Natural Family Planning Teachers Association of Ireland (NFPTAI)

WHAT IS THE MENOPAUSE ?

The menopause is the final menstrual period (FMP) and it marks the end of the woman’s child-bearing years. Every girl when she is born already has the finite number of oocytes to last her child-bearing years and she will obtain no new ova after birth. The basis of reproductive aging is oocyte depletion in the ovary⁵with a steady loss of oocytes through atresia or ovulation throughout the child-bearing years, which does not necessarily occur at a constant rate.⁵ In fact even though the oocyte pool is depleted only about 500 ovulations have occurred over the child-bearing years.⁸

DEFINITION OF THE MENOPAUSE:

The World Health Organization (1996) defines the menopause as the permanent cessation of menstruation resulting from loss of ovarian follicular activity.(1) It is identified retrospectively by the absence of menstruation for one year^1,4 or if the woman is charting her cycle has evidence that she has not ovulated for one year.⁶ Menopause occurs within a wide age range between the ages of 42 to 58, ^{(ref 5)} and the age of the menopause has not changed since ancient times. In the Massachusetts Women’s Health Study (ref 9, McKinlay), involving over 2500 women aged between 45-55 the median age of the final menstrual period (FMP) was 51.3 years.^1,9

DEFINITION OF PRE-MENOPAUSE / PERIMENOPAUSE :

The perimenopause is a natural and healthy phase of a woman’s life but some women may have troubling symptoms associated with it.¹ It is well recognized that the decline of fertility and the symptoms associated with this stage of life, become more evident the closer the menopause approaches. Therefore some researchers refer to the pre-menopause as the five to eight years leading up to the menopause when the physiological decline in fertility has already begun, but without any noticeable clinical manifestations. The peri-menopause refers to the years immediately preceding and the two years or so following the menopause when clinical manifestations are very much in evidence.⁶ The Massachusssetts study⁹ found that the median age of the peri-menopause, based on the appearance of menstrual irregularity was 47.5 years, with the length of the typical menopausal transition estimated at nearly 4 years.^1,9 For a given interval of amenorrhoea the probability that menopause has occurred increases with age.¹⁰ “An amenorrheic interval of 6 months is predictive of menopause in 45% of women aged 45-49 years and in 70% of women over 53 years of age. That is 50% and 30% of women in those respective age groups could be expected to have one or more additional episodes of menstruation after 6 months without menses.”¹⁰

MENOPAUSAL TRANSITION

Menopausal Transition: In the medical literature these two terms, pre-menopause and peri-menopause are now called the menopausal transition. The two criteria for measuring the beginning of the menopausal transition are:

• The onset of irregular cycle lengths
• The change in hormone levels, specifically of FSH

One definition states the menopausal transition begins with variations in menstrual cycle length in a woman who has levels of FSH in the early follicular phase that are increased above levels found in regularly menstruating women under the age of 35, and ends with the final menstrual period, (ref 1). The median age of onset of transition in one study was quoted as 45.5 years, with a median duration of 4.8 years.⁷

STRAW REPORT -The definition of the menopausal transition

In order to reach agreement as to when the menopause transition begins, a consensus document was issued in 2001 by the STRAW Report⁵ (Stages of Reproductive Aging Workshop), which proposed that reproductive life could be characterized by seven stages. Before menopause the reproductive life could be divided into the reproductive years (three stages) and the transition years (two stages: early and late transition). Postmenopause (two stages) follows the final menstrual period. (FMP). The STRAW report uses two criteria to assess menopausal transition- cycle length and FSH level. STRAW proposes an elevated FSH level obtained in the early follicular phase that exceeds 2SDs of the mean level for a sample of normal women of peak reproductive age (25-30years).⁵ According to STRAW in the early menopausal transition (stage -2), a woman’s menstrual cycles remain regular but the duration changes by 7 days or more (e.g. her regular cycles are now every 24 instead of 31 days).⁵ According to STRAW the late menopausal transition (stage -1) is characterized by two or more skipped menstrual periods and at least one intermenstrual interval of 60 days or more.⁵ An article by Harlow et al⁷ which reviewed the work of STRAW and others suggests that the onset of early menopausal transition may be best described by ovarian activity consistent with the persistent >6 day difference, i.e. the length of the cycle is >6 day different from the previous cycle and this magnitude of difference is observed again within ten cycles.⁷

WHAT IS HAPPENING IN THE BODY IN PRE-MENOPAUSE

As the woman approaches the end of her child-bearing years the number of follicles in the ovary has reduced from 250,000 at puberty⁸ to about 10,000 follicles at the age of 45.⁶ At the menopause many of these remaining follicles become atretic (degenerate) without ever achieving an ovulation. This reduced ovarian activity results in decreased levels of the ovarian hormones, oestrogen and progesterone which is the basis of the symptoms of pre-menopause. This can result in:

• Long cycles which may be anovulatory or with delayed ovulation.
• Short cycles due to a short luteal phase, a short follicular phase and early ovulation,⁶ or the luteinized unruptured follicle syndrome (LUF syndrome).

FSH secretion by the pituitary gland is increased due to the absence of the follicular fluid peptide inhibin B, as during normal reproductive life the secretion of FSH is inhibited by inhibin B. The earliest endocrine change marking entry into the menopausal transition is a major fall in inhibin B. However inhibin B is a very difficult and relatively unavailable assay and would not contribute to the staging system.⁵

SYMPTOMS OF MENOPAUSAL TRANSITION

The symptoms associated with menopausal-transition (pre-menopause) include fertility decline, irregular cycles, heavy periods, irregular bleeding, hot flushes.

