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Menopause: Lori A. Bastian, MD, MPH, discusses the clinical examination for menopause and perimenopause.
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Menopause: Lori A. Bastian, MD, MPH, discusses the clinical examination for menopause and perimenopause.
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>> I'm Joan Stephenson, editor of JAMA's Medical News and Perspectives section. Today I have the pleasure of speaking with Dr. Lori Bastian about menopause and perimenopause. Dr. Bastion, why don't you introduce yourself to our listeners? >> Thanks! Hi! My name is Lori Bastian, and I am Associate Professor of Medicine and OB/GYN at Duke University. I also serve as a clinician at the Durham VA in Durham, North Carolina. >> Dr. Bastian, what is perimenopause, and in what population should perimenopause be considered?
>> So there are all kinds of terms that go with perimenopause, and I'll try to give you a few of those terms and then try to make it as simple as possible, or at least the way I think of it. Perimenopause refers to the time around menopause, and menopause is defined as 12 months of amenorrhea. So in most studies, perimenopause refers to the year before the final period, through the first year after the final period. And just speaking about that, it sounds crazy. I feel like it's talking about speaking in circles.
The simplified definition of perimenopause is three to 11 months of amenorrhea, or irregular periods. Because these definitions are awkward, a national panel of experts met to try to come up with a new staging system. And they have developed this staging system, but it has not been validated yet. So we are stuck with the definition of perimenopause, which is three to 11 months of amenorrhea or irregular periods. The population that should be considered for perimenopause include women in their 40s who report irregular periods and/or new climacteric symptoms.
And climacteric symptoms are symptoms related to menopause, and those include hot flashes and night sweats. Perimenopause should also be considered in women who report longer periods than normal, shorter periods than normal, or in general just irregular periods. In particular if this has lasted for more than three months. And then women should also be considered for perimenopause if they're in their 40s and have had a hysterectomy. >> What's the value of asking a woman whether she thinks she's starting menopause?
>> Well, I think the actual value in terms of looking at the likelihood ratio, and that is whether asking a woman whether she thinks she's starting menopause has any predictive value in whether she actually might be perimenopausal. Our research has shown that the likelihood ratio is somewhere between 1.5 and 2, which would mean that there's a modest value in actually asking a woman whether she thinks she is going through the change, or starting the change. But the more important questions to ask are related to, again, her menstrual history, the presence of hot flashes, and knowing her age.
>> How accurate are symptoms and signs in detecting perimenopause? >> Not very is the short answer to that question. The longer answer is to kind of break down and talk about both the symptoms and the signs. The symptoms I just mentioned briefly, with the highest likelihood ratio -- that is the symptoms that are most likely to predict perimenopause are hot flashes. There are other symptoms such as night sweats and depressed mood, which are not as good predictors of perimenopause.
And that's because you can see these symptoms in other conditions. The specificity for the diagnosis of perimenopause is not very good. With regards to signs, which when we talk about signs, we're thinking physical exam features in the diagnosis of perimenopause, the data are even worse. By that I mean that there aren't any signs on exam that are actually predictive of perimenopause. Partly that may be because those haven't been studied well, and we don't have the data to examine it.
But also I think the physical exam changes associated with perimenopause are very subtle and not something that one would pick up on exam. >> Is there any value in asking about family and medical history in determining menopausal status? >> There is some value in asking about family history of early menopause in the mother. So if the mother had -- went through menopause at an age less than 40, then that has a likelihood ratio of 2, which is a modest value, much the similar likelihood ratio we might see with hot flashes, for example, for identifying a younger woman between the ages of 36 and 45 becoming perimenopausal in the next three years.
So this could be an important question for a woman in her late 30s or early 40s. If she's 42, and she says that my mom went through menopause when she was 38, I think the clinician could pay attention to that because there is an association between mothers and daughters and early age of menopause. I don't think this is a particularly important question, family history, that is, for women over the age of 45. >> And what about medical history? Is there any value to medical history in determining menopausal status?
