Menarche to Menopause: Difference between revisions

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== Introduction ==
== Introduction ==
Consider this. Okay. Factoring in the average life span, approximately 82 years based on US stats, and ages of onset, rounding off to the nearest whole number, a woman will spend only 12% of her life from birth and infancy to menarche and 40% of her life after menarche and through her reproductive years. And this can include pregnancy of course, and 40% of her life, 40% of her life from menopause through her post-menopausal years. So we've given a lot of attention to pregnancy, which, conception to birth to the end of the postpartum period, 12 months or 21 months in a complicated case, and that's about 1-2% of a woman's total lifespan. So just saying that 12% leading up to menarche, and then 40% in the menopause transition, we really should be focusing more on the menopause transition.
A female will spend approximately 12% of her life from birth to menarche, approximately 40% after menarche and through her reproductive years, and approximately 40% from menopause through her post-menopausal years.<ref name=":0">Piché S. Menarche to Menopause Course. Plus , 2022.</ref> Pregnancy and the postpartum period can take from 12 to 21 months, for a complicated case, which works out to possibly 2% of a woman's life. Women spend a great deal of time preparing for and understanding pregnancy and birth, but often do not apply the same understanding and consideration to the other aspects of their health, including menarche and menopause. It is important that we focus understanding on these transitions in life and encourage women to adequately prepare for them.


Consider this, in her lifespan a Female will spend:
==== Complex Female Developmental Process ====
[[File:Continuum of Aging Female-CreatedbyDaphneXuan.jpg|center|frameless|750x750px]]
The diagram above shows the transitions a female will pass through in an average life span. The onset of these transitions can be estimated by looking at common signs and symptoms. 


* only 12% of her life from birth & infancy to menarche
== Diagnosis of Stages ==
Transitional phases are not "diseases" that need a specific diagnosis.<ref name=":0" /> But a functional diagnosis can be made based on the signs and symptoms a women is experiencing. The aim of making a "diagnosis" is to offer the person support, care and education. Not all women pass through the stages in life in a completely linear process. They might move back and forth between stages or even skip a stage. This does not always indicate a problem or that the woman is not healthy. Rather, it shows that these stages and transitions should be understood by the individual, so they can care for themselves appropriately based on the phase they are currently in.<ref name=":0" />


* 40% of her life after menarche and through her reproductive years (this may include pregnancy)
===== Common considerations =====
 
* Age of female
* 40% of her life from menopause through her post menopausal years
** Younger (8-16 years) for menarche transition
 
** Older (45-54 years) for menopause transition
* 1%-2% /pregnancy, (conception, birth, to the end of the postpartum period of 12 months or 21 months in complicated cases)
* Character of menses
 
** Regularity
==== Complex NORMAL developmental processes ====
** Duration
*  
** Flow heaviness
                         Puberty                     Sexual                             Climacteric                Post-Climacteric
* Physical changes
** Breast budding
** Growth spurt
** Low energy / fatigue
** Acne, bloating
** Fluid retention
* Mental changes
** Moodiness
** Short temperedness
** Difficulty concentrating


Infancy          Adolescence             Maturation         Menopause Transition    Post-menopause
=== Puberty ===
Puberty is the transitional stage from childhood up to menarche. <ref>Howard SR. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9291332/pdf/CEN-95-702.pdf Interpretation of reproductive hormones before, during and after the pubertal transition-Identifying health and disordered puberty.] Clin Endocrinol (Oxf). 2021 Nov;95(5):702-715. </ref> Regular monitoring<ref>Mendle J, Beltz AM, Carter R, Dorn LD. [https://onlinelibrary.wiley.com/doi/abs/10.1111/jora.12371 Understanding puberty and its measurement: ideas for research in a new generation.] Journal of Research on Adolescence. 2019 Mar;29(1):82-95.</ref> using a Health Client Check should be conducted during this phase, with regular educational conversations from the age of approximately 6 years old.<ref name=":0" /> 


                                                         Reproductive
During this phase, fertility cannot be assumed as there is no definitive point at which eggs become viable. This knowledge can only be assumed after the onset of menarche. Education regarding contraception is essential to the health of a female in this transitional time.<ref name=":0" /> 


Puberty happens to everyone between the ages of 6-16 yrs, but menarche is unique to females. It occurs approximately 2 years after the onset of secondary sex characteristic changes (specifically breast budding), at an approximate age of 12.4 years. This age has been decreasing, presumably due to nutrition and lifestyle changes, but further research is required on this topic.<ref name=":0" /> 


===== HPG Axis =====
The structures involved in this stage are the HPG axis and the adrenal glands. The HPG axis consists of the hypothalamus, pituitary gland and the ovaries. A pulsing release of gonadotropin-releasing hormone stimulates the pituitary gland to release two important hormones: luteinising hormone (LH), and follicle-stimulating hormone (FSH). This initiates the production of oestrogen, which is needed to stimulate the secondary sexual characteristics, along with the adrenals. Adrenal gland maturation is an independent but interrelated process. Other hormones are also involved before puberty to mature the eggs in the ovaries and they become key to maintaining the cyclic reproductive function.<ref name=":0" />


puberty is the lead up to menarche
===== Health Client Check =====
The onset of puberty for a female should be identified and monitored to support good health or to identify disease processes that may require treatment. Regular health visit monitoring should include a visual examination of external primary sex characteristics, including the external genitalia. When a female is sexually active, an examination of the internal primary sex characteristics should be advised. A Health Client Check also entails a height and weight measurement with the identification of the appearance of any secondary sex characteristics.<ref name=":0" /> These basic markers should be reviewed at each health visit:<ref name=":0" />
* Visual examination for external primary sex characteristics


It's the transitional stage that alerts providers and clients to the upcoming event. Regular monitoring with client health checks should be done and a conversation initiated by the provider about the time the client is six years old. Now, obviously this conversation is with the client's parents or guardians, but it needs to be done beforehand and preparation is key in these kinds of things. There are a number of hormones and organs that begin this process. The main players are the HPG axis and the adrenal glands. The HPG axis consists of the hypothalamus and pituitary gland, they're up in the brain, and the gonads. In women they're the ovaries. So a pulsing release of gonadotropin-releasing hormone stimulates the pituitary gland to release two important hormones: LH, luteinising hormone, and follicle-stimulating hormone, FSH. Together, these two will start the ball rolling to produce the oestrogen needed to stimulate the secondary sexual characteristics along with the adrenals. Other hormones are also involved before puberty to mature the eggs in the ovaries and become key to maintaining the cyclic reproductive function. 
* Height / weight
Health visit monitoring. The onset of puberty for a female should be identified and monitored for evidence of supporting good health or to identify disease processes that may require treatment. Regular health visit monitoring should include a visual exam of external primary sex characteristics. Primary sex characteristics are internal and external genitalia. So, only the external genitalia needs to be visualised. Only if there's a problem would you do anything further than that. Later on, when you know the female is sexually active, then the internal primary sex characteristics can be examined regularly and should be. But, in this particular case, until menarche happens and until you know that that female is sexually active, you will do an external examination only, and all the average stuff. You would do height and weight and identify the appearance of any secondary sex characteristics and these are basic markers to be reviewed at each health visit. 


