STRAW+10 Reproductive Stages -5, -4, -3b, -3a
Early reproductive stage -5 Starts at menarche and cycles are typically irregular for several years
Reproductive stage -4 Peak stage
Cycles are regular
Ranging from 21-35 days
Late Reproductive stage: -3 (-3a & -3b) Fecundability (the chance of becoming pregnant) declines
cycles may start to change
Late reproductive stage: -3b FSH and cycle length are normal, but AFC and AMH decline
Late reproductive stage: -3a Subtle changes in menstrual cycle length and flow
often increasing frequency of shorter cycles
Variable FSH levels
AMH and AFC are low
AMH Produced by the granulosa cells of preantral and small antral follicles (unmeasured by
ultrasound)
Not a screening tool in women without a diagnosis of infertility because it does not
correlate with time to pregnancy
Peak AMH 24.5 years old
Not reliable before 25
Slight fluctuation during cycles
When not to check AMH before 25 y.o.
when pregnant
when on contraceptive as it may 25-50% lower
AMH by race higher in white
lower in black and Hispanic
AFC Ultrasound detected follicles 2mm-10mm
represent primordial follicles
are considered available pool of follicles
Follicles are decreasing in their ability to produce AMH
Menopause transition: Stages -2 & -1 Menstrual cycle irregularity
ends with menopause
Changing hormone levels
inconsistent ovulation
Early menopause transition: Stage -2 7 day difference in cycle length
Elevated FSH (variables still)
low AMH and AFC
Lasting for 10 + cycles
Late menopause transition: Stage -1 60 or more consecutive days of amenorrhea
only one episode is needed to define this stage in women over 45 yo
2 or more episodes between age 40-44 is more predictive of this transition
Increased variability in length
extreme fluctuations is hormones
increased anovulation
FSH >25 in random blood draw
lasts 1-3 years on average
LOOP Cycles Elevated estradiol lelves
luteal out of phase event
one in every four cycles in early menopause transition and 1/3 of cycles in late
High FSH recruits a follicle in the luteal phase
superimposed estradiol from each follicular phase - high levels
Ovulation 50% of time, with shorter cycle <21 days if not ovulation, you will have a long
cycle >36 days
, LOOP Cycles symptoms high estradiol = mastalgia, menorrhagia, uterine fibroid growth, endometrial
hyperplasia
Androgen aromatization in menopause transition increase with age to compensate for low estradiol levels
increases with body weight
increase estradiol levels
Longer menopause transition risk longer exposure to unopposed estradiol = increase risk for reproductive cancers
Anovulatory cycles low progesterone levels
increase in the menopause transition
40-60% of cycles are anovulatory in late menopause transition
More common in obese women
Postmenopausal: +1a, b, c and +2 Initiated by FMP
Early postmenopausal: +1 a, b, c 2 years after FMP
FSH increases
Estradiol decreases
Stage +1a postmenopausal year 1
the 12 months after FMP
FSH high
Estradiol low
VMS start
Stage +1b Late postmenopausal year 2 after FMP
Stage +1c Year 3-6 after FMP
FSH and estradiol have stabalized
late postmenopause stage +2 6-8 + years after FMP
no more reproductive changes
somatic aging predominates
GSM increases
Risk factors for lower testosterone levels White, low body weight, bilateral oopherctomy, corticosteroid usage and oral estrogen
usage
Inhibin B and AMH role restrain follicle growth
Why does the cycle length shorten in early menopause Follicular phase is compressed
transition as follicle growth is accelerated due to declining inhibin B and AMH which typically
restrain follicle growth
This leads to longer luteal phase and more PMS symptoms
Menopause transition for women with PCOS AMH and inhibin B are declining
Causes regular cycling as these have been suppressing follicle growth during
reproductive years
These years can be fertile for these women
fertility increase for women with PCOS in this transition
Why transdermal estradiol over oral? - avoids first pass
- no risk of VTE
-oral raises trigs and inflammation, more CVD risk
- oral increases SHBG, lowers free T and causes sexual SE
What is vaginal DHEA FDA approved for? Dysparenunia from GSM
Early reproductive stage -5 Starts at menarche and cycles are typically irregular for several years
Reproductive stage -4 Peak stage
Cycles are regular
Ranging from 21-35 days
Late Reproductive stage: -3 (-3a & -3b) Fecundability (the chance of becoming pregnant) declines
cycles may start to change
Late reproductive stage: -3b FSH and cycle length are normal, but AFC and AMH decline
Late reproductive stage: -3a Subtle changes in menstrual cycle length and flow
often increasing frequency of shorter cycles
Variable FSH levels
AMH and AFC are low
AMH Produced by the granulosa cells of preantral and small antral follicles (unmeasured by
ultrasound)
Not a screening tool in women without a diagnosis of infertility because it does not
correlate with time to pregnancy
Peak AMH 24.5 years old
Not reliable before 25
Slight fluctuation during cycles
When not to check AMH before 25 y.o.
