more educated on this essential topic, but my “guy” genes are kicking in right now, and I feel an insatiable urge to change into sweats, sit in a recliner, shove my hand down my pants like Al Bundy and watch sports on TV. (My apologies for the run on sentence…)

  4. Ok, a maybe weird question….If you’re on the pill and use it to suppress bleeding most of the time (no breakthrough bleeding), how do you know when that last period might be?

  5. Love the post, the joke, and the comments. Just curious how the definition of menopause is altered by TAH&BSO. Does it start at the date of surgery or 12 months later (after that last period)?

  6. Anonymous – the answer to your question is “yes” – read the most again for more details.

    Seaspray – A postmenopausal bleed does not mean rpegnancy is likely -at that late juncture, it’s pretty near impossible. The risk of pregnancy is so low that I would not consider the need for birth control.

    Schruggling – I hear you. Maybe you want to head over to Grunt Doc – he has a nice post up today about how he almost killed himself once.

    Ananymous – If you are on the pill you won’t know when menopause hits. Generally I have patients stop the pill at some point near age 50-51 and see where they are.

    RL – Thanks. And yes, if one has a surgical menopause, then the date of menopause is the date of the surgery, and you’re pretty much post menopausal the next day.

    The STRAW terminology folks actually wants to make “postmenopausal” mean any time after the final menstrual period, but we can’t really date that till we know it’s final – which means 12 months later. So it’s really at 12 months that we call it. But if you have had an oophorectomy, then you know it’s final, so you get to call it right away.

    Of course, if you only had your uterus removed, and your ovaries are still there, then you can’t use the final menses to mean anything, and have to rely on hormonal testing to find out if your are really menoapusal.

    Confusing, right?

    Thanks all for your comments!

  7. And it’s even crazier when you throw PCOS into the mix. I am on BCP’s and still have problems with cysts on the ovaries and erratic periods…it’s frustrating. Ugh!

  8. I am in surgical menopause from ooperectomy at age 40. Someone told me that my hormones are still not equivalent to that of an older woman, and that it’s possible that my body is making enough estrogen elsewhere to compensate somewhat for the lack of ovarian estrogen. Is this true? Is my body chemistry identical to that of a 70 year old woman, or did it find some way to produce excess estrogen?

    This is an important issue to me as I don’t know whether I should stay on tamoxifen (for breast cancer) or switch to an aromatase inhibutor (the latter of which has only been tested on post menopausal women).

    Thanks!

  9. Laura-

    The decision between tamoxifen and an AI is best made with your concologist. I would set up a time with him/her to address these questions and decide the best course of treatment for your cancer.

    Good luck!

  10. TBTAM: Thanks, but I’m not asking you to give advice re: cancer. 🙂

    I’m only asking something that my oncologist doesn’t know: are estrogen levels in a 40 year old after oopherectomy equivalent to a 75 year old woman who has gone through natural menopause? Or, does the younger body make more estrogen in other parts of her body? Thanks!

  11. Great, great post! Loved the joke… love the overall tone… loved the careful explanations that anyone can understand (even a dense man like me)

  12. Anonymous –
    I don’t like to make gross generalizations about anything, becuase every woman is different. That said, the 40 year old with no ovaries may have lower hormone levels than the 70 yr ofd. especially when you consider testosterone, which the post menopausla ovary continues to produce, and which can be converted to estrogen.

    However, a 70 yr old can have delcineing testosterone leves and be similar to the 40 yr old.

    Why not just have your estrogen levels measure and settle the question?

  13. Wonderful post, and comments! I had my last period at age 50, never have had hot flashes or sweats, etc. But when my doc sent me four years later to a great endocrinologist for something else, he told me, by-the-by, that I was just in the beginning of menopause!?

    My mother got preggies a full 13 months after her last period at age 49!!! Gave me a beautiful, brilliant baby sister!

  14. The definition of “no periods for one year” is not applicable to spontaneous premature ovarian failure, at least not according to NIH POF website and many POF researchers. Also from POF support group (Q&A from Dr Sontoro who spent time researching POF): Generally, it is said that the diagnosis requires at least 4 months without a period and two FSH tests, taken at least one month apart that are greater than 40 (some doctors will use 30) mIU/ML

    Women with POF often have their follicles left, it just that for some reason – often auto-immune, ovaries don’t function. As a result, sometimes periods return after years without them. The probability of pregnancy is around 5-10% even after years without periods. The chance is better if a woman is younger or still menstruating. There was even one case of a 44 year old woman getting pregnant after 15 years without periods. For this reason, by the way, NIH doctors prefer cyclical HRT for younger women with POF: if there is pregnancy, the woman will notice the missed period.

  15. Kitty –

    You are correct – premature ovarian failure is indeed a separate diagnosis from normal menopause. It can present at any age, and management depends on the childbearing desires of the woman and other things beyond the scope of this post.

    Thanks for reading!

  16. Shruggling…if I could I would have my husband get a vasectomy in a heartbeat but is it fair this stage of the game? To me it is, but he was never willing and so I never pushed it. Also, I vaguely remember some study where having a vasectomy elevated cholesterol or did some coronary thing and is why I also didn’t push it at the time. I never knew if that was true though. it was more his resistance. But it seems from what I have read in urology blogs that it is a very simple procedure. Admittedly I have been jealous (happy for them) of my friends whose husbands had it done. The FREEDOM!

    TBTAM…thanks again for this wonderfully informative post. Love the jokes too! I am linking this because I am sure there are others that will benefit from your well laid out information.

  17. I’m 43, done having kids, had horrific cramps all my life, PCOS … I cannot wait for menopause!
    I seem to be in a drastic minority in our gender.
    The organs have served their purpose, and they do nothing but cause pain and discomfort and it takes medications (which I do not need, I’m on too many as it is)

    The sooner I can be done with them, the better. I’m also hoping my migraines disappear with the rest of the hormonal ups and downs … a girl can dream anyway

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