Sexual Maturity Rating, SMR, better known as Tanner Stages is an objective classification system that providers use to document and track the development and sequence of secondary sex characteristics of children during puberty. Those are characteristics that appear during puberty so we can tell the boy humans from the girl humans. And in females, the most important are breast development and pubic hair growth, but other features show up like that rounded figure that we have, the hourglass figure, getting bigger hips, a slower ability to generate muscle mass, less upper body strength, and increased body fat composition. About two to two-and-a-half years after Tanner stage two, that's when the breasts are budding and a female will start to have her period. So once you identify that a female is in Tanner stage two, then two to two-and-a-half years after that, she will probably be starting her period. This is menarche. When she begins to bleed, this is the start of menstrual cycles and the reproductive stage.
* Identification of appearance of secondary sex characteristics
* Prepubertal genital exam by a doctor


At the beginning of these cycles, there's usually a lot of erratic hormone fluctuations, but eventually they should stabilise. Follicles are present in a high percentage of girls. However, ovulation does not occur until the girl has had an average of six regular menstrual cycles and monthly ovulation does not become regular for several years.
===== Sexual Maturity Rating (SMR) - Tanner Stages =====
Sexual Maturity Rating (SMR), better known as the Tanner Stages, is an objective classification system that providers use to document and track the development and sequence of secondary sex characteristics of children during puberty. In females, the most important characteristics are breast development and pubic hair growth. There are other characteristics that are noteworthy: a rounded or hourglass figure; increased hip girth; an increased body fat composition; and comparatively to our male counterparts, a slower ability to generate muscle mass and less upper body strength.


An idealised menstrual cycle is 28 days long. Day one is the menses, that's when the bleeding starts. And normally this lasts for five to seven days. Menses is included in the follicular phase. After bleeding, the endometrial lining, that's the inner lining of the uterus, begins to thicken until the egg is released. And that's when ovulation occurs, that's when the egg is released. In the luteal phase, the egg is fertilised and implants in the thickened endometrium. And if it's not fertilised, then the egg and the thickened portion of the endometrium, they're broken down for expulsion and the girl begins to bleed again, and the cycle begins all over.
Approximately 2 to 2.5 years after a female is Tanner stage 2, a female will start to have her period. This is known as menarche, and when she begins to bleed, this is the start of the menstrual cycle and the reproductive stage.<ref name=":0" />


Menarche                  
Please click here to see a [https://quizlet.com/514600861/tanner-stages-flash-cards/ Tanner Stages Image].


* Occurs at the beginning of the reproductive stage
=== Menarche                   ===
* Marked by the first menstrual period
Menarche occurs at the beginning of the reproductive stage and is marked by the first menstrual period. It occurs during the late stages of puberty and signals the probability of ovulation and the beginning of a woman’s reproductive years.<ref>Lacroix AE, Gondal H, Langaker MD. [https://www.ncbi.nlm.nih.gov/books/NBK470216/ Physiology, menarche]. InStatPearls [Internet] 2021 Mar 27. StatPearls Publishing.</ref> Chronological age is not a useful predictor; the Tanner Stages and signs and symptoms are more accurate.<ref name=":0" />
* Menarche – mēn (month) + arkhē (beginning)  It is when the first ‘period’ starts. It occurs during the late stages of puberty and signals the probability of ovulation and the beginning of a woman’s reproductive years.
Menopause
* Occurs at the end of the reproductive stage
* Marked by the final menstrual period
* Exact timing of this period can not be forecast
* Menopause – mēn (month) +  pausis (to cease)  It is when the final menstrual ‘period’ (FMP) occurs. This occurs at the end of the reproductive years BUT can only be pinpointed in retrospect, when 12 months have passed without a period. 12 months after that FMP before we know it's an Final Menstrual period
* <br />Menopause  Perimenopause to Postmenopause
** Triggered by ovaries
*** viable follicles number less than 1,000
*** S&S begin to disrupt life
** Normally begins between 45-58 yrs
** End occurs after FMP – determined in retrospect, when post menopause starts
Fertility can not be guaranteed or ruled out Birth Control is an important discussion.


Now that you have the basics, we're going to slide into menopause. Fast forward in a female's lifespan into the late reproductive years, to a point where all those viable follicles number less than 1000. So then we're going to see the beginnings of the menopause transition. The beginning of this transition is defined as perimenopause, it's triggered by the ovaries when the egg count drops so low, whereas in a menarche transition with puberty, we saw that the stimulation came from the HPG axis, when the signal came from the brain and went through to the gonads. In this particular case, it's turned around. Now we're getting the gonads, the ovaries in a female, are creating the signal to say, hey, there's not enough eggs here.
'''Important definitions:'''


So, all the signs and symptoms will start to disrupt a woman's life. And normally it begins around 45 to 58 years old. As we've already said, it can only be determined in retrospect, after the female has had no menstrual cycles for 12 months, that's a year. Then a woman enters the post-menopause stage. Menopause has been described as puberty in reverse or puberty part two due to the fact that much of the same mechanisms are involved, but those mechanisms behave differently. It is a transition, perimenopause and puberty are comparable regarding the signs and symptoms they affect, from a client perspective though.
*  '''Precocious puberty''' - the early onset of puberty before the age of 8 in females<ref>Kota AS, Ejaz S. [https://www.ncbi.nlm.nih.gov/books/NBK544313/ Precocious puberty.] InStatPearls [Internet] 2021 Jul 25. StatPearls publishing.</ref>
*  '''Amenorrhea''' is the absence of menarche onset; can be indicative other disease processes in the body<ref name=":0" />
**  '''Primary amenorrhea''' is a failure to reach menarche - evaluation is required in the following situations:<ref name=":2">Gasner A, Rehman A. [https://www.statpearls.com/articlelibrary/viewarticle/17440/ Primary amenorrhea]. 2022 Mar 20. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 32119356.</ref>
***  Client is 13 years old and has no secondary sex characteristics
***  Menarche does not occur after five years of initial breast development
***  Client is 15 years or older and menarche has not occurred
** '''Secondary amenorrhea''' - "cessation of previous menses for more than 6 months"<ref name=":2" />


rtgkeu
=== Menstruation ===
A menstrual period is defined as “the monthly shedding of the functional layer (the endometrial lining) of the uterus.”<ref name=":0" /> 


the reproductive stage is separated from the menopausal transition. However, in practice, the late reproductive period will overlap into the menopausal transition. So more commonly it's known as the perimenopause
At the beginning of menstruation, there are erratic hormone fluctuations which eventually stabilise. Follicles are present in a high percentage of girls, but ovulation does not occur until the girl has had an average of six regular menstrual cycles and monthly ovulation does not become regular for several years.<ref name=":0" />


== Menstruation ==
An "ideal" menstrual cycle is 28 days long. Day one is the menses, or when the bleeding starts. This commonly lasts for five to seven days and menses is included in the follicular phase. After the cessation of bleeding, the endometrial lining, which is the inner lining of the uterus, begins to thicken until the egg is released. Ovulation, which is the release of the egg, then occurs. The following phase is the luteal phase. The egg could either be fertilised and implanted in the thickened endometrium, or if it is not fertilised, the the egg and the thickened portion of the endometrium are broken down and expelled. This is the beginning of Menses Day 1.<ref name=":0" />
A menstrual period defined as “the monthly shedding of the functional layer (the endometrial lining) of the uterus.” It occurs approximately every 28 days. (hence it ‘cycles’, it is ‘periodic’). This process occurs when the egg (ovum) is not fertilied.  


