Predicting the Start of ‘the Change’

By the time many women realize they have reached menopause, they have missed the chance to ease symptoms, stave off early bone loss or even become pregnant.

Menopause is not formally diagnosed until a woman has completed a full year with no menstrual period. But by that time many have suffered hot flashes, insomnia or other symptoms without understanding their significance.

Two new developments, however, may help women understand the changes in their bodies--and make health decisions accordingly.

In the first, doctors have now labeled the stages of reproductive aging. By assessing hormone levels and menstrual cycle patterns, they place women in one of seven categories related to fertility--from “early reproductive” to “late postmenopause.”

Use of the stages, the doctors say, will give women and their physicians a more accurate picture of where women are in the aging process. It also should encourage earlier discussions about the gradual decline of fertility, leading to better decisions about pregnancy planning, contraceptives, hormone replacement therapy and strategies to avoid uncomfortable symptoms linked to menopause.

In the other development, a North Carolina company has developed a home menopause test kit that will show women whether they are beginning to lose fertility.

“Many women really want to understand what is going on with their bodies,” says E.C. Henley, executive vice president of Physicians Laboratories, the maker of the Menopause Home Test. “If you are 45 and are having irregular periods, or something is different, then it might be important to get a real-time indication of your menopausal status.”

Closer attention to women’s health issues over the last two decades has clarified the impact of menopause, says Dr. Robert Rebar, associate executive director of the American Society of Reproductive Medicine, which helped create the new definitions of reproductive aging. There is good evidence, for example, that hormonal changes that accompany menopause can affect other organs in the body.

And there are social reasons to get a better handle on female aging, Rebar says. “Our population is aging, but we don’t regard the average age of menopause--51--as being elderly anymore,” he says. “And as more women delay childbearing in order to begin careers, there are more older women wanting to have children but discovering they are perimenopausal.”

Perimenopause is generally described as the years prior to menopause, when women can begin experiencing symptoms such as missed periods, decreased fertility, hot flashes and weight gain. The new stages distinguish women who are beginning the transition from those who are further along.

Neither of the two new tools, however, will give women hard and fast answers, Rebar and others warn. In fact, the women’s health experts who labeled the phases were surprised that they could come up with even broadly defined stages.

What researchers could agree on is “that the terminology is all garbled,” says Dr. Michael R. Soules, director of the division of reproductive endocrinology at the University of Washington. “There is premenopause, perimenopause, the menopause transition. Everyone knew these [terms] weren’t really defined.”

The biggest problem with the use of such terms is in research, Soules said. Studies of perimenopausal women, for example, often look at people who differ in symptoms and age. It is difficult, then, to apply the findings of those studies--such as whether a particular herb may relieve hot flashes--to consumers.

To overcome the differences in terminology and ages, the new stages focus on objective data, including the length and variability of menstrual cycles and the level of a particular hormone called follicle-stimulating hormone, or FSH. FSH is produced by the pituitary gland in the brain to prod the ovaries to develop and release eggs.

An increase in the hormone is thought to constitute a decline in fertility, Rebar says.

The stages are similar to the well-known Tanner/Marshall system for defining puberty. In that system, clues such as breast development and body hair are used to estimate where a girl is in the years-long process of puberty.

The method of determining reproductive aging, which was produced by the American Society of Reproductive Medicine, the National Institute on Aging and the North American Menopause Society, was published simultaneously in four medical journals late last year.

But experts caution that it is still very rudimentary. “You can detect elevated levels of FSH, but we still can’t say if that stage [in a particular woman] will be six months long, a year long or a decade long,” Rebar says.

Researchers hope to fine-tune the phases’ definitions as more techniques are developed that explain reproductive aging. For example, says Soules, ultrasound imaging of the ovarian follicles may yield information in the future about aging.

The doctors caution that defining the stages of menopause does not mean that women need to have regular FSH blood tests. And many are dubious about the usefulness of the Home Menopause Test because it just looks at a single symptom of reproductive aging.

While many doctors order FSH blood tests, which cost about $50, for women who are experiencing menopausal symptoms, the home test allows women to learn FSH levels on their own. The urine test was cleared for marketing by the Food and Drug Administration in 1999, although it has not been available in the U.S. until recently.

According to the manufacturer, two consecutive readings of elevated FSH indicate that a woman is in the menopausal transition. What this means to an individual woman may vary, says Henley of Physicians Laboratories. “There are very extensive patient education materials enclosed with the test,” Henley says. “Women are recommended repeatedly to discuss the results with their physician.”

The test kit, which costs about $60, may appeal to women who think that their doctors don’t try hard enough to help them understand reproductive aging, says Susan Doughty, a nurse practitioner and director of the New England WomenCenter in Portland, Maine.

“Women want to know, ‘Where am I in the process? When am I likely to stop bleeding?’” she says. “But it’s like getting your blood pressure done; it’s helpful to take the information and have it put into context. It’s a piece of the picture, but it’s not the only piece.”

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The Stages of a Woman’s Reproductive Life

The new method of determining reproductive aging takes into account the length and variability of menstrual cycles, plus the level of a hormone that prompts the ovaries to release eggs. Before menopause, the length of the stages varies.

Early Reproductive--Menstrual cycles variable to regular; level of follicle-stimulating hormone (FSH) is normal.

Peak Reproductive--Menstrual cycles regular; FSH is normal.

Late Reproductive--Menstrual cycles regular, but FSH is elevated.

Early Menopausal Transition--Length of menstrual cycle varies by seven days or more; FSH is elevated.

Late Menopausal Transition--Two or more menstrual cycles are skipped, with an interval between cycles of 60 days or more; FSH is elevated.

(Menopause occurs--This is not a stage but is defined as 12 months without a menstrual period.)

Early Postmenopause--Lasts for four years after menopause; FSH is elevated.

Late Postmenopause--Lasts until death; FSH is elevated.

These stages should not be applied to all women, researchers caution. They recommend the exclusion of women who smoke, who are very heavy or very thin, who do heavy aerobic exercise, who have chronically irregular menstrual cycles, who have had a hysterectomy or who have uterine fibroids or endometriosis.