About ten years ago, a group of medical professionals put their heads together to create a set of guidelines that would chart the course of normal menopause in a more systematic way. They came up with a series of three stages that were each divided into several phases that women normally experience during menopause. These were the reproductive stage, which contained three phases; the menopausal transition, which contained two phases; the postmenopausal stage, which contained two phases.
The stages were determined by the changes that normally occur in a woman’s menstrual cycle and by follicle-stimulating hormone (FSH) levels. (Read this MiddlesexMD blog post for more information about FSH.)
Each phase was given a number, from -5 for the early reproductive phase, in which a woman has regular menses but increasing FSH levels, to +2 for late postmenopausal phase, in which menstruation has completely stopped.
This diagnostic system is called the Stages of Reproductive Aging Workshop, or STRAW, and it’s been a widely used tool for further research. But clinicians have also found it useful as a roadmap for normal menopause—to determine where a woman is in the transition and to predict the course ahead.
Physicians felt that some sort of system was important because menopause marks such a significant change in a woman’s health and quality of life. Some of these changes are temporary (sleep disturbances, hot flashes), and others, such as changes in bone density and urogenital symptoms, are permanent. Given the importance of this transition, some guideline that outlines a normal course through menopause might help in making healthcare decisions about issues like contraception and hormone replacement.
“When women have an awareness of their progress during the shifting manifestations of natural aging, it can be very reassuring,” says Dr. Cynthia Steunkel at the University of California, San Diego, for an article in Menopause.
While helpful for “normal” menopause, however, the original STRAW guidelines specifically exclude women who smoke, are obese, engage in strenuous exercise, have had a hysterectomy, have a significant illness, such as AIDS or cancer, or who have chronic menstrual irregularities. It also fails to address possible differences due to ethnicity, age, and lifestyle.
In 2011, ten years after the first conference, the group reconvened to update the guidelines to take into account the significant body of new research that has emerged and to broaden the subgroups of women for whom the guidelines would apply. The updated guidelines that resulted from this latest review of the research is called STRAW + 10.
Specifically, the updated staging system includes new measures of specific hormones and other “biomarkers” that help to determine the stages of menopause. It added three new subphases that further define the late reproductive and postmenopausal stages. And it can be applied to “most women,” regardless of lifestyle and ethnic diversity, although some exceptions still apply for issues like ovarian failure and chronic illness.
Despite all the fancy testing and technology, however, the most dependable indicator of the stage of menopause is, still, a woman’s menstrual cycle. “...The menstrual cycle remains the single best way to estimate where a woman is along the reproductive path,” said Dr. Margery Gass, one of the coauthors of the new criteria and the executive director of the North American Menopause Society.
In fact, all those other tests for biomarkers are considered “supportive,” and because of the expense of testing and the need for additional research, they aren’t normally called for. I don’t recommend testing for FSH or other biomarkers, either. The tests just aren’t helpful enough.
The new STRAW + 10 guidelines fills in some gaps left by the original system and gives us all a clearer roadmap (which I'll detail in another blog post), but since it relies mainly on the menstrual cycle to determine the course of menopause, your best bet, as I said before, is to tune into your body and work to make peace with the changes you’re experiencing. You're not alone! We're here to help.
Dr. Barb DePree, M.D., has been a gynecologist and women’s health provider for almost 30 years and a menopause care specialist for the past ten.