'''Schedule a medical check up if:'''<ref name=":0" />


Cycles are erratic at beginning
* The girl has not started menstruating within 3 years of breast growth or by the age of 15
* Follicles are present in a high % of girls but ovulation may not occur until after a half dozen menstrual cycles
* Breasts have not started to grow by the age of 13
* Monthly cycles may not regulate for years
* A period lasts more than 7 days
* There is severe pain during periods
* There is bleeding between periods
* The girl / woman gets sick or has a sudden onset of fever after using a tampon
* A period occurs more frequently than 21 days or less frequently than 45 days
* A girl / woman goes 3 months without a period after beginning menstruation


* There are thousands of euphemisms for a menstrual period throughout the world. (more than 5,000 to be more exact)
*


== Diagnosis of Disease ==
For more information, please see [[Menstruation and Menstrual Rehab]]
A functional diagnosis in order to provide direction and support for client care is made primarily by looking at signs and symptoms. Age of the female, younger women, eight to 16 years old, obviously menarche, or older women, 45 to 54 years old. You're looking at the menopause transition. Character of the menses, how often does it occur? How long is it? How heavy is the flow? Physical, emotional, mental changes. Breast budding, growth spurts, signs and symptoms in younger or older females, low energy, fatigue, moodiness, short-temperedness, difficulty concentrating, acne, bloating. Oh my gosh, the list goes on and on. Those signs and symptoms are enough to say whether this female is in the transition towards menarche or in the transition to menopause. So if you look at the stages, not all women progress from one stage to the next. Most women do, most women do however, but some move back and forth between the stages or skip a stage. Then this doesn't mean that they're not healthy. It's just some women do something different.


“Functional” Diagnosis
=== Menopause ===
This stage occurs at the end of the reproductive stage and is marked by the final menstrual period (FMP).<ref>Talaulikar V. [https://www.sciencedirect.com/science/article/abs/pii/S1521693422000426 Menopause transition: Physiology and symptoms.] Best Practice & Research Clinical Obstetrics & Gynaecology. 2022 Mar 16.</ref> Exact timing of this period cannot be forecast and is pinpointed retrospectively when 12 months have passed without a period. The beginning of this transition is referred to as perimenopause and is triggered by the ovaries. The number of viable follicles drops to less than 1,000 and various signs and symptoms can begin to disrupt life.<ref>Santoro N, Kravitz HM. [https://www.obgyn.theclinics.com/article/S0889-8545(18)30074-3/fulltext The Disruptive Changes of Midlife: A Biopsychosocial Adventure]. Obstetrics and Gynecology Clinics. 2018 Dec 1;45(4):xv-ii.</ref> This phase usually occurs between the ages of 45-58 years, but chronological age is not an accurate predictor. The STRAW+10 Staging Scale and common signs and symptoms are a far more useful predictor.<ref name=":0" />


* Age of female
After a female has had no menstrual cycles for 12 months, she enters the post-menopause stage.<ref name=":0" />
** Younger (8-16 yrs) or Older (45-54 yrs)
* Character of Menses:
** How often does it occur?
** How long does it occur?
** How heavy is the flow?
* Physical & Mental changes:
** Breast budding and growth spurt in younger females
** Low energy/fatigue, moodiness, short temperedness, difficulty concentrating, acne, bloating, fluid retention…
** Etc., etc., etc….


<nowiki>*</nowiki>Note: not all women progress from one stage to the next, most women do, but some move back and forth between stages or skip a stage…this doesn’t mean that they aren’t healthy.
'''<u>Schedule a medical check up if the woman:</u>''' 


== Transitions ==
* Has lengthening or skipped cycles (3 or more) before age 40
Now, with respect to these processes of transition, in both cases, the exact timing of this all-important menstrual period can't be forecasted. It can't. Providers can estimate probable timings from signs and symptoms. And as these all-important periods approach, well, fertility is questionable since we can't tell if the woman's eggs are viable or not, so a conversation regarding birth control is not just acceptable, it is essential. both these transitions are not diseases that need to be diagnosed
* Has a period that lasts more than 7 days
* Has unusual or severe pain during / between periods, or in post-menopause
* Has vaginal dryness, pain or blood when wiping after toileting
* Has difficulty sleeping and / or feels tired all the time
* Is experiencing decreased quality of life due to symptoms
* Is bleeding in post-menopause


Puberty is the lead up to menarche.


* a transitional stage that alerts providers & clients to the upcoming event. There are a number of hormones and organs that begin this process.
For more information, please see [[Menopause|Menopause.]]
* regular monitoring should be done
* Conversation should be initiated by provider by approximately age 6 of client


=== HPG Axis ===
===== Signs & Symptoms =====
* Controls & synchronizes
Health care providers should be approaching menopause in the same way as menarche:<ref name=":0" />
** Adrenal gland maturation is an independent but interrelated process
* Monitoring for regular functioning
 
* Identifying issues early and treating accordingly
Health visit monitoring:
* Initiating conversations prior to transitions
 
* Encouraging clients to make ‘healthy choices’ within their capability
* Visual exam External Primary sex characteristics
The following table summarises the signs associated with the transitions between puberty and menarche, and perimenopause and menopause.
 
* Height/Weight
 
* Identification of appearance of Secondary Sex characteristics
* Prepubertal genital exam  <nowiki>https://obgynkey.com/prepubertal-genital-examination/</nowiki>  Doctor visit <nowiki>https://www.shutterstock.com/search/doctor%2Bmeasuring%2Bheight%2Bchild?gender=female&mreleased=true</nowiki>
 
