Menarche to Menopause

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

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. Pregnancy and the postpartum can take from 12 to 24 months, for a complicated case, which works out to possibly 2% of her life. Women spend a great deal of time preparing for and understanding pregnancy and birth, but don't seem to apply the same understanding and consideration to the other aspects of their health, that includes menarche and menopause. We should be focusing understanding on these transitions in life and preparing adequately for them.

Complex Female Developmental Process

The above illustration 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

A functional diagnosis in order to provide direction and support for client care is made primarily by looking at signs and symptoms. 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

• Age of Female
  • Younger (8-16 yrs) for menarche transition
  • Older (45-54 yrs) for menopause transition
• Character of Menses
  • Regularity
  • Duration
  • Flow heaviness
• Physical & Mental changes
  • Breast budding
  • Growth spurt
  • Low energy/fatigue
  • Moodiness
  • Short temperedness
  • Difficulty concentrating
  • Acne, bloating
  • Fluid retention

Puberty

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

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

Puberty happens to everyone within the ages of 6-16 yrs, but menarche is unique to females occurring approximately 2 years after the onset of secondary sex characteristic changes (specifically breast budding), approximately age 12.4 yrs (This depends on reference used. And the age has been decreasing presumably due to nutrition changes, further research required)

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 become key to maintaining the cyclic reproductive function.

Health Client Check:

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.

• Visual exam 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

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.

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.

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.

Tanner Stages Image

Menarche                  

This 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.

chronological age is not a useful predictor (Tanners Stages better) S&S

Early onset, “Precocious Puberty” that occurs before age 8, may indicate endocrine disorders related to obesity, low birth weight, mother preeclampsia, stress, lack of exercise

Late or delayed onset, “Primary Amenorrhea” when menarche fails to occur 3 years after breast development or age 16 yrs, may indicate Diabetes mellitus type 1, asthma, untreated celiac disease, cystic fibrosis, and inflammatory diseases. On the positive side late menarche is associated with a decreased risk of developing breast cancer, a decreased frequency of coronary heart disease and reduction in teen pregnancy

The absence of menarche onset, or amenorrhea, could be indicative other processes, pregnancy should be the first thing to be ruled out

Menstruation

A menstrual period defined as “the monthly shedding of the functional layer (the endometrial lining) of the uterus.” It occurs approximately every 28 days. This process occurs when the egg (ovum) is not fertilised. Cycles are commonly erratic at the start.

Follicles are present in a high percentage of females but ovulation may not occur until after a half dozen menstrual cycles. These monthly cycles may not regulate for the first few years.

Schedule a medical check up if the girl:

• -has not started menstruating within 3 years of breast growth or by the age of 15
• -the breast hasn’t started to grow by the age of 13
• -has a period that lasts more than 7 days
• -has severe pain during periods
• -is bleeding between periods
• -gets sick or has a sudden onset of fever after using a tampon
• -has a period that occurs more frequently than 21 days or less frequently than 45 days
• -goes 3 months without a period after beginning menstruation

For more information, please see Menstruation and Menstrual Rehab

Menopause

This stage occurs at the end of the reproductive stage and is marked by the final menstrual period (FMP). Exact timing of this period can not 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 drop to less than 1,000 and the signs and symptoms can begin to disrupt life. Usually occurs between the ages of 45-58 years.

chronological age is not a useful predictor

(STRAW+10 Staging) S&S

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

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 postmenopause
• -has vaginal dryness, pain or blood when wiping after toileting
• -has difficulty sleeping &/or feeling tired all the time
• -is experiencing decreased quality of life due to symptoms
• -is bleeding in postmenopause

For more information, please see Menopause.

Signs & Symptoms (S&S)

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

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

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
Diarrhea/constipation	Diarrhea/constipation
Trouble sleeping	Trouble sleeping

Common Medical Concerns in the Menopause Transition:

• Primary Ovarian Insufficiency
  • when the ovaries stop working before the age of 40
• Genitourinary Syndrome in Menopause
  • 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.
• Diseases of higher risk:
  • Cardiovascular
  • Diabetes/Obesity
  • Osteoporosis
  • Dementia
  • Cancer, mainly breast and uterine

Regular Assessments to include:

• Blood work –
  • to establish baselines +/or eliminate other things thyroid, diabetes
  • 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
• Height/Weight/ECG baseline
• Bone density scan (age 40 yrs at least for baseline, repeat every 5 years as indicated)
• Assess for sleep/rest habits (sleep apnea is prevalent here)
• Assess for depression as it’s prevalence increases
• Prescriptions that are immediately helpful (acne cream, smoking cessation aids, etc)
• Referrals that are immediately helpful (Physio, PFPT, Mental health-CBT, Sleep Clinic, etc)
• Gynecologist &/or Endocrinologist referral
• Pap test
• Mammogram beginning age 40 and continue every 3 years
• Colonoscopy age 55
• Follow up Appointment
• Encourage Clients to track S&S, to facilitate & direct care and review this regularly

Healthy Choices

• **Exercise (aerobic, strengthening and balance) you can include sex in this repertoire
• Diet/Nutrition to maintain health
• Stop smoking
• Moderation of alcohol intake
• Sleep
• Relax/De-stress

Stages of Reproductive Aging Workshop (STRAW)

STRAW divided the adult female life into three broad phases: reproductive, the menopausal transition, and postmenopause. These three phases included a total of seven stages centered on the FMP (Stage 0).1–4 The reproductive phase was divided into Stages–5, –4, and –3 corresponding to early, peak, and late, respectively. The menopausal transition phase consisted of Stage –2 (early) and Stage –1 (late), and the postmenopause phase contained Stages +1 (early) and +2 (late). Stage–3 was characterized by regular menstrual cycles and increasing levels of FSH. Stage –2 was characterized by variability in menstrual cycle length and increased levels of FSH. Stage –1 was characterized by onset of skipped cycles or amenorrhea of at least 60 days and continued elevation of FSH.

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.

Summing Up:

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 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.

Links to helpful pages

• Menstruation and Menstrual Rehab
• Menopause

Additional Resources

Reading

1. Menopause Practice: A Clinician’s Guide, 6th Edition. C.J. Crandall, Editior-in-Chief. North American Menopause Society, 2019
2. Female Development, 2021, Remien & Pillarisetty, National Library of Medicine, NIH
3. Physiology of Menarche, 2021, Lacroix/Gondal/Langaker, National Library of Medicine, NIH
4. Tanner Stages, 2021, Emmanuel & Bokor, National Library of Medicine, NIH
5. The Menopause Manifesto, Jen Gunter PhD OB/GYN, Penguin Random House Canada, 2021
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
7. The Complete Guide to Menopause, Annice Mukherjee PhD, Penguin Random House UK, first pub by Vermilion, 2021

Videos:

1. What is Menarche? Everything you need to know.- May 2021 (4 ½ mins)
2. Medical Centric - https://www.youtube.com/watch?v=kNlmOe-e23k
3. Menstrual cycle, NHS site video (2:41 mins) October2020 - https://www.nhs.uk/conditions/periods/fertility-in-the-menstrual-cycle/
4. What Really Happens to Your Body During Menopause - June 2021 (5 mins)
5. Dr Jen Gunter, TED Talks https://www.ted.com/talks/jen_gunter_what_really_happens_to_your_body_during_menopause?language=en
6. Video: Am I Normal?, Kids Health.org (2 mins) - https://kidshealth.org/en/kids/puberty-normal-video.html

Recommended for Providers:

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 & Parents/Guardians :

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. Menopause Barbie
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 personalize your journey.