Vasomotor symptoms are an important early warning sign, especially in women who don’t regularly menstruate. Experts say treatment shouldn’t be delayed.
Symptoms such as hot flushes and night sweats identify perimenopausal women more quickly than changes to bleeding, according to new research from Monash University.
The findings offered a new approach to managing women and gender-diverse people who don’t menstruate or have abnormal menstruation, and these symptoms needed to be formally recognised, the authors said.
Importantly, almost 40% of women in the study in late perimenopause appeared to be untreated for moderately-to-severely bothersome vasomotor symptoms, prompting hopes that alternative criterion to menstrual changes could help women get treatment earlier.
Professor Susan Davis AO and colleagues at Monash University surveyed more than 5500 women aged 40-69, as part of The Australian Women’s Midlife Years Study, about their menopausal symptoms and severity over the previous four weeks.
According to the Stages of Reproductive Aging Workshop +10 (STRAW+10) criteria, which uses changes to menstrual cycle frequency to define the transition, 1250 women were premenopausal, 344 were early perimenopausal, 271 were late perimenopausal and 3644 were postmenopausal.
“We already knew that VMS symptoms like hot flushes and night sweats are typical menopausal symptoms; however, our study clearly shows that a new onset of VMS is highly specific to perimenopause, being nearly five times more likely than in premenopause,” Professor Davis, an endocrinologist and director of the university’s women’s health research program, told media.
The study showed 8.8% of premenopausal women experienced hot flushes, compared with 37.3% of late perimenopausal women.
Other symptoms such as poor memory and low mood were less variable over time.
Vaginal dryness, however, was 2.5 times more common in perimenopause compared with premenopause. This was the most discriminative sexual symptom they found.
“While other symptoms might emerge in the perimenopausal stage, they lack specificity to that stage as these other symptoms are also common in premenopausal women, e.g.; poor memory was only 1.7 and 1.3 times more likely in early and late perimenopause compared with premenopause,” said Professor Davis.
“A major finding was that women with regular cycles, but with changed menstrual flow and VMS, who are presently classified as premenopausal, had a similar severity of a wide range of symptoms as early perimenopausal women who, by definition, have cycles that become shorter or longer by at least a week.”
“This finding supports the likelihood of perimenopause commencing before menstrual cycles vary by at least a week, and that women whose periods have become much heavier or much lighter and who also have VMS should be considered as having entered their perimenopause.”
Dr Marita Long, the Victorian and Tasmanian board director of the Australasian Menopause Society, welcomed the addition of VMS as an adjunct to the STRAW criteria, which made diagnosis a challenge in women who had interventions such as IUDs, hysterectomies or ablations.
This study reinforced the significance of VMS as part of the menopause transition, which offered the possibility for women to be effectively treated with MHT or non-MHT options, she said.
“The take home message for women and health professionals is that they can be treated, and no one should feel like they have to suffer through these symptoms,” Dr Long said.
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It was also vital that treatment wasn’t delayed until post-menopause, she said, noting the almost 40% proportion of perimenopausal women who had moderate-to-severe symptoms.
Nevertheless, there was a lack of therapies indicated for perimenopause.
“We know that MHT can sometimes make symptoms worse,” Dr Long said. “This can be particularly tricky for women over 50 where combined oral contraceptives are not recommended, and for younger women where they are contraindicated.”
The role of vaginal dryness as an indicator of the menopausal transition was a good reminder of the need to discuss and treat genitourinary syndromes of menopause (GUSM), Dr Long added.
“We know these tend to get worse and can be particularly significant in women who have had breast cancer.”
Professor Rodney Baber, clinical professor of obstetrics and gynaecology at the University of Sydney, said the paper gave new guidance on what symptoms were critical in the diagnosis of perimenopause.
“When we are unable to assess menstrual patterns, it is clear that moderate-to-severe bothersome vasomotor symptoms are the most important indicator or symptom over all others,” he said.
The authors of the paper said that it was “crucial” to have formal recognition “that the onset of moderately-to-severely bothersome vasomotor symptoms heralds the menopause transition in women without regular menstrual bleeding”.
Professor Davis told TMR she believed it was time to update guidelines to include vasomotor symptoms and, in fact, to incorporate perimenopause at all.
She said the Practitioner’s Toolkit for the Management of the Menopause had a section on how to manage perimenopause, but noted many international and national guidelines focused on menopause alone.
“If a woman comes in and says, ‘For the last six months, I’m having really heavy bleeds, I’ve got clots, and I’m getting hot flashes’, or ‘I’m getting these night sweats’, she’s perimenopausal,” Professor Davis said. “But at the moment, until her periods vary by at least a week, she’s told she’s not.”
While Professor Baber praised the quality of the study and the importance of the findings, he said more data was needed for a guideline change.
“The key for GPs is that if women have a myriad of symptoms which are often associated with perimenopause, if they do not have vasomotor symptoms +/- menstrual irregularity it is much less likely to be perimenopause,” he said.
It was a “very difficult diagnosis”, Professor Baber added.
“We must all listen to our patients and try to tease out what is important to them. As usual, a good history is the key.”
Dr Long echoed this point, saying it was important for doctors to keep their diagnostic net broad and not to blame everything in midlife women on perimenopause or menopause.
As well as seeking help from non-GP specialists if needed, Dr Long recommended resources such as menopause.org.au and jeanhailes.org.au/health-professionals.