Sexual Maturity Rating (SMR) - Tanner’s Stages
 
https://quizlet.com/514600861/tanner-stages-flash-cards/
 
*  
 
*  
 
=== Signs & Symptoms (S&S) ===
Signs and symptoms:
{|
{|
|+
|+
!
Table 1. Signs associated with puberty to menarche and perimenopause to menopause.
!Puberty to Menarche
!'''<u>Puberty to Menarche</u>'''
!Perimenopause to Menopause
!'''<u>Perimenopause to Menopause</u>'''
|-
|-
!
|Secondary sex characteristics more pronounced
!secondary sex characteristics more pronounced
|Vasomotor symptoms VMS (hot flashes/ night sweats)
!Vasomotor symptoms VMS (hot flashes/ night sweats)
|-
|-
!
|Growth spurt
!Growth spurt
|Vaginal dryness or Genitourinary Syndrome of Menopause (GSM)
!vaginal dryness or Genitourinary Syndrome of Menopause (GSM)
|-
|-
!
|Moodiness, short-tempered, emotional
!Moodiness, short tempered, emotional
|Moodiness, short-tempered, emotional
!moodiness, short tempered, emotional
|-
|-
!
|Low energy / fatigue
!low energy/fatigue
|Low energy / fatigue
!low energy/fatigue
|-
|-
!
|Breast tenderness
!breast tenderness
|Breast tenderness
!breast tenderness
|-
|-
!
|Muscle aches
!muscle aches
|Muscle aches
!muscle aches
|-
|-
!
|Headaches
!headaches
|Headaches
!headaches
|-
|-
|
|Abdominal cramps
|abdominal cramps
|Abdominal cramps
|abdominal cramps
|-
|-
|
|Lower back pain
|lower back pain
|Lower back pain
|lower back pain
|-
|-
|
|Difficulty concentrating
|difficulty concentrating
|Difficulty concentrating
|difficulty concentrating
|-
|-
|
|Bloating, fluid retention
|bloating, fluid retention
|Bloating, fluid retention
|bloating, fluid retention
|-
|-
|
|Joint pain
|joint pain
|Joint pain
|joint pain
|-
|-
|
|Food cravings
|food cravings
|Food cravings
|food cravings
|-
|-
|
|Acne
|acne
|Acne
|acne
|-
|-
|
|Diarrhoea / constipation
|diarrhea/constipation
|Diarrhoea / constipation
|diarrhea/constipation
|-
|-
|
|Trouble sleeping
|trouble sleeping
|Trouble sleeping
|trouble sleeping
|}
|}
Providers should be approaching menopause in the same way as menarche:
* -monitoring for normal functioning
* -identifying issues early and treating
* -initiating conversations prior to the transition at about age 6 with parent/guardian and 35 with client…regardless of whether the transition is asked about or not
* -encouraging clients to make ‘healthy choices’ within their capability
==== Common Medical Concerns in the Menopause Transition that need identification and treatment include: ====
* POI – Primary Ovarian Insufficiency (1% in US)
* GUSM – Genitourinary Syndrome in Menopause (50-70% US)
* Diseases of higher risk:
** Cardiovascular (1 woman dies every minute from CVD)
** Diabetes/Obesity
** Osteoporosis
** Dementia
** Cancer (Breast & Uterine)
Common medical concerns in the menopause transition that need identification and treatment include primary ovarian insufficiency, POI. 1% of women in the US, I don't have stats for other places, but in the US that actually translates to quite a lot of women who have primary ovarian insufficiency. And that is when the ovaries stop working before the age of 40, and there's a number of reasons that could happen. And this is why we need to look for it so that we can try to figure out, is it something that needs to be treated? GSM or GUSM, genito-urinary syndrome in menopause is in 50 to 70% of US females when they hit the menopause transition. It's quite an uncomfortable condition where the vaginal walls and the vulva become so friable, that means so thin that they become easy to break down, so they feel possibly hot, they feel rough, like sandpaper. It's extremely uncomfortable. There can be bleeding when wiping after toileting. So this is a condition that needs to be diagnosed as soon as possible. This particular condition cannot be ameliorated. So it needs to be stopped. It needs to have treatment immediately. it's not urgent, but it's important.


Okay, diseases with high risks that skyrocket after menopause include cardiovascular. One woman dies every minute from cardiovascular disease. Diabetes and obesity, osteoporosis, dementia, cancer, both breast and uterine cancer, the list goes on, but those are the top ones. So you can see where regular assessments become quite important and prevention and treatment are high on our list as providers of what we need to do for clients.
===== Common Medical Concerns during the Menopause Transition =====
* Primary Ovarian Insufficiency
** This is diagnosed when the ovaries stop working before the age of 40
* Genitourinary Syndrome in Menopause
** A condition in which the vaginal walls and the vulva become thin and easily break down. Symptoms often include: feeling hot and rough, bleeding when wiping after toileting and discomfort. This condition can be treated with topical creams.
* Diseases which increase in risk post-menopause:
**[[Cardiovascular Disease|Cardiovascular disease]]
**[[Diabetes]] / [[obesity]]
**[[Osteoporosis]]
**[[Dementia]]
** [[Oncology|Cancer]], mainly breast and uterine


Regular assessments need to include blood work to establish baselines and/or eliminate other things, such as thyroid, diabetes, et cetera. Lipid levels should be done every three years, starting at age 40. More often if there's a risk for cardiovascular disease. Calcium, vitamin D levels, hormones only if there's an indication. Honestly, unless you're looking for indicators of POI, the primary ovarian insufficiency, you're not going to need any hormone levels. It's not going to tell you whether someone's going through the menopause transition or not. Height, weight, ECG, even if for baseline an ECG is an important thing to have. Height and weight should be normal markers that you're collecting all the time. Assess for sleep and rest habits. Sleep apnoea is prevalent in this transition. Assess for depression as its prevalence increases throughout the transition. Prescriptions that are immediately helpful. Anything that's going to treat symptoms, acne cream, helping to stop someone from smoking, any kind of antidepressant medication, something to help someone sleep, things that are going to help them in the short term, and then consider referrals. Referrals that are immediately helpful, such as OB-GYN appointments, gynaecology referrals and endocrinologist referrals, physiotherapy, pelvic floor physiotherapy specialists. If there's a genito-urinary syndrome going on, it can help with that as well. Mental health and CBT, you can send to a counsellor or you can send to psychiatry. I have found in the past, generally counsellors are better because CBT has been found far more often to be productive in alleviating symptoms. Sleep clinics. Whatever is needed at this point in time, get on these things early and get the referrals out. Pap tests. Other tests that you could do in your office as opposed to sending them out to gynaecologists, but still, referrals to gynaecologists are important in order for follow-up because there may be things that you might miss, and there may be things that that particular gynaecologist will pick up. Mammograms, beginning at around age 40. There are different policies in different countries, so the ages that I give you depends on where you're living, of course, and healthcare that's provided or not provided. So mammograms beginning at around age 40, 45 and continuing every three years, approximately, unless there's an indication. Colonoscopy at age 55 and then afterwards every five years or as indicated. Any follow-up appointments that there might be. Bone density scan, at age 40, you should at least send a female for a bone density scan as a baseline because osteoporosis is so prevalent and bone begins to thin after age 30, you only build up your bone to age 30. So after that, I mean, you could have something happen anytime. And you need to repeat that every five years, unless there's an indication. If a female has a fracture, it needs to be done more often.
===== Regular Assessments =====
 
The following assessments should be included:<ref name=":0" />
Healthy choices. Help your client to make healthy choices. And as I indicated earlier, healthy choices are within the parameters of what the client can do. In different countries, there are different choices that they may or may not have, and in different socioeconomic status. If you are in a poverty situation, then you may not have the same choices as someone else, or if your healthcare doesn't cover certain things. But the biggest, the number one thing that you can do is advise your clients to exercise at any age. Any age. From children on to 80-year-old women. Exercise, and you are never too old to start. It is the number one research-based thing that you can do to alleviate signs and symptoms of menopause and the menopause transition and it is recommended by every organisation that I know that supports research for menopause. Diet and nutrition is aimed at maintaining weight, no fad diets or weight loss. That's not the point. The point is maintaining a regular weight and eating a variety of foods. Stop smoking if you do, if you do smoke, stop smoking. If you don't, don't start. So if you're a younger woman, don't start. Keep alcohol intake within moderation. Moderation means one or less alcoholic drink a day, less being the preferable there, but once you get into two drinks a day, when you're in the menopausal transition phase, it increases your breast cancer risk by approximately 20%. So, all the things that we're recommending, there's reasons behind the recommendations. Sleep, make sure you're getting enough sleep, six to eight hours per night, and you find things that you can do to relax and de-stress because those will help decrease your signs and symptoms with regards to the menopause transition as well. So these are all things that you need to talk to your client about and refer.
* Blood work
 