>> I think so. I think there's some value. In particular with regards to asking about current smoking status. Now I should tell the audience that I am a smoking cessation researcher, and so I'm quite passionate about people stopping smoking. So I always think it's important to ask about smoking status. But interestingly, in epidemiologic studies, women who smoke experience menopause one to two years earlier than non-smokers. And in our assessment, smoking status, the likelihood ratio was extremely modest, with a likelihood ratio of 1.3 and so was not an important predictor of menopause, or perimenopause, in our study.
But I think it still has some value because I think it's important clinically to remind our female patients about the negative effects of smoking. So for example, in a case where we have a woman who's 41 and she reports smoking, you know, based on her age of 41, the pretest probability of perimenopause is quite low. It's about 10%. And knowing that she's a smoker only increases this probability from about 10% to about 13%.
So it's not adding a lot of value in terms of the diagnosis, but I think it serves as a potential teachable moment in a time when you're talking about perimenopause to remind patients that there could be a relationship with their smoking and that they should be counseled to quit smoking. >> It occurs to me also because of smoking's connection with other conditions -- heart disease, for example -- that its effect on estrogen levels. Is that correct? From the chapter I read, that estrogen levels tend to be lower in smokers?
>> That's right. >> And that's related to perhaps the earlier perimenopause, that this is also related to the undesirable effects of smoking on the heart. >> Well, you know, I think that's a great observation. And that has not been teased out in research studies to my knowledge such that -- the problem with the association between smoking and estrogen is it really decreases the estrogen bioavailability. But that doesn't mean that when you measure the estrogen levels they're necessarily lower. It's just that the estrogen circulating is not as available.
And that's why these women have sometimes more severe hot flashes and go through menopause earlier. So I do think it's important to remind women that smoking is bad for you, and smoking has effects on your estrogen. And as you just said, the heart disease risk is an important thing to talk about in a perimenopausal woman and an opportunity to talk to her about quitting smoking. >> Are there laboratory tests that are more useful than clinical examination in diagnosing perimenopause?
>> Well, there are laboratory tests, but they're in general not more useful than asking about age and menstrual history and climacteric symptoms, in particular hot flashes. And I think that's best demonstrated in a discussion of a case. So the case would be a 45-year-old woman who's had a hysterectomy at the age of 42 and presents for her annual exam and notes new onset of hot flashes and irritability. So when you're thinking about her pretest probability of perimenopause, based on her age alone, her pretest probability is 40%, based on the fact that she's 45.
So her symptoms of hot flashes and irritability increase the post-test probability of her being perimenopausal by anywhere between 1.5 to twofold. You have to have a likelihood ratio calculator to exactly come up with those numbers. But when I do those calculations, her post-test probability is anywhere from 40% to 100%. So in this case, I wouldn't recommend drawing blood to check an SSH or any other kind of hormone test, because it would not change our clinical opinion that she's likely perimenopausal.
And I think that is probably one of the take-home messages of this article and this review that we did was that the age of the woman is the best predictor of pre-menopause. And then if you talk to her about her menstrual history, assuming she hasn't had a hysterectomy, and her symptoms, in particular hot flashes, most of the time have a pretty good answer about whether she's perimenopausal. Hormones, in particular the follicle-stimulating hormone FSH, does become elevated in women who are going through perimenopause and menopause.
And so the times that I would recommend doing a laboratory test are quite infrequent. I was trying to think of a situation where clinically I might do it, and it might be a situation where a woman asks whether she's perimenopausal, and she's had a hysterectomy, and she's in the lower 40 range. Let's say 43, 42, so that her pretest probability is going to be around 20 to 30%. And she really wants to know if she's becoming perimenopausal, but is not having any hot flashes or other new symptoms, then one could check an FSH in that woman and see if it's elevated.
