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changes that may be associated hot flushes, night sweats, and vaginal dryness The average age at menopause in Western societies today is 51 years Premature menopause is defined as ovarian failure and menstrual cessation before age 40; this often has a genetic or autoimmune basis Surgical menopause due to bilateral oophorectomy is common and can cause more severe symptoms owing to the sudden rapid drop in sex hormone levels There is no objective evidence that cessation of ovarian function is associated with severe emotional disturbance or personality changes However, mood changes toward depression and anxiety can occur at this time Furthermore, the time of menopause often coincides with other major life changes, such as departure of children from the home, a midlife identity crisis, or divorce These events, coupled with a sense of the loss of youth, may exacerbate the symptoms of menopause and cause psychological distress
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pregnancy test if the next menses is missed, and repeat the VDRL test in 6 weeks Obtain blood (10 mL without anticoagulant) and urine (100 mL) specimens if there is a history of forced ingestion or injection of drugs or alcohol 7 Transfer clearly labeled evidence, eg, laboratory specimens, directly to the clinical pathologist in charge or to the responsible laboratory technician, in the presence of witnesses (never via messenger), so that the rules of evidence will not be breached
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Give analgesics or sedatives if indicated Administer tetanus toxoid if deep lacerations contain soil or dirt particles Give ceftriaxone, 125 mg intramuscularly, to prevent gonorrhea In addition, give metronidazole, 2 g as a single dose, and azithromycin 1 g orally or doxycycline, 100 mg twice daily for 7 days to treat chlamydial infection Incubating syphilis will probably be prevented by these medications, but the VDRL test should be repeated 6 weeks after the assault Prevent pregnancy by using one of the methods discussed under Emergency Contraception, if necessary (this chapter) Vaccinate against hepatitis B Consider HIV prophylaxis (see 31) Make sure the patient and her family and friends have a source of ongoing psychological support
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1 Cessation of menstruation Menstrual cycles generally become irregular as menopause approaches Anovular cycles occur more often, with irregular cycle length and occasional menorrhagia Menstrual flow usually diminishes in amount owing to decreased estrogen secretion, resulting in less abundant endometrial growth Finally, cycles become longer, with missed periods or episodes of spotting only When no bleeding has occurred for 1 year, the menopausal transition can be said to have occurred Any bleeding after this time warrants investigation by endometrial curettage or aspiration to rule out endometrial cancer 2 Hot flushes Hot flushes (feelings of intense heat over the trunk and face, with flushing of the skin and sweating) occur in 80% of women as a result of the decrease in ovarian hormones Hot flushes can begin before the cessation of menses An increase in pulsatile release of GnRH from the hypothalamus is believed to trigger the hot flushes by affecting the adjacent temperature-regulating area of the brain Hot flushes are more severe in women who undergo surgical menopause Flushing is more pronounced late in the day, during hot weather, after ingestion of hot foods or drinks, or during periods of tension Occurring at night, they often cause sweating and insomnia and result in fatigue on the following day 3 Vaginal atrophy With decreased estrogen secretion, thinning of the vaginal mucosa and decreased vaginal lubrication occur and may lead to dyspareunia The introitus decreases in diameter Pelvic examination reveals pale, smooth vaginal mucosa and a small cervix and uterus The ovaries are not normally palpable after the menopause Continued sexual activity will help prevent tissue shrinkage 4 Osteoporosis Osteoporosis may occur as a late sequela of menopause
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