** To establish baselines or to eliminate conditions such as thyroid disease and diabetes
==== Regular Assessments to include: ====
** Test lipid levels every 2-3 years starting at the age of 40 (but more often if this is a risk of [[Cardiovascular Disease|cardiovascular disease]])
* Blood work – to establish baselines +/or eliminate other things thyroid, diabetes, etc, lipid levels every 2-3 yrs starting at age 40 yrs more often if CVD is a risk, calcium & Vit D, Hormones ONLY if there’s an indication
** ONLY if there is an indication, it might be recommended to test levels of calcium, vitamin D and hormones
* Height/Weight/ECG baseline
* Height and weight
* Bone density scan (age 40 yrs at least for baseline, repeat every 5 years as indicated)
* ECG baseline
* Assess for sleep/rest habits (sleep apnea is prevalent here)
* Bone density scan is recommended from the age of 40 for a baseline, with a repeat every 5 years
* Assess for depression as it’s prevalence increases
* Assess for sleep / rest habits
* Prescriptions that are immediately helpful (acne cream, smoking cessation aids, etc)
* Assess for depression as its prevalence increases
* Referrals that are immediately helpful (Physio, PFPT, Mental health-CBT, Sleep Clinic, etc)
* Gynecologist &/or Endocrinologist referral
* Pap test
* Pap test
* Mammogram beginning age  
* A mammogram is recommended from the age 40, with monitoring every 3 years
* Colonoscopy age 55
* Colonoscopy is recommended from the age of 55
* Follow up Appointment
* Encourage clients to track signs and symptoms to facilitate and direct care - this information should be reviewed regularly
* Encourage Clients to track S&S, to facilitate & direct care and review this regularly


==== Healthy Choices ====
===== Healthy Choices =====
* **Exercise (aerobic, strengthening and balance) you can include sex in this repertoire
* Exercise should include aerobic, strengthening and balance exercises
* Diet/Nutrition
* Diet / nutrition for maintenance of health
* Stop smoking if you do, don’t start if you don’t
* Do not smoke
* Keep alcohol intake within moderation moderation
* Moderate intake of alcohol  
* Sleep
* Sleep 8 hours per day
* Relax/De-stress
* Relaxation techniques


==== Summing Up: ====
=== Stages of Reproductive Aging Workshop (STRAW) ===
12% of a female’s lifespan is spent in ‘lead up’ to menarche, more people are aware these milestones and predictive benchmarks, like Tanners stages, but there’s a gap in the knowledge and practice regarding preparation for menopause.  
*
 
In 2001, the Stages of Reproductive Aging Workshop, otherwise known as STRAW, put together a standard for reproductive ageing. In 2011, STRAW was updated and modified to STRAW+10, which is the gold standard to identify stages within the sexual reproductive periods of a woman's lifespan.<ref name=":0" />
In order to understand menopause it’s essential to understand the mechanisms that exist throughout the reproductive stage, that’s what we’ve discussed here. “The tip of the menopause iceberg.”
 
40% of a female’s lifespan will be spent in the menopause transition, therefore there is a significant amount more information that would focus on prevention, screening and treatment options. This is a positive period in a woman’s life provided she is prepared and given adequate health care.


Thank you for joining me. I hope this has been helpful.
STRAW identifies the stages within the sexual reproductive periods of a woman's lifespan. It divides the adult female life into three broad phases: reproductive, menopausal transition, and post-menopause. These three phases include seven stages which centre on the final menstrual period, which is called Stage 0.<ref name=":1">Harlow SD, Gass M, Hall JE, Lobo R, Maki P, Rebar RW, Sherman S, Sluss PM, De Villiers TJ, STRAW+ 10 Collaborative Group. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3340903/pdf/nihms361103.pdf Executive summary of the Stages of Reproductive Aging Workshop+ 10: addressing the unfinished agenda of staging reproductive aging.] The Journal of Clinical Endocrinology & Metabolism. 2012 Apr 1;97(4):1159-68.</ref>


There’s some reading material and videos as well as helpful references.
STRAW divides the reproductive phase into Stages -5 (which is early), -4, (which is classified as peak), and -3 (which is late). Stage–3 is characterised by regular menstrual cycles, as well as increasing levels of follicle-stimulating hormone (FSH).<ref name=":1" />


The menopausal transition phase includes Stage -2 (early) and Stage -1 (late). During Stage –2, there is variability in the length of the menstrual cycle and increased levels of FSH. During Stage –1, there is the onset of skipped cycles / amenorrhea which lasts at least 60 days, as well as continued elevation of FSH.<ref name=":1" /><ref>Woods NF, Mitchell ES, Coslov N, Richardson MK. [https://journals.lww.com/menopausejournal/Abstract/2021/04000/Transitioning_to_the_menopausal_transition__a.16.aspx Transitioning to the menopausal transition: a scoping review of research on the late reproductive stage in reproductive aging.] Menopause. 2021 Apr 1;28(4):447-66.</ref>


This course is directed towards ‘normal’ female aging, women born with ovaries.
The post-menopause phase includes Stages +1 (early) and +2 (late).<ref name=":1" /> 


Those trans & non-binary persons must be looked at independently since studies are lacking in order to provide adequate general information.
Please see Harlow et al.'s article: [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3340903/ Executive summary of the Stages of Reproductive Aging Workshop + 10: addressing the unfinished agenda of staging reproductive aging] for more information.  


By understanding the ‘norm’ we can better deal with irregularities
== Links to Helpful Pages ==
 
Before we get too far ahead of ourselves, I want to outline the normal transitions of the female reproductive lifespan. In 2001, Stages of Reproductive Aging Workshop, STRAW, another acronym because medical people like to use acronyms, they gave us a standard for reproductive ageing. Now in 2011, STRAW was updated and modified to STRAW+10, and it's still used today. It's the gold standard to identify stages within the sexual reproductive periods of a woman's lifespan. This figure is the STRAW outline. From a client point-of-view, it's a bit complicated, but as a provider, it is the springboard of female care throughout the lifespan.
 
== Links to helpful pages ==


* [[Menstruation and Menstrual Rehab]]
* [[Menstruation and Menstrual Rehab]]
* [[Menopause]]
* [[Menopause]]


== References ==
== Additional Resources ==
Resources:


1) Menopause Practice: A Clinician’s Guide, 6th Edition. C.J. Crandall, Editior-in-Chief. North American Menopause Society, 2019
===== Videos: =====


2) Female Development, 2021, Remien & Pillarisetty, National Library of Medicine, NIH
# [https://www.nhs.uk/conditions/periods/fertility-in-the-menstrual-cycle/ Menstrual cycle] an NHS site video
# Dr Jen Gunter, TED Talks on [https://www.ted.com/talks/jen_gunter_what_really_happens_to_your_body_during_menopause?language=en What really happens to your body during Menopause?]
# Video: [https://kidshealth.org/en/kids/puberty-normal-video.html Am I Normal?] (Girls and Puberty)  
# What is Menarche? Everything you need to know
{{#ev:youtube|kNlmOe-e23k}}
===== Recommended for Providers =====


3) Physiology of Menarche, 2021, Lacroix/Gondal/Langaker, National Library of Medicine, NIH
# [https://www.jeanhailes.org.au/health-professionals/tools Menopause Health Tool], Dr Jean Hailes
# [https://www.monash.edu/medicine/sphpm/units/womenshealth/toolkit-management-of-the-menopause Practitioner’s Toolkit], Monash University 2014
# [https://swhr.org/swhr_resource/menopause-preparedness-fact-sheet/ Menopause Preparedness Fact Sheet], The Society of Women’s Health Research -October 2021.