And then that would increase your post-test probability to something probably closer to 60% if her FSH was elevated. But in general, I'm not sure how that would change how I would manage her. And especially since she's not having symptoms, it wouldn't direct me to give her any new medication, for example. So in general, I would recommend waiting in this particular woman until she's older, closer to 45, 46, and if she's starting having new symptoms, then I would say that she's perimenopausal.
But I just don't see a lot of added value in doing the laboratory tests at this time. >> Is there anything else you'd like to tell our listeners about the diagnosis of perimenopause? >> You asked and alluded to some of my ideas about what I wanted to tell the audience with regards to when women ask about their menopausal status, that it can create a potential teachable moment. So it's an opportunity to talk about smoking cessation, an opportunity to talk about osteoporosis prevention and increasing calcium intake.
An opportunity to talk about cancer screening, the recommendations for mammography and colon cancer screening tend to occur, depending on the woman's history, but in -- 50 is kind of a magic age for a lot of cancer screening. And most women become perimenopausal by the age of 50. So it's just a good time to be talking about disease prevention. You know, as you mentioned, the heart disease prevention, it's a good time to remind women of the importance of smoking cessation, blood pressure control, weight loss if overweight or obese, and exercise are all important factors to be thinking about, of course, all of our lives, but when women become perimenopausal, hopefully a teachable moment to be thinking more about disease prevention.
>> And it might be a time when the patient is more receptive to that information. >> Well, that's what I'm hoping with the teachable moments. You know, when they ask you the question, am I perimenopausal? Are they really saying hey, am I getting older? And it's part of the question and part of what they're thinking, you know, then the answer could be let's talk about how to live for many more years as healthy as possible. So I do feel like it is a potential teachable moment. >> Thank you, Dr. Bastian, for this overview of perimenopause and menopause.
And for additional information about this topic, JAMAevidence subscribers can consult the chapter on menopause in the Rational Clinical Examination. This chapter was co-authored by Dr. Bastian. This has been Joan Stephenson of JAMA, talking with Dr. Lori Bastian for JAMAevidence.
Segment:0 .
>> I'm Joan Stephenson, editor of JAMA's Medical News and Perspectives section. Today I have the pleasure of speaking with Dr. Lori Bastian about menopause and perimenopause. Dr. Bastion, why don't you introduce yourself to our listeners? >> Thanks! Hi! My name is Lori Bastian, and I am Associate Professor of Medicine and OB/GYN at Duke University. I also serve as a clinician at the Durham VA in Durham, North Carolina. >> Dr. Bastian, what is perimenopause, and in what population should perimenopause be considered?
>> So there are all kinds of terms that go with perimenopause, and I'll try to give you a few of those terms and then try to make it as simple as possible, or at least the way I think of it. Perimenopause refers to the time around menopause, and menopause is defined as 12 months of amenorrhea. So in most studies, perimenopause refers to the year before the final period, through the first year after the final period. And just speaking about that, it sounds crazy. I feel like it's talking about speaking in circles.
The simplified definition of perimenopause is three to 11 months of amenorrhea, or irregular periods. Because these definitions are awkward, a national panel of experts met to try to come up with a new staging system. And they have developed this staging system, but it has not been validated yet. So we are stuck with the definition of perimenopause, which is three to 11 months of amenorrhea or irregular periods. The population that should be considered for perimenopause include women in their 40s who report irregular periods and/or new climacteric symptoms.
And climacteric symptoms are symptoms related to menopause, and those include hot flashes and night sweats. Perimenopause should also be considered in women who report longer periods than normal, shorter periods than normal, or in general just irregular periods. In particular if this has lasted for more than three months. And then women should also be considered for perimenopause if they're in their 40s and have had a hysterectomy. >> What's the value of asking a woman whether she thinks she's starting menopause?
