Snapshot A 52-year-old female presents with a feeling of heat beginning in the face, neck, and chest followed by profuse sweating in the upper body that lasts five minutes.These episodes are happening repetitively throughout the day and disturb her sleep at night. Her last menstrual period was over six months ago. Introduction Permanent cessation of menstruation secondary to oocyte depletion leading to decreased estrogen and progesterone hot flash symptoms a result of declining levels of estradiol-17β Epidemiology mean age in the US is 51 early menopause is associated with cigarette smoking Premature menopause is defined by menopause before age 40 Post-menopausal women lose the protective effects of estrogen with increased risk for osteoporosis heart disease Presentation Symptoms hot flashes and sweats sleep disturbance mood changes and depression vaginal atrophy and dryness dysuria urge incontinence dyspareunia (painful intercourse) osteoporosis menstrual cycle is no longer normal with no premenstrual symptoms Evaluation This is a clinical diagnosis Elevated serum FSH (> 30 mIU/mL) depletion of ovarian follicles leads to a drop in estrogen and results in elevated FSH and LH Androstenedione levels do not change DEXA scan (at 65 years or older) a T-score of -2.5 or less is significant indicates osteoporosis treatment is recommended Differential Premature ovarian failure Rule out other conditions that can cause amenorrhea pregnancy, thyroid disease, and hyperprolactinemia Treatment Estrogen hormone replacement therapy (HRT) opposed with progestin (if patient still has uterus) unopposed estrogen therapy if no uterus total abdominal hysterectomy with bilateral salpingo-oophorectomy indications for HRT (in a healthy woman < 60 years and no contraindications) vasomotor symptoms mood lability/depression vulvovaginal atrophy benefits of HRT relief of menopause symptoms decrease risk of heart disease and stroke decrease osteoporosis decrease dementia risks of HRT endometrial CA breast CA (controversial) deep venous thrombosis/pulmonary embolism breast pain contraindications of HRT deep venous thrombosis/pulmonary embolism patient at high risk for breast cancer breast pain (due to estrogen stimulation) liver disease (chronic hepatitis) estrogen is metabolized in the liver route of administration topical estrogen used if mainly vaginal symptoms Alternative drugs for vasomotor symptoms SSRIs (paroxetine) SSNRIs clonidine gabapentin Prognosis, Prevention, and Complications Complications osteoporosis coronary artery disease