4) Tanner Stages, 2021, Emmanuel & Bokor, National Library of Medicine, NIH
===== Recommended for Clients and Parents / Guardians =====


5) The Menopause Manifesto, Jen Gunter PhD OB/GYN, Penguin Random House Canada, 2021
# [https://www.jeanhailes.org.au/resources/menopause-multilingual-fact-sheets Menopause Fact Sheet], August 2019, Dr Jean Hailes, Women’s Health, Available in English, Arabic, Chinese (Simplified), Farsi, Greek, Hindi, Italian, Turkish and Vietnamese. (This project was funded by the Victorian Government)
 
# [http://www.menopause.org/docs/default-source/2015/menonote-menstrual-calendar-english.pdf Menstrual Calendar], for tracking perimenopause phase, NAMS, 2015
6) Menopause Preparedness: perspectives for patient, provider, and policymaker considerations, 2021, Menopause: The Journal of the North American Menopause Society, Vol 28, No.10 pp.1186-1191
# [https://redhotmamas.org/ Red Hot Mamas]
 
# [https://vajenda.substack.com/about The Vajenda]
7) The Complete Guide to Menopause, Annice Mukherjee PhD, Penguin Random House UK, first pub by Vermilion, 2021
# [https://www.menopause.org/for-women The North American Menopause Society]
 
# [https://www.womenshealth.gov/menopause/menopause-symptoms-and-relief US Department of Health and Human Services]
Videos:
# [https://www.healthywomen.org/content/blog-entry/7-effective-ways-deal-menopause Healthy Women]
 
# [https://www.menopauseandu.ca/ Canadian Society of Obstetricians and Gynaecologists]
What is Menarche? Everything you need to know.- May 2021 (4 ½ mins)
# [https://www.yourperiod.ca/normal-periods/menstruation-around-the-world/ Menstruation Around the World] 
 
# [https://www.hormone.org/menopausemap/index.html Menopause Map] is a great interactive tool to start with to personalise your journey.
Medical Centric
 
<nowiki>https://www.youtube.com/watch?v=kNlmOe-e23k</nowiki>
 
 
Menstrual cycle, NHS site video (2:41 mins) October2020
 
<nowiki>https://www.nhs.uk/conditions/periods/fertility-in-the-menstrual-cycle/</nowiki>
 
What Really Happens to Your Body During Menopause - June 2021 (5 mins)
 
Dr Jen Gunter, TED Talks
 
<nowiki>https://www.ted.com/talks/jen_gunter_what_really_happens_to_your_body_during_menopause?language=en</nowiki>
 
 
 
Recommended for Providers:Recommended for Providers:
 
Menopause Health Tool, Dr Jean Hailes
 
<nowiki>https://www.jeanhailes.org.au/health-professionals/tools</nowiki>
 
Practitioner’s Toolkit, Monash University 2014
 
<nowiki>https://www.monash.edu/medicine/sphpm/units/womenshealth/toolkit-management-of-the-menopause</nowiki>
 
The toolkit is now published online in the journal Climacteric and can be accessed in full at <nowiki>http://informahealthcare.com/doi/full/10.3109/13697137.2014.929651</nowiki>
 
Menopause Preparedness Fact Sheet, The Society of Women’s Health Research -October 2021,
 
<nowiki>https://swhr.org/swhr_resource/menopause-preparedness-fact-sheet/</nowiki>
 
Recommended for Clients & Parents/Guardians :
 
Menopause Fact Sheet, August 2019, Dr Jean Hailes, Women’s Health, Available in English, Arabic, Chinese (Simplified), Farsi, Greek, Hindi, Italian, Turkish and Vietnamese. (This project was funded by the Victorian Government)
 
<nowiki>https://www.jeanhailes.org.au/resources/menopause-multilingual-fact-sheets</nowiki>
 
Menstrual Calendar, for tracking perimenopause phase, NAMS, 2015
 
<nowiki>http://www.menopause.org/docs/default-source/2015/menonote-menstrual-calendar-english.pdf</nowiki>
 
Video: Am I Normal?, Kids Health.org (2 mins)
 
<nowiki>https://kidshealth.org/en/kids/puberty-normal-video.html</nowiki>
 
 
Hormone Health Network from the Endocrinsociety (Meno Map) <nowiki>https://www.hormone.org/menopausemap/index.html</nowiki>
 
Red Hot Mamas  
 
<nowiki>https://redhotmamas.org/</nowiki>
 
Menopause Barbie
 
<nowiki>https://menopausetaylor.me/</nowiki>
 
The North American Menopause Society
 
<nowiki>https://www.menopause.org/for-women</nowiki>
 
US Department of Health and Human Services
 
<nowiki>https://www.womenshealth.gov/menopause/menopause-symptoms-and-relief</nowiki>
 
Healthy Women
 
<nowiki>https://www.healthywomen.org/content/blog-entry/7-effective-ways-deal-menopause</nowiki>
Canadian Society of Obstetricians and Gynaecologists
<nowiki>https://www.menopauseandu.ca/</nowiki>
 
<nowiki>https://www.yourperiod.ca/normal-periods/menstruation-around-the-world/</nowiki>
 
<nowiki>https://www.menopauseandu.ca/</nowiki>
 
https://www.menopause.org/for-women
 
https://www.imsociety.org/
 
* Menopause Map (link here) is a great interactive tool to start with to personalize your journey.
* <nowiki>https://www.hormone.org/menopausemap/index.html</nowiki>


== References ==
[[Category:Course Pages]]
[[Category:Course Pages]]
[[Category:Physioplus Content]]
[[Category:Plus Content]]
<references />
[[Category:Womens Health]]
[[Category:Pelvic Health]]

Latest revision as of 15:16, 23 March 2023

Original Editor - Carin Hunter based on the course by Sue Piché
Top Contributors - Carin Hunter, Jess Bell, Kim Jackson, Wanda van Niekerk and Ewa Jaraczewska

Introduction[edit | edit source]

A female will spend approximately 12% of her life from birth to menarche, approximately 40% after menarche and through her reproductive years, and approximately 40% from menopause through her post-menopausal years.[1] Pregnancy and the postpartum period can take from 12 to 21 months, for a complicated case, which works out to possibly 2% of a woman's life. Women spend a great deal of time preparing for and understanding pregnancy and birth, but often do not apply the same understanding and consideration to the other aspects of their health, including menarche and menopause. It is important that we focus understanding on these transitions in life and encourage women to adequately prepare for them.

Complex Female Developmental Process[edit | edit source]

Continuum of Aging Female-CreatedbyDaphneXuan.jpg

The diagram above shows the transitions a female will pass through in an average life span. The onset of these transitions can be estimated by looking at common signs and symptoms.