>> Well, I think the actual value in terms of looking at the likelihood ratio, and that is whether asking a woman whether she thinks she's starting menopause has any predictive value in whether she actually might be perimenopausal. Our research has shown that the likelihood ratio is somewhere between 1.5 and 2, which would mean that there's a modest value in actually asking a woman whether she thinks she is going through the change, or starting the change. But the more important questions to ask are related to, again, her menstrual history, the presence of hot flashes, and knowing her age.
>> How accurate are symptoms and signs in detecting perimenopause? >> Not very is the short answer to that question. The longer answer is to kind of break down and talk about both the symptoms and the signs. The symptoms I just mentioned briefly, with the highest likelihood ratio -- that is the symptoms that are most likely to predict perimenopause are hot flashes. There are other symptoms such as night sweats and depressed mood, which are not as good predictors of perimenopause.
And that's because you can see these symptoms in other conditions. The specificity for the diagnosis of perimenopause is not very good. With regards to signs, which when we talk about signs, we're thinking physical exam features in the diagnosis of perimenopause, the data are even worse. By that I mean that there aren't any signs on exam that are actually predictive of perimenopause. Partly that may be because those haven't been studied well, and we don't have the data to examine it.
But also I think the physical exam changes associated with perimenopause are very subtle and not something that one would pick up on exam. >> Is there any value in asking about family and medical history in determining menopausal status? >> There is some value in asking about family history of early menopause in the mother. So if the mother had -- went through menopause at an age less than 40, then that has a likelihood ratio of 2, which is a modest value, much the similar likelihood ratio we might see with hot flashes, for example, for identifying a younger woman between the ages of 36 and 45 becoming perimenopausal in the next three years.
So this could be an important question for a woman in her late 30s or early 40s. If she's 42, and she says that my mom went through menopause when she was 38, I think the clinician could pay attention to that because there is an association between mothers and daughters and early age of menopause. I don't think this is a particularly important question, family history, that is, for women over the age of 45. >> And what about medical history? Is there any value to medical history in determining menopausal status?
>> I think so. I think there's some value. In particular with regards to asking about current smoking status. Now I should tell the audience that I am a smoking cessation researcher, and so I'm quite passionate about people stopping smoking. So I always think it's important to ask about smoking status. But interestingly, in epidemiologic studies, women who smoke experience menopause one to two years earlier than non-smokers. And in our assessment, smoking status, the likelihood ratio was extremely modest, with a likelihood ratio of 1.3 and so was not an important predictor of menopause, or perimenopause, in our study.
But I think it still has some value because I think it's important clinically to remind our female patients about the negative effects of smoking. So for example, in a case where we have a woman who's 41 and she reports smoking, you know, based on her age of 41, the pretest probability of perimenopause is quite low. It's about 10%. And knowing that she's a smoker only increases this probability from about 10% to about 13%.
So it's not adding a lot of value in terms of the diagnosis, but I think it serves as a potential teachable moment in a time when you're talking about perimenopause to remind patients that there could be a relationship with their smoking and that they should be counseled to quit smoking. >> It occurs to me also because of smoking's connection with other conditions -- heart disease, for example -- that its effect on estrogen levels. Is that correct? From the chapter I read, that estrogen levels tend to be lower in smokers?
>> That's right. >> And that's related to perhaps the earlier perimenopause, that this is also related to the undesirable effects of smoking on the heart. >> Well, you know, I think that's a great observation. And that has not been teased out in research studies to my knowledge such that -- the problem with the association between smoking and estrogen is it really decreases the estrogen bioavailability. But that doesn't mean that when you measure the estrogen levels they're necessarily lower. It's just that the estrogen circulating is not as available.
And that's why these women have sometimes more severe hot flashes and go through menopause earlier. So I do think it's important to remind women that smoking is bad for you, and smoking has effects on your estrogen. And as you just said, the heart disease risk is an important thing to talk about in a perimenopausal woman and an opportunity to talk to her about quitting smoking. >> Are there laboratory tests that are more useful than clinical examination in diagnosing perimenopause?
