New criteria clarify menopause stages
Clinicians and researchers now have more comprehensive parameters to assess the stages of menopause with updated criteria known as the Stages of Reproductive Aging Workshop +10 (STRAW +10). The new guidance, which updates information originally issued in 2001, will help clinicians predict when a woman will enter menopause and aid in selection of treatment options for menopausal symptoms and other related conditions.1 (To access a copy of the guidance, go to http://bit.ly/xziuTc.)
The new report is the result of findings gathered during a fall 2011 symposium co-sponsored by the National Institute on Aging, Office of Research on Women's Health, North American Menopause Society, American Society for Reproductive Medicine, International Menopause Society, and the Endocrine Society.
"The North American Menopause Society convened a group of experts from key medical societies around the world to update our understanding of the stages women go through from adolescence to menopause and beyond," stated Margery Gass, MD, executive director of the North American Menopause Society, in a statement accompanying the report. "This new update has broader application to more women and provides additional details for determining where a woman is in these reproductive stages."
Check new guidance
The new guidance offers simplified bleeding criteria for the early and late menopausal transition; recommends modifications to criteria for the late reproductive and the early postmenopausal stages; provides information on the duration of the late transition and early postmenopause; and recommends application regardless of women's age, ethnicity, body size, or lifestyle characteristics.
Family planning clinicians might want to look at the late reproductive stage, labeled as Stage -3. This stage marks the time when fecundability begins to decline and a woman might begin to notice changes in her menstrual cycles. Endocrine parameters, which are important to fertility assessments, begin to shift prior to overt changes in menstrual cycles; therefore, the late reproductive stage now has been subdivided into two substages: -3b and -3a. In -3b, menstrual cycles remain regular without change in length or early follicular phase levels of follicle-stimulating hormone (FSH); however, antimüllerian hormone (AMH) and antral follicle counts are low. In Stage -3a, subtle changes in menstrual cycle characteristics, specifically shorter cycles, begin. In early follicular phase (cycle days 2-5), FSH increases and becomes more variable, with the other three markers of ovarian aging being low.1
Another important point of reference is early menopause. New data on the trajectories of change in mean levels of FSH and estradiol now indicate that FSH continues to increase and estradiol continues to decrease until about two years after the final menstrual period, after which the levels of each of these hormones stabilize.2,3 With these findings in hand, the new guidance divides early menopause into three stages.
According to the new guidance, stages +1a and +1b each last one year and end at the time point at which FSH and estradiol levels stabilize. Stage +1a marks the end of the 12-month period of amenorrhea required to define that the final menstrual period has occurred; it corresponds to the end of perimenopause.
Stage +1b includes the remainder of the period of rapid changes in mean FSH and estradiol levels. Menopausal symptoms, most notably vasomotor symptoms, are most likely to occur during the +1a and +1b period.1 Stage +1c represents the period of stabilization of high FSH levels and low estradiol values; it is estimated to last 3-6 years.
Stage +2 marks the late post menopause period, a time in which changes in reproductive endocrine function are more limited and processes of somatic aging become apparent. Clinicians need to note this stage, as symptoms of vaginal dryness and urogenital atrophy become increasingly prevalent at this time, the report states.1
More research needed
While scientific advances have provided a greater insight into ovarian aging, important gaps in scientific knowledge persist, say 2011 workshop participants. Seven research priorities have been identified:
- development of an international standard for the assessment of AMH;
- empirical analysis across multiple cohorts to develop precise menstrual cycle criteria for Stages -3b and -3a;
- studies to characterize the hormonal changes of postmenopause from Stage +1 to +2;
- application of STRAW + 10 staging criteria to reanalyze key findings on clinical changes that occur across the menopausal transition;
- characterization of the pattern, timing, and level of reproductive biomarkers across nations;
- research into reproductive aging and appropriate staging criteria for women with polycystic ovary syndrome and primary ovarian insufficiency, as well as those who have had removal of a single ovary and/or hysterectomy;
- studies to better evaluate staging in women with chronic illness such as HIV infection and those undergoing cancer treatment.1
References
- Harlow SD, Gass M, Hall JE, et al. Executive summary of the Stages of Reproductive Aging Workshop + 10: addressing the unfinished agenda of staging reproductive aging. Menopause 2012. Doi:10.1097/gme.0b013e31824d8f40
- Sammel MD, Freeman EW, Liu Z, et al. Factors that influence entry into stages of the menopausal transition. Menopause 2009; 16:1,218-1,227.
- Randolph JF Jr, Zheng H, Sowers MR, et al. Change in follicle-stimulating hormone and estradiol across the menopausal transition: effect of age at the final menstrual period. J Clin Endocrinol Metab 2011; 96:746-754.
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