Diagnosis of Stages[edit | edit source]

Transitional phases are not "diseases" that need a specific diagnosis.[1] But a functional diagnosis can be made based on the signs and symptoms a women is experiencing. The aim of making a "diagnosis" is to offer the person support, care and education. Not all women pass through the stages in life in a completely linear process. They might move back and forth between stages or even skip a stage. This does not always indicate a problem or that the woman is not healthy. Rather, it shows that these stages and transitions should be understood by the individual, so they can care for themselves appropriately based on the phase they are currently in.[1]

Common considerations[edit | edit source]
  • Age of female
    • Younger (8-16 years) for menarche transition
    • Older (45-54 years) for menopause transition
  • Character of menses
    • Regularity
    • Duration
    • Flow heaviness
  • Physical changes
    • Breast budding
    • Growth spurt
    • Low energy / fatigue
    • Acne, bloating
    • Fluid retention
  • Mental changes
    • Moodiness
    • Short temperedness
    • Difficulty concentrating

Puberty[edit | edit source]

Puberty is the transitional stage from childhood up to menarche. [2] Regular monitoring[3] using a Health Client Check should be conducted during this phase, with regular educational conversations from the age of approximately 6 years old.[1]

During this phase, fertility cannot be assumed as there is no definitive point at which eggs become viable. This knowledge can only be assumed after the onset of menarche. Education regarding contraception is essential to the health of a female in this transitional time.[1]

Puberty happens to everyone between the ages of 6-16 yrs, but menarche is unique to females. It occurs approximately 2 years after the onset of secondary sex characteristic changes (specifically breast budding), at an approximate age of 12.4 years. This age has been decreasing, presumably due to nutrition and lifestyle changes, but further research is required on this topic.[1]

HPG Axis[edit | edit source]

The structures involved in this stage are the HPG axis and the adrenal glands. The HPG axis consists of the hypothalamus, pituitary gland and the ovaries. A pulsing release of gonadotropin-releasing hormone stimulates the pituitary gland to release two important hormones: luteinising hormone (LH), and follicle-stimulating hormone (FSH). This initiates the production of oestrogen, which is needed to stimulate the secondary sexual characteristics, along with the adrenals. Adrenal gland maturation is an independent but interrelated process. Other hormones are also involved before puberty to mature the eggs in the ovaries and they become key to maintaining the cyclic reproductive function.[1]

Health Client Check[edit | edit source]

The onset of puberty for a female should be identified and monitored to support good health or to identify disease processes that may require treatment. Regular health visit monitoring should include a visual examination of external primary sex characteristics, including the external genitalia. When a female is sexually active, an examination of the internal primary sex characteristics should be advised. A Health Client Check also entails a height and weight measurement with the identification of the appearance of any secondary sex characteristics.[1] These basic markers should be reviewed at each health visit:[1]

  • Visual examination for external primary sex characteristics
  • Height / weight
  • Identification of appearance of secondary sex characteristics
  • Prepubertal genital exam by a doctor
Sexual Maturity Rating (SMR) - Tanner Stages[edit | edit source]

Sexual Maturity Rating (SMR), better known as the Tanner Stages, is an objective classification system that providers use to document and track the development and sequence of secondary sex characteristics of children during puberty. In females, the most important characteristics are breast development and pubic hair growth. There are other characteristics that are noteworthy: a rounded or hourglass figure; increased hip girth; an increased body fat composition; and comparatively to our male counterparts, a slower ability to generate muscle mass and less upper body strength.

Approximately 2 to 2.5 years after a female is Tanner stage 2, a female will start to have her period. This is known as menarche, and when she begins to bleed, this is the start of the menstrual cycle and the reproductive stage.[1]

Please click here to see a Tanner Stages Image.

Menarche                  [edit | edit source]

Menarche occurs at the beginning of the reproductive stage and is marked by the first menstrual period. It occurs during the late stages of puberty and signals the probability of ovulation and the beginning of a woman’s reproductive years.[4] Chronological age is not a useful predictor; the Tanner Stages and signs and symptoms are more accurate.[1]

Important definitions:

  • Precocious puberty - the early onset of puberty before the age of 8 in females[5]
  • Amenorrhea is the absence of menarche onset; can be indicative other disease processes in the body[1]
    • Primary amenorrhea is a failure to reach menarche - evaluation is required in the following situations:[6]
      • Client is 13 years old and has no secondary sex characteristics
      • Menarche does not occur after five years of initial breast development
      • Client is 15 years or older and menarche has not occurred
    • Secondary amenorrhea - "cessation of previous menses for more than 6 months"[6]

Menstruation[edit | edit source]

A menstrual period is defined as “the monthly shedding of the functional layer (the endometrial lining) of the uterus.”[1]

At the beginning of menstruation, there are erratic hormone fluctuations which eventually stabilise. Follicles are present in a high percentage of girls, but ovulation does not occur until the girl has had an average of six regular menstrual cycles and monthly ovulation does not become regular for several years.[1]

An "ideal" menstrual cycle is 28 days long. Day one is the menses, or when the bleeding starts. This commonly lasts for five to seven days and menses is included in the follicular phase. After the cessation of bleeding, the endometrial lining, which is the inner lining of the uterus, begins to thicken until the egg is released. Ovulation, which is the release of the egg, then occurs. The following phase is the luteal phase. The egg could either be fertilised and implanted in the thickened endometrium, or if it is not fertilised, the the egg and the thickened portion of the endometrium are broken down and expelled. This is the beginning of Menses Day 1.[1]

Schedule a medical check up if:[1]

  • The girl has not started menstruating within 3 years of breast growth or by the age of 15
  • Breasts have not started to grow by the age of 13
  • A period lasts more than 7 days
  • There is severe pain during periods
  • There is bleeding between periods
  • The girl / woman gets sick or has a sudden onset of fever after using a tampon
  • A period occurs more frequently than 21 days or less frequently than 45 days
  • A girl / woman goes 3 months without a period after beginning menstruation


For more information, please see Menstruation and Menstrual Rehab

Menopause[edit | edit source]

This stage occurs at the end of the reproductive stage and is marked by the final menstrual period (FMP).[7] Exact timing of this period cannot be forecast and is pinpointed retrospectively when 12 months have passed without a period. The beginning of this transition is referred to as perimenopause and is triggered by the ovaries. The number of viable follicles drops to less than 1,000 and various signs and symptoms can begin to disrupt life.[8] This phase usually occurs between the ages of 45-58 years, but chronological age is not an accurate predictor. The STRAW+10 Staging Scale and common signs and symptoms are a far more useful predictor.[1]

After a female has had no menstrual cycles for 12 months, she enters the post-menopause stage.[1]

Schedule a medical check up if the woman:

  • Has lengthening or skipped cycles (3 or more) before age 40
  • Has a period that lasts more than 7 days
  • Has unusual or severe pain during / between periods, or in post-menopause
  • Has vaginal dryness, pain or blood when wiping after toileting
  • Has difficulty sleeping and / or feels tired all the time
  • Is experiencing decreased quality of life due to symptoms
  • Is bleeding in post-menopause


For more information, please see Menopause.

Signs & Symptoms[edit | edit source]

Health care providers should be approaching menopause in the same way as menarche:[1]

  • Monitoring for regular functioning
  • Identifying issues early and treating accordingly
  • Initiating conversations prior to transitions
  • Encouraging clients to make ‘healthy choices’ within their capability

The following table summarises the signs associated with the transitions between puberty and menarche, and perimenopause and menopause.

