Menopause and Menopause: Symptoms, Diagnosis, and Modern Treatments
Menopause is the last spontaneous menstruation in a woman's life. It is diagnosed retrospectively after 12 months of no menstruation. The average age of menopause in Russia is 51–52 years.
Menopause occurs as a result of the natural decline in ovarian function and the cessation of estrogen secretion. It is not a disease, but a physiological transition. However, estrogen deficiency affects virtually all organ systems, and for a significant number of women, this transition is accompanied by severe symptoms that reduce quality of life.
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According to the new 2025 ROAG clinical guidelines, which came into effect and replaced the 2021 version, the terminology has been clarified:
- Premenopause — the entire reproductive period of a woman's life before menopause.
- Perimenopause — the transitional period (usually 2–8 years) before menopause and 1 year after it; characterized by irregular cycles and hormonal fluctuations.
- Postmenopause — the period after menopause.
Diagnostics and Laboratory Tests
| Indicator | What is assessed |
|---|---|
| FSH | An increase of ≥25 IU/L in two measurements confirms postmenopause |
| Estradiol (E2) | Decrease < 20–30 pg/ml |
| AMH (anti-Müllerian hormone) | Marker of ovarian reserve; decreases long before clinical menopause |
| TSH | Ruling out hypothyroidism (a common cause of menopause-like symptoms) |
| Prolactin | Ruling out hyperprolactinemia |
Instrumental diagnostics (KR ROAG 2025)
DXA (densitometry) of the lumbar spine and proximal femur is recommended for all peri- and postmenopausal women to detect osteoporosis and assess fracture risk.
Mammography is a mandatory screening before starting HRT.
Pelvic ultrasound is an assessment of the endometrium and ovaries.
FRAX is a 10-year fracture risk calculator.
Menopausal hormone therapy (MHT)
MHT is the most effective method for correcting menopausal symptoms. According to the updated 2025 guidelines for the Russian Society of Gynecologists, the approach to MHT has become more personalized: the restrictive phrases "only when clearly indicated" have been replaced by the principle of an individual assessment of the balance of benefits and risks at least once a year.
Indications for HRT
- Moderate to severe vasomotor symptoms
- Genitourinary menopausal syndrome
- Prevention of osteoporosis in women at high risk (when other antiosteoporotic drugs cannot be used)
- Premature ovarian failure (before age 40) or early menopause (40–45 years)
MGT modes
- Estrogen monotherapy - only for women after hysterectomy
- Combination therapy (estrogen + progestogen) - with the uterus intact (progestogen protects the endometrium)
- Cyclic regimen - in perimenopause (cycle imitation)
- Continuous combination regimen - in postmenopause
- Tibolone - a synthetic steroid with estrogenic, progestogenic, and androgenic effects
Routes of administration
Oral (tablets) — convenient, but pass through the liver.
Transdermal (patches, gels) — preferred for those with a high risk of thrombosis, obesity, and metabolic disorders.
Intravaginal (for GUMS) — minimal systemic absorption, high local efficacy.
Contraindications to systemic HRT
- History of breast cancer or breast cancer based on examination
- History of thrombosis (venous thromboembolism) without an established cause
- Acute cardiovascular events (MI, stroke)
- Active liver disease
- Untreated endometrial hyperplasia
Monitoring of the MHT
Follow-up examination 3 months after starting HRT, then at least once a year:
- Gynecological examination + mammogram
- Endometrial ultrasound
- Assessment of symptoms and tolerance
Non-hormonal methods for correcting menopausal symptoms
If HRT is contraindicated or the patient refuses:
- Vasomotor symptoms: Fluoxetine/paroxetine (SSRIs), venlafaxine (SNRIs), clonidine — proven, but less pronounced effect than HRT.
- GUMS (urogenital symptoms): Local vaginal estriol therapy (at minimal doses — systemic absorption is minimal)
- Phytoestrogens (soy and red clover isoflavones) — weak estrogen-like effect; used as an alternative for mild symptoms and contraindications to HRT. Level of evidence: moderate
- Osteoporosis: bisphosphonates, denosumab – regardless of the decision on MHT
Frequently Asked Questions (FAQ)
Are menopause and climacteric the same thing?
Menopause (climacteric) is a broader term: it encompasses the entire transitional period of a woman's life, including perimenopause and postmenopause. Menopause refers to a specific moment (the last menstrual period). In common parlance, the terms are used interchangeably.
How long do the hot flashes last?
On average, it lasts 5–7 years, but for some women, it lasts longer. Without treatment, hot flashes persist for more than 10 years in 30% of women. HRT eliminates hot flashes in 90% of patients.
Is HRT dangerous for breasts?
The risk of breast cancer with combined HRT is slightly increased with use for more than 5 years and levels off after a few years of discontinuation. This risk is comparable to that of excess weight or drinking a glass of alcohol daily. Mammography is mandatory before starting HRT, and then annually thereafter.
Is it possible to start HRT 10 years after menopause?
Use with caution. There is a concept called a "window of opportunity": HRT is most effective and safe when started within 10 years of menopause or before age 60. After age 60 or with prolonged postmenopause, the risks of HRT (including cardiovascular risks) increase.
Is contraception necessary during perimenopause?
Yes, as long as you haven't had a period for 12 months (that is, until menopause is confirmed). Ovulation is still possible during perimenopause.
Does feeling empty nest and stress mean menopause symptoms or depression?
Often, both. Estrogen deficiency reduces the brain's sensitivity to serotonin and dopamine, which intensifies depressive symptoms. Assessing hormonal status helps differentiate between "pure" depression and menopausal depressive syndrome.
What is surgical menopause?
This is menopause resulting from bilateral oophorectomy (removal of the ovaries). It occurs immediately and is typically more severe than natural menopause due to the sharp drop in estrogen levels. In such cases, HRT is especially important and is recommended until the age of natural menopause.
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Symptoms of climacteric syndrome
Symptoms are classified by time of onset:
Early symptoms (peri- and early postmenopause)
Vasomotor:
Psycho-emotional:
Moderate symptoms (after 1–5 years)
Urogenital atrophy (genitourinary menopausal syndrome, GUMS):
Late consequences (after 5-10 years)