As a woman ages, there is a natural depletion of ovarian oocytes. This point in time coincides with the cessation of menstrual cycles permanently and is defined as menopause. The diagnosis is typically made retrospectively after the woman has missed menses for 12 consecutive months. It marks the permanent end of fertility. However, clinically it doesn’t make sense to define it as a point in time when the menses stop. The changes can be broken down into three stages: Peri-menopause, Menopause proper, and Post Menopause. They are each distinguished by their symptoms which reflect the hormone changes that are occurring at the time.

The major hormonal changes associated with the occurrence of the final menstrual period in most patients include a significant drop in circulating oestradiol and progesterone, beginning up to about 1 year earlier, and an accompanying significant increase in the circulating gonadotropins like follicle stimulating hormone (FSH) and luteinising hormone (LH).

The diagnosis of menopause is usually made clinically, through the patient’s history and presenting symptoms. But laboratory testing may be performed to confirm the diagnosis of menopause. Elevated FSH and low estrogen (oestradiol), progesterone is consistent with menopause. Any hormonal therapy, including birth control pills, will invalidate the FSH and reproductive hormone tests. There are other medical conditions that can result in the lack of menses, so it is advisable to also check the patients thyroid function, prolactin level, and possibly other tests based on their history and physical examination.

Since menopause is due to the depletion of ovarian follicles/oocytes and severely reduced functioning of the ovaries, it is associated with lower levels of reproductive hormones, especially oestrogen and progesterone. These low circulating levels of hormones can result in vasomotor instability (such as hot flushes and night sweats), psychological changes (such as mood swings, depression, and difficulty concentrating), insomnia, genital tract atrophy (such as vaginal dryness, painful intercourse, and urinary incontinence), skin changes (such as thinning, formication and decreased elasticity). Lower androgen levels (testosterone) can contribute to the loss of sex drive. Any abnormal vaginal bleeding should be investigated immediately by the treating physician, since this may represent a precancerous or cancerous condition of the uterus or endometrial lining.

A vital understanding for treatment is that we cannot treat all women with a one-size- fits-all treatment. Combination oestrogen + progesterone therapy is the most effective means of treating symptoms of menopause. It will also help prevent bone loss. In a woman with an intact uterus, unopposed oestrogen therapy increases the risk of endometrial hyperplasia and cancer. Therefore, women who have not had a hysterectomy it is essential they take progesterone as well to provide endometrial protection. Each woman’s needs are highly specific, and these needs do change over the course of her transition.