Table 1. Signs associated with puberty to menarche and perimenopause to menopause.
Puberty to Menarche Perimenopause to Menopause
Secondary sex characteristics more pronounced Vasomotor symptoms VMS (hot flashes/ night sweats)
Growth spurt Vaginal dryness or Genitourinary Syndrome of Menopause (GSM)
Moodiness, short-tempered, emotional Moodiness, short-tempered, emotional
Low energy / fatigue Low energy / fatigue
Breast tenderness Breast tenderness
Muscle aches Muscle aches
Headaches Headaches
Abdominal cramps Abdominal cramps
Lower back pain Lower back pain
Difficulty concentrating Difficulty concentrating
Bloating, fluid retention Bloating, fluid retention
Joint pain Joint pain
Food cravings Food cravings
Acne Acne
Diarrhoea / constipation Diarrhoea / constipation
Trouble sleeping Trouble sleeping
Common Medical Concerns during the Menopause Transition[edit | edit source]
  • Primary Ovarian Insufficiency
    • This is diagnosed when the ovaries stop working before the age of 40
  • Genitourinary Syndrome in Menopause
    • A condition in which the vaginal walls and the vulva become thin and easily break down. Symptoms often include: feeling hot and rough, bleeding when wiping after toileting and discomfort. This condition can be treated with topical creams.
  • Diseases which increase in risk post-menopause:
Regular Assessments[edit | edit source]

The following assessments should be included:[1]

  • Blood work
    • To establish baselines or to eliminate conditions such as thyroid disease and diabetes
    • Test lipid levels every 2-3 years starting at the age of 40 (but more often if this is a risk of cardiovascular disease)
    • ONLY if there is an indication, it might be recommended to test levels of calcium, vitamin D and hormones
  • Height and weight
  • ECG baseline
  • Bone density scan is recommended from the age of 40 for a baseline, with a repeat every 5 years
  • Assess for sleep / rest habits
  • Assess for depression as its prevalence increases
  • Pap test
  • A mammogram is recommended from the age 40, with monitoring every 3 years
  • Colonoscopy is recommended from the age of 55
  • Encourage clients to track signs and symptoms to facilitate and direct care - this information should be reviewed regularly
Healthy Choices[edit | edit source]
  • Exercise should include aerobic, strengthening and balance exercises
  • Diet / nutrition for maintenance of health
  • Do not smoke
  • Moderate intake of alcohol
  • Sleep 8 hours per day
  • Relaxation techniques

Stages of Reproductive Aging Workshop (STRAW)[edit | edit source]

In 2001, the Stages of Reproductive Aging Workshop, otherwise known as STRAW, put together a standard for reproductive ageing. In 2011, STRAW was updated and modified to STRAW+10, which is the gold standard to identify stages within the sexual reproductive periods of a woman's lifespan.[1]

STRAW identifies the stages within the sexual reproductive periods of a woman's lifespan. It divides the adult female life into three broad phases: reproductive, menopausal transition, and post-menopause. These three phases include seven stages which centre on the final menstrual period, which is called Stage 0.[9]

STRAW divides the reproductive phase into Stages -5 (which is early), -4, (which is classified as peak), and -3 (which is late). Stage–3 is characterised by regular menstrual cycles, as well as increasing levels of follicle-stimulating hormone (FSH).[9]

The menopausal transition phase includes Stage -2 (early) and Stage -1 (late). During Stage –2, there is variability in the length of the menstrual cycle and increased levels of FSH. During Stage –1, there is the onset of skipped cycles / amenorrhea which lasts at least 60 days, as well as continued elevation of FSH.[9][10]

The post-menopause phase includes Stages +1 (early) and +2 (late).[9]

Please see Harlow et al.'s article: Executive summary of the Stages of Reproductive Aging Workshop + 10: addressing the unfinished agenda of staging reproductive aging for more information.

Links to Helpful Pages[edit | edit source]

Additional Resources[edit | edit source]

Videos:[edit | edit source]
  1. Menstrual cycle an NHS site video
  2. Dr Jen Gunter, TED Talks on What really happens to your body during Menopause?
  3. Video: Am I Normal? (Girls and Puberty)
  4. What is Menarche? Everything you need to know
Recommended for Providers[edit | edit source]
  1. Menopause Health Tool, Dr Jean Hailes
  2. Practitioner’s Toolkit, Monash University 2014
  3. Menopause Preparedness Fact Sheet, The Society of Women’s Health Research -October 2021.
Recommended for Clients and Parents / Guardians[edit | edit source]
  1. Menopause Fact Sheet, August 2019, Dr Jean Hailes, Women’s Health, Available in English, Arabic, Chinese (Simplified), Farsi, Greek, Hindi, Italian, Turkish and Vietnamese. (This project was funded by the Victorian Government)
  2. Menstrual Calendar, for tracking perimenopause phase, NAMS, 2015
  3. Red Hot Mamas
  4. The Vajenda
  5. The North American Menopause Society
  6. US Department of Health and Human Services
  7. Healthy Women
  8. Canadian Society of Obstetricians and Gynaecologists
  9. Menstruation Around the World
  10. Menopause Map is a great interactive tool to start with to personalise your journey.

References[edit | edit source]

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 Piché S. Menarche to Menopause Course. Plus , 2022.
  2. ↑ Howard SR. Interpretation of reproductive hormones before, during and after the pubertal transition-Identifying health and disordered puberty. Clin Endocrinol (Oxf). 2021 Nov;95(5):702-715.
  3. ↑ Mendle J, Beltz AM, Carter R, Dorn LD. Understanding puberty and its measurement: ideas for research in a new generation. Journal of Research on Adolescence. 2019 Mar;29(1):82-95.
  4. ↑ Lacroix AE, Gondal H, Langaker MD. Physiology, menarche. InStatPearls [Internet] 2021 Mar 27. StatPearls Publishing.
  5. ↑ Kota AS, Ejaz S. Precocious puberty. InStatPearls [Internet] 2021 Jul 25. StatPearls publishing.
  6. ↑ 6.0 6.1 Gasner A, Rehman A. Primary amenorrhea. 2022 Mar 20. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 32119356.
  7. ↑ Talaulikar V. Menopause transition: Physiology and symptoms. Best Practice & Research Clinical Obstetrics & Gynaecology. 2022 Mar 16.
  8. ↑ Santoro N, Kravitz HM. The Disruptive Changes of Midlife: A Biopsychosocial Adventure. Obstetrics and Gynecology Clinics. 2018 Dec 1;45(4):xv-ii.
  9. ↑ 9.0 9.1 9.2 9.3 Harlow SD, Gass M, Hall JE, Lobo R, Maki P, Rebar RW, Sherman S, Sluss PM, De Villiers TJ, STRAW+ 10 Collaborative Group. Executive summary of the Stages of Reproductive Aging Workshop+ 10: addressing the unfinished agenda of staging reproductive aging. The Journal of Clinical Endocrinology & Metabolism. 2012 Apr 1;97(4):1159-68.
  10. ↑ Woods NF, Mitchell ES, Coslov N, Richardson MK. Transitioning to the menopausal transition: a scoping review of research on the late reproductive stage in reproductive aging. Menopause. 2021 Apr 1;28(4):447-66.
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