7.1 Diagnosis of Natural Menopause

Natural menopause in a woman >45 years of age is diagnosed retrospectively following 12 months of amenorrhea and is associated with elevated gonadotrophins and oestrogen deficiency. Bilateral oophorectomy will induce immediate menopause. The diagnosis of the menopausal transition in a woman older than 45 years with menstrual disturbance and vasomotor symptoms is usually clinical.  Fluctuating gonadotrophin and oestradiol levels with ovulatory and anovulatory menstrual cycles are common and therefore hormone measurements are rarely useful.  (See section 4: Physiology Table: Changes across the menopause transition from pre- to postmenopause). 

7.2 Diagnosis of early/premature menopause

See the Early Menopause website for more information.

The clinical presentation of spontaneous premature menopause is variable (see Table: Clinical Presentation of Premature menopause) and includes menstrual disturbance or infertility. Menopausal symptoms, including vasomotor symptoms, may/may not also be present. It is important to remember that women taking the oral contraceptive pill have an artificial withdrawal bleed which does not reflect the natural menstrual pattern. The commonly used diagnostic criteria for premature menopause are shown in the Table: Diagnostic criteria for premature menopause. Gonadotrophin and oestradiol levels cannot be accurately assessed while a woman is taking the oral contraceptive pill which must be withdrawn for at least one month prior to hormone measurements (see laboratory investigations).

7.3 Diagnosis of menopause in women with Breast cancer

As most women diagnosed with BC are already postmenopausal, the diagnosis of menopause will usually have been made. Difficulties determining menopausal status are observed in the 25% of women who are premenopausal at BC diagnosis and may develop oligo/amenorrhoea as a result of BC therapy. Chemotherapy may induce amenorrhea (CIA) with permanent ovarian failure/ menopause or menstrual function may resume (10% of women reported return of non-regular menses up to 5 years post chemotherapy (Sukumvanich, Case et al. 2010). The onset of amenorrhea/menopause may occur abruptly or insidiously. The onset of menopausal symptoms may occur even while the woman is still experiencing some menstrual bleeding analogous to the natural perimenopausal phase. In a prospective cohort study of 466 women aged 20-45 years with breast cancer, 41% of women reported 6 months of CIA with 29% and 23% of women experiencing 12 and 24 months of amenorrhea respectively (Sukumvanich, Case et al. 2010).

The diagnosis of menopause follows WHO criteria (definitions); however, there are no consistent diagnostic criteria for chemotherapy induced amenorrhea. The definition of chemotherapy induced amenorrhea in the literature varies from one missed period within 1 year to continuous cessation of menses for more than one year (Walshe, Denduluri et al. 2006). Serial measurement of FSH and oestradiol levels (physiology) and recording menstrual bleeding patterns has been suggested to establish the diagnosis of menopause (Walshe, Denduluri et al. 2006; Ortmann, Pagani et al. 2011). However, tamoxifen use may also be associated with un-interpretable reproductive hormone levels (Ortmann, Pagani et al. 2011). Reports of unintended pregnancies emphasize that premenopausal women who develop CIA should have evidence of permanent cessation of ovarian function with prolonged follow-up before initiating aromatase inhibitor therapy (Walshe, Denduluri et al. 2006).
 

Table: Diagnostic criteria for premature menopause.  

Selected References:

Nelson LM . Primary Ovarian Insufficiency. New Engl J Med (2009) 360:606-614

Walshe JM, Denduluri N et al. Amenorrhea in premenopausal women after adjuvant chemotherapy for breast cancer. J Clin Oncol. (2006) 24:5769-5779.

8. Long Term Consequences of Menopause

Content updated May 16, 2011