Menopause: Demystifying Management of Common Clinical Challenges

Lubna Pal, M.B.B.S., M.R.C.O.G., M.S.

In recent years, much energy (intellectual, emotional, and physical) has been expended on rationalizing the disparate data emanating from randomized controlled trials versus observational studies of menopausal hormone therapy (MHT). While many strive to make sense of the long-term implications of MHT, others remain along the sidelines waiting for the haze to lift; for yet another group, the chapter of MHT has closed. The symptomatic menopausal women and the clinicians are left to grapple amid reams of absolutes as they relate to the therapeutic role for MHT in the context of reproductive aging. While the researchers await further evidence that may better define the long-term risk-benefit profile for MHT, this volume of the Seminars in Reproductive Medicine attempts to bring back our focus on the symptomatic aging woman.

Dr. Rees's contribution, “Emerging Facade of Menopausal Hormone Therapy,” brings us up to speed with where we currently stand regarding the long-term health implications of MHT. The remainder of the issue is categorized into self-explanatory sections. The review on early menopause conveys salient distinctions between premature ovarian insufficiency, surgical truncation of the reproductive span, and age-appropriate natural menopause. Dr. Kodaman underscores that the severity and the spectrum of symptoms and the long-term health sequelae faced by those experiencing early menopause are distinct from the naturally menopausal population. She cautions that the ongoing debate and dogma around the role of hormone therapy in menopause management must not be extrapolated en bloc to the chronologically distinct population experiencing early menopause.

Whereas the review on early menopause focuses on the mechanistic aspects of ovarian failure, Dr. Buyak and colleagues introduce and elaborate on newer findings that identify hypothalamic processes that are distinct from gonadal events and may contribute to the overall paradigm of reproductive senescence.

Symptoms of vasomotor instability and sexual distress are significant contributors to an overall compromised quality of life in a substantial proportion of aging women. Dr. Chervenak provides an in depth review of the spectrum of sexual disturbances commonly encountered in the context of reproductively aging, while encouraging consideration of potential differential diagnoses for the symptoms. The articles by Drs. Shah and Agrawal and by Dr. Huang highlight not just the ethnic diversity of the symptomatology of menopause, but they also bring forth an appreciation of the racial heterogeneity within the populations of Asia. The review by Dr. Joffe and colleagues on sleep disturbances elaborates on a dimension of menopausal symptomatology that, although commonly acknowledged, remains sparsely addressed.

Any volume on reproductive aging-related concerns would be amiss if it did not acknowledge the long-term sequelae of menopause. Keeping in perspective that skeletal fragility dominates the spectrum of aging-related morbidities, Dr. Freeman's penultimate article follows skeletal dynamics across the spectrum of reproductive aging and places in perspective the implications of reproductive hormones. Lastly, Drs. Polotsky and Polotsky provide an in-depth introduction to the metabolic implications of menopause. Changes in the phenotype, energy expenditure, and the metabolic milieu that occur concomitant with reproductive aging are discussed, the risk for diabetes and cardiovascular disease is placed in perspective in the context of reproductive hormone status, and strategies that may translate into slowing the aging-related cascade of metabolic deterioration are presented.

It indeed has been my privilege to have had the opportunity to work with a team of contributors passionately committed to the well-being of the aging woman. It is our hope that the assembled selection will prove equally meaningful to those caring for reproductively aging women as well as those striving to better define the direction of menopause management in the foreseeable future.