when pregnant
when on contraceptive as it may 25-50% lower
AMH by race higher in white
lower in black and Hispanic
AFC Ultrasound detected follicles 2mm-10mm
represent primordial follicles
are considered available pool of follicles
Follicles are decreasing in their ability to produce AMH
Menopause transition: Stages -2 & -1 Menstrual cycle irregularity
ends with menopause
Changing hormone levels
inconsistent ovulation
Early menopause transition: Stage -2 7 day difference in cycle length
Elevated FSH (variables still)
low AMH and AFC
Lasting for 10 + cycles
Late menopause transition: Stage -1 60 or more consecutive days of amenorrhea
only one episode is needed to define this stage in women over 45 yo
2 or more episodes between age 40-44 is more predictive of this transition
Increased variability in length
extreme fluctuations is hormones
increased anovulation
FSH >25 in random blood draw
lasts 1-3 years on average
LOOP Cycles Elevated estradiol lelves
luteal out of phase event
one in every four cycles in early menopause transition and 1/3 of cycles in late
High FSH recruits a follicle in the luteal phase
superimposed estradiol from each follicular phase - high levels
Ovulation 50% of time, with shorter cycle <21 days if not ovulation, you will have a long
cycle >36 days
, LOOP Cycles symptoms high estradiol = mastalgia, menorrhagia, uterine fibroid growth, endometrial
hyperplasia
Androgen aromatization in menopause transition increase with age to compensate for low estradiol levels
increases with body weight
increase estradiol levels
Longer menopause transition risk longer exposure to unopposed estradiol = increase risk for reproductive cancers
Anovulatory cycles low progesterone levels
increase in the menopause transition
40-60% of cycles are anovulatory in late menopause transition
More common in obese women
Postmenopausal: +1a, b, c and +2 Initiated by FMP
Early postmenopausal: +1 a, b, c 2 years after FMP
FSH increases
Estradiol decreases
Stage +1a postmenopausal year 1
the 12 months after FMP
FSH high
Estradiol low
VMS start
Stage +1b Late postmenopausal year 2 after FMP
Stage +1c Year 3-6 after FMP
FSH and estradiol have stabalized
late postmenopause stage +2 6-8 + years after FMP
no more reproductive changes
somatic aging predominates
GSM increases
Risk factors for lower testosterone levels White, low body weight, bilateral oopherctomy, corticosteroid usage and oral estrogen
usage
Inhibin B and AMH role restrain follicle growth
Why does the cycle length shorten in early menopause Follicular phase is compressed
transition as follicle growth is accelerated due to declining inhibin B and AMH which typically
restrain follicle growth
This leads to longer luteal phase and more PMS symptoms
Menopause transition for women with PCOS AMH and inhibin B are declining
Causes regular cycling as these have been suppressing follicle growth during
reproductive years
These years can be fertile for these women
fertility increase for women with PCOS in this transition
Why transdermal estradiol over oral? - avoids first pass
- no risk of VTE
-oral raises trigs and inflammation, more CVD risk
- oral increases SHBG, lowers free T and causes sexual SE
What is vaginal DHEA FDA approved for? Dysparenunia from GSM