>> Well, there are laboratory tests, but they're in general not more useful than asking about age and menstrual history and climacteric symptoms, in particular hot flashes. And I think that's best demonstrated in a discussion of a case. So the case would be a 45-year-old woman who's had a hysterectomy at the age of 42 and presents for her annual exam and notes new onset of hot flashes and irritability. So when you're thinking about her pretest probability of perimenopause, based on her age alone, her pretest probability is 40%, based on the fact that she's 45.
So her symptoms of hot flashes and irritability increase the post-test probability of her being perimenopausal by anywhere between 1.5 to twofold. You have to have a likelihood ratio calculator to exactly come up with those numbers. But when I do those calculations, her post-test probability is anywhere from 40% to 100%. So in this case, I wouldn't recommend drawing blood to check an SSH or any other kind of hormone test, because it would not change our clinical opinion that she's likely perimenopausal.
And I think that is probably one of the take-home messages of this article and this review that we did was that the age of the woman is the best predictor of pre-menopause. And then if you talk to her about her menstrual history, assuming she hasn't had a hysterectomy, and her symptoms, in particular hot flashes, most of the time have a pretty good answer about whether she's perimenopausal. Hormones, in particular the follicle-stimulating hormone FSH, does become elevated in women who are going through perimenopause and menopause.
And so the times that I would recommend doing a laboratory test are quite infrequent. I was trying to think of a situation where clinically I might do it, and it might be a situation where a woman asks whether she's perimenopausal, and she's had a hysterectomy, and she's in the lower 40 range. Let's say 43, 42, so that her pretest probability is going to be around 20 to 30%. And she really wants to know if she's becoming perimenopausal, but is not having any hot flashes or other new symptoms, then one could check an FSH in that woman and see if it's elevated.
And then that would increase your post-test probability to something probably closer to 60% if her FSH was elevated. But in general, I'm not sure how that would change how I would manage her. And especially since she's not having symptoms, it wouldn't direct me to give her any new medication, for example. So in general, I would recommend waiting in this particular woman until she's older, closer to 45, 46, and if she's starting having new symptoms, then I would say that she's perimenopausal.
But I just don't see a lot of added value in doing the laboratory tests at this time. >> Is there anything else you'd like to tell our listeners about the diagnosis of perimenopause? >> You asked and alluded to some of my ideas about what I wanted to tell the audience with regards to when women ask about their menopausal status, that it can create a potential teachable moment. So it's an opportunity to talk about smoking cessation, an opportunity to talk about osteoporosis prevention and increasing calcium intake.
An opportunity to talk about cancer screening, the recommendations for mammography and colon cancer screening tend to occur, depending on the woman's history, but in -- 50 is kind of a magic age for a lot of cancer screening. And most women become perimenopausal by the age of 50. So it's just a good time to be talking about disease prevention. You know, as you mentioned, the heart disease prevention, it's a good time to remind women of the importance of smoking cessation, blood pressure control, weight loss if overweight or obese, and exercise are all important factors to be thinking about, of course, all of our lives, but when women become perimenopausal, hopefully a teachable moment to be thinking more about disease prevention.
>> And it might be a time when the patient is more receptive to that information. >> Well, that's what I'm hoping with the teachable moments. You know, when they ask you the question, am I perimenopausal? Are they really saying hey, am I getting older? And it's part of the question and part of what they're thinking, you know, then the answer could be let's talk about how to live for many more years as healthy as possible. So I do feel like it is a potential teachable moment. >> Thank you, Dr. Bastian, for this overview of perimenopause and menopause.
And for additional information about this topic, JAMAevidence subscribers can consult the chapter on menopause in the Rational Clinical Examination. This chapter was co-authored by Dr. Bastian. This has been Joan Stephenson of JAMA, talking with Dr. Lori Bastian for JAMAevidence.
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