• Fertility decline: Fertility in the pre-menopause is diminished due to the decline in the number of ovarian follicles. The loss of follicles accelerates after the age of 38 years and very few oocytes remain by the last menstrual period.^1,11 The pre-menopause presumably begins when a critical number of functional follicles are lost through the process of follicular atresia.
• Irregular cycles: There is an increase in the mean cycle lengths, however very long cycles may be interspaced with extremely short cycles.¹⁰ Peri-menopause is characterized by ovulatory cycles interspersed with anovulatory cycles of varying lengths.⁸ The cycle lengths although regular become shorter initially usually due to earlier ovulation and a shortened follicular phase. A short cycle may also be due to a short luteal phase. Then the cycles become irregular and later they get longer, up to two or three months or more in length. The irregular cycles in the >45 age group may well indicate anovulation.¹

• Heavy periods, Irregular bleeding: Prolonged raised oestrogen levels which occurs in the long anovulatory cycles, and/or altered oestrogen to progesterone levels may lead to a greater build-up of the endometrium. Due to fluctuating oestrogen levels the thickened endometrium can break down causing menorrhagia (heavy and prolonged periods), or irregular bleeding or spotting. The irregular bleeding occurring at different times in the cycle e.g. in the late luteal phase or at ovulation, may be associated with low levels of circulating oestrogen and progesterone. If intermittent bleeding persists the woman should consult her doctor.

• Hot flush: The hot flush is related to vasomotor instability and results in a sudden sensation of heat or a warm feeling. Its duration varies from part of a second to several minutes and its frequency from once weekly to numerous hot flushes daily. Generally the rate of occurrence of the hot flush increases until the menopause and gradually disappears during the years after menopause.⁶

The Fertility Indicators and Pre-Menopause - (Mucus, Temperature, Palpation of Cervix)

Cervical Mucus and pre-menopause: Cervical mucus as a fertility indicator is less clear in the pre-menopause as:

• The normal oestrogenic build-up to peak mucus may not occur due to anovulatory cycles.
• Even in the ovulatory cycle, mucus is not always discernible as fertile-type mucus is scant and occasionally absent making the mucus an unreliable symptom.(LINK to page 11h, S mucus).
• With natural aging of the cervix the S crypts decline in number so that the quantity and the duration of the more-fertile mucus symptom is diminished. The S mucus may occur for one day or part of a day during the fertile phase and the woman may miss this symptom altogether.
• The area in the vulva sensitive to the presence of mucus is also diminished making it more difficult to appreciate the mucus symptom.

Palpation of the Cervix and pre-menopause:

The changes in the cervix itself are more objective and a more reliable fertility indicator in the pre-menopausal years.⁴

Temperature (BBT) and pre-menopause:

In the peri-menopause the thermal shift is the only positive sign of ovulation and of the definitively infertile phase of the cycle. Therefore it is important to record temperature every day during the pre-menopause so that delayed ovulation and also the very early ovulation can be detected.

Special RULES apply in the pre-menopause situation in the symptothermal double-check method of natural family planning, and the woman must be taught these rules by a qualified NFP teacher.

References:

1. Liu JH, Gass ML; ‘Management of the perimenopause’; 2006; Pub. McGraw-Hill, ISBN 0-0-142281-1
2. Odeblad Erik; ‘The discovery of different types of cervical mucus and the Billings Ovulation Method’; Bulletin of the Ovulation Method Research and Reference Centre of Australia, Vol 21, No3; 3-35; Sept 1994. (on the internet if you google ‘Erik Odeblad, cervical mucus’).
3. Odeblad E, ‘Investigations on the physiological basis for fertility awareness’ page 7; Bulletin for the Ovulation Method Research and ReferenceCentre of Australia, vol 29, no 1, p2-11, march 2002, (internet, Billings Ovulation Method)
4. Flynn A, Brooks M; ‘The Manual of Natural Family Planning’; pages 74-80; 1996; ISBN 0 7225 3115 X
5. Soules MR, Sherman S, Parrot E et al; Executive summary: Stages of Reproductive Aging Workshop (STRAW). Fertil Steril. 2001; 76: 874
6. Flynn A, Worthington W; ‘Teachers Training Manual’; ’symptothermal multiple index method’ of natural family planning.
7. Harlow S D, Mitchell ES, Crawford S; ‘The ReStage Collaboration: defining optimal bleeding criteriafor onset of early menopausal transition’; Fertil Steril; vol 89, No1, Jan 2008.
8. Alvero Ruben, Schlaff William D; ‘Reproductive endocrinology and infertility, The Requisites in Obstetrics and Gynecology’; 2007, page 229; ISBN-13:978-0-323-04054-9
9. McKinlay SM; ‘The normal menopause tradition: and overview ‘; Maturitas; 1996; 23:137
10. Wallace RB, Sherman BM et al; ‘Probability of menopause with increasing duration of amenorrhea in middle-aged women’; Am. J. Obstet. Gynecol. 135: 1021, 1979.
11. Richardson SJ, Senikas V, Nelson JF; ‘Follicular depletion during the menopausal transition: evidence for accelerated loss and ultimate exhaustion’; J Clin Endocrinol Metab. 1987; 65:1231

To be most effective, the woman must be taught the symptothermal double-check method of Natural Family Planning by a qualified natural family planning teacher.