Womens Health

Perimenopause and Early Menopause

Frederick R. Jelovsek MD


A menses after menopause -- can pregnancy occur?

How long does menopause last?

Does extreme fatigue mean low estrogen levels?

Terrible hot flashes after stopping HRT

Differential Diagnosis of

Mood, Feelings, Menopause Problems

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A menses after menopause -- can pregnancy occur?

My wife who is 47 years old was informed by an Ob/Gyn that a hormone test revealed that she is now menopausal. That was 4 months ago and we have used no protection relative to intercourse. She is now having a period with bleeding, bloating and cramping. I'm interested in references/journal articles citing the cause or an explanation of event.

This happens fairly frequently which is why the definition of post menopause is one year without any menstruation. I couldn't find exact numbers on how frequently it occurs but have included some abstracts below that show it is well known to happen. My subjective impression is that ovulation can still take place sporadically for up to a year after menopausal FSH levels in about 20-30% of women. There are many other factors negatively affecting fertility at that age that we don't usually put women on contraception during that time but it is remotely possible to get pregnant.

Commonly now, during the perimenopause/?menopause period we will have women use very low dose contraceptives (1/20 level) as estrogen replacement if they are non smokers. This obviously has dual benefits although before we started doing this it was still quite rare (but not impossible) to have a late age pregnancy at 47.

Eur J Endocrinol 1994 Jan;130(1):38-42

Diagnostic role of follicle-stimulating hormone measurements during menopause :analysis of FSH, oestradiol and inhibin.

Burger HG
Prince Henry's Institute of Medical Research, Clayton, Victoria, Australia.

This review examines the role of follicle-stimulating hormone (FSH) measurement in assessing the significance of symptoms and possible continuing fertility during the menopausal transition. Follicle-stimulating hormone measurement is advocated frequently as a useful diagnostic tool in perimenopausal patients. Several investigators have shown that the serum FSH level increases in the early--mid-follicular and early postovulatory phases in women over the age of 40 years who continue to experience regular menstrual cycles. The serum oestradiol level may fall (although this is controversial) and the immunoreactive inhibin level falls, being inversely correlated with the rising FSH level. When alterations in menstrual cyclicity or flow commence, signalling the onset of the menopausal transition, FSH levels may change abruptly, rising into the normal postmenopausal range and falling again into the range normally seen in young fertile women. Oestradiol and inhibin generally fluctuate in parallel with each other but inversely to FSH, although at times oestradiol in particular may be increased markedly. Postmenopausal FSH levels may be followed by endocrine evidence compatible with normal ovulation. After the menopause, FSH levels rise 10-15-fold, with low oestradiol and undetectable inhibin levels. It is concluded that FSH measurement is of little value, if any in the assessment of women during the menopausal transition because it cannot be interpreted reliably and because, apparently, ovulatory (and, presumably, potentially fertile) cycles may occur subsequent to the observation of postmenopausal FSH levels. Both oestradiol and inhibin are important negative feedback regulators of circulating FSH.


N Z Med J 1988 Mar 9;101(841):103-106

The approach of menopause: a New Zealand study.

Metcalf MG
Department of Endocrinology, Princess Margaret Hospital, Christchurch.

Once weekly observations of the excretion of FSH, LH, oestrogens and pregnanediol have been used to monitor the changes which occur as New Zealand women approach and pass through the menopause. There were 3 patterns of hormone excretion. (1) Premenopausal women (aged 40-51 yr) had regular menstrual cyclicity with hormone patterns similar to those seen in the ovulatory cycles of fertile young women. (2) Women in the menopausal transition (40-55 yr) had irregular menstrual cyclicity with erratic hormone fluctuations. There were ovulatory cycles, postmenopausal episodes in which amenorrhoea was associated with high gonadotrophin levels and low urinary oestrogens, and times when the excretion of both gonadotrophins and oestrogens soared. Ovarian activity did not cease at the menopause, and postmenopausal women in the 6 months following final menstruation (44-55 yr) had hormone patterns which were indistinguishable from those observed in the long anovulatory cycles of the menopausal transition. (3) Older women (57-67 yr) had senescent ovaries with the unvarying high gonadotrophin and low oestrogen levels which are a consequence of ovarian failure.


How long does menopause last?

When a person has a hysterectomy and is put in surgical menopause, how long do you go through menopause? I am 42, 43 next month and am on hormones.

Symptoms (without hormone replacement) can last 1-25 years. Most women though, don't have symptoms that last much past about 10 years.

Does extreme fatigue mean low estrogen levels?

Could lethargy be attributed to a need to review/adjust HRT levels?

I began pre-menopause at age 38 - seven years ago - and have been on HRT for approximately 4 years. (taking 1.25mg Premarin everyday, and Provera on calendar days 14 through 25). My blood count is fine, thyroid is fine, no mono - but could just SLEEP ALL DAY - unlike my usual "run for 16 hrs per day" self.

By pre-menopause I assume you mean premature menopause, i.e., you are menopausal rather than perimenopausal. The doses you are on are at the level of menopausal replacement. Sometimes the estrogen levels need to be checked (estradiol) to see if you are on a correct level of replacement. To answer your question, yes, fatigue can be a result of too low estrogen levels but usually if that is true, you are also having sleep disturbances and hot flashes at the same time.

Most common causes of fatigue, assuming thyroid and estrogen levels are ok, is:

  1. stress
  2. sleep-deprivation
  3. sometimes allergy flares and certainly antihistamine therapy
  4. depression
  5. medications affecting mood
  6. other medical conditions

To see if hormonal levels or replacement therapy is it cause, ask yourself the following questions. Does the fatigue vary with the estrogen, Provera® therapy? Does it get better, worse, on weekends (if you have any)? If is doesn't vary with the hormonal therapy and it gets better on weekends, then look to causes other than hormones.


Terrible hot flashes after stopping HRT

I have been told that I am in menopause. I have tried HRT and had success for a while then, I could see no change. I decided to go the natural route with herbs. I was having terrible hot flashes worse than before I went on anything. I decided to go back on the HRT. I have had numerous symptoms - nervousness, can't drive some days, nothing makes me happy, off balance, headaches. I have been going through this for six years and feel like it should be under control by now. My husband is very supportive but I know he has to be getting tired of all this too. Any suggestions? The herbs were not working very well but the hot flashes were so severe that I really did not give them long enough. I also have high blood pressure and high cholesterol, so I have to be careful of herbs and medicines that I take so that it does not cause me more problems. I would appreciate any or all the help you can give me. I cannot keep doing this. Each day is a struggle.

You need estrogen replacement that is more consistent than with herbal preparations alone. It is very common to take estrogens, come off them and have hot flashes that are much worse worse than when you first started. Somehow the estrogen therapy sensitizes the receptors and when it is withdrawn, your "addiction" shows. That will get better over time. The main challenge now is to find hormonal therapy that will be absorbed by your body and cease of decrease you symptoms.


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