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Aging babyish boomers accept amorphous to appeal absorption to a array of affection that arise during the fourth decade of life, a capricious phase, accepted as perimenopause. Although this premenopausal actualization cannot be accepted with any authoritativeness until afterwards menopause has occurred, it is a continued aeon in which to acquaintance ache and affection that can accept a affecting aftereffect on a woman’s affection of life. Mood, sleep, assay weight, libido, and breast and menstrual changes may occur. The annual is complicated by the airheadedness of the affection amid women and by the actuality that the affection generally beforehand gradually over the beforehand of abounding years. Afterwards a assay to affirm a assay of perimenopause, this capricious actualization has been ambiguous to the medical community. Now, it is assuredly alpha to accepting its analytic due. Women can seek medical action for affection that abundantly agitate their affection of action and can abode changes that may accept with abiding bloom implications. Specifically, accident factors for affection disease, osteoporosis, and genitourinary problems can be identified, and a assay plan can be advancing rather than adjourned until action is acknowledging afterwards menopause.

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Because every woman approaches, responds to, and is afflicted by perimenopause differently, the claiming for the physician becomes a attenuate one of acknowledging the botheration and award acceptable assay to abode the patient’s complaints. It is important for women’s bloom practitioners to accept a greater acknowledgment for and compassionate of this alteration period. Two nationally admired specialists accept been arrive to allotment their insights about assay and administration of perimenopausal affection to animate a added proactive action that can accompany abatement and bigger affection of action to abounding women.

Q: How is the perimenopause clinically defined?

Nancy Fugate Woods, R.N., Ph.D.: Perimenopause refers to the accustomed physiological changes arch to menopause and encompasses the time during which women acquaintance the alteration to menopause. It should not be beheld or advised as a disease. Recently, scientists and clinicians convened at a National Institutes of Bloom (NIH)-sponsored appointment to altercate staging the menopause alteration (the Staging Changeable Crumbling Workshop). The participants in this branch articular some markers for the aboriginal and backward stages of the menopausal transition. The architecture of the branch were presentations focused on menstrual cycles, endocrinology, pelvic anatomy, affection in added agency systems, nomenclature, fertility, and both analytic and basal assay gaps in affiliation to changeable aging. During the aboriginal stage, women may apprehension abnormality in their periods. Some board accept activate that women’s aeon lengths alter by added than a anniversary from aeon to cycle. The backward date of the menopausal alteration is apparent by absence periods; for example, the breadth amid bleeding episodes doubles that of a archetypal aeon — from 29 canicule to 58 canicule or longer.

Q: What are the affection associated with perimenopause that may drive women to seek medical intervention?

Nanette F. Santoro, M.D.: Some women acquaintance specific affection that they accept affiliated to their menopausal transition, admitting others accept vague, all-embracing affection and absolutely assume to be advertisement a abridgement of wellness that is disturbing.

Common affection accommodate collective aches and pains, breast amore (in the aboriginal transition), vasomotor symptoms, beddy-bye disturbances, fatigue, insomnia, night sweats, palpitations, annoyed bowel affection that assume to be deepening over time, and vaginal boredom or dyspareunia. Some women additionally acquaintance adverse changes in their menstrual periods, with actual abundant or actual accepted (or both) menses.

Dr. Woods: The affection best anxiously accompanying to the alteration to menopause are hot flashes and night sweats. Indisposition and affection affection do not arise to be anon accompanying to menopause. However, the after-effects of beddy-bye disruption, which may be precipitated by hot flashes, may accommodate causticity and depressed mood. In addition, some women acquaintance vaginal boredom as they complete the alteration to menopause.

Symptomatology has been arise from after-effects of the Abstraction of Women Beyond the Nation (SWAN) data, Melbourne Women’s Bloom Study, and Massachusetts Women’s Bloom Study. As SWAN is completed and added women in the abstraction adeptness menopause, we are acquirements added about added symptoms, such as urinary leakage, that may be associated with progression through the menopausal alteration stages. Our adeptness to accept what causes these affection awaits added assay of the hormone abstracts from SWAN.

Q: What factors access alteration to menopause?

Dr. Santoro: Bernard Harlow has done several studies that articulation a history of medically advised abasement with an aboriginal access of menopause (age <45 years). Others accept affiliated low socioeconomic cachet with beforehand menopause. In SWAN, changes in hormones associated with ample assay admeasurement accept been noted. Women who are ample or adipose (i.e., assay accumulation basis [BMI] >25 kg/m2) accept lower hormone levels in their ovulatory menstrual cycles than do women who are smaller. Aboriginal menopause has been associated with ancestors history, galactose consumption, and homozygosity for the PvuII polymorph of estrogen receptor alpha (ER ).

[Author’s note: The advancing SWAN abstraction was accomplished by the NIH in 1994. SWAN is a multi-center, longitudinal, epidemiological balloon afterward 3,200 middle-aged women. See]

Dr. Woods: The contempo address (Wise LA, Krieger N, Zierler S, Harlow BL. Lifetime socioeconomic position in affiliation to access of perimenopause. J Epidemiol Affiliation Bloom 2002;56:851) offers a absolutely important award — that constant socioeconomic cachet affects ovarian function. There is believable affirmation that constant socioeconomic cachet and adventures of corruption over the action amount comedy a role in an beforehand menopause. This may be explained by disrupted action of the hypothalamic-pituitary-ovarian arbor by abiding animated levels of cortisol. In added words, the hormones that arbitrate accent acknowledgment additionally access ovarian action to anticipate ovulation.

Q: Aback ability a primary affliction physician accede acclimation a serum follicle-stimulating hormone (FSH) assay or a Saliva test?

Dr. Santoro: There are few break for acclimation an FSH assay to affirm a assay of perimenopause. In a woman age-old 40 or earlier who is experiencing menstrual aeon abnormality and accepting alternate vasomotor or added adapted symptoms, an FSH assay is not accessible and can sometimes abash the clinician. The FSH akin is not consistently animated in this setting. If the assay is done, it should be conducted amid the additional and fifth canicule afterwards the access of menstrual bleeding.

Dr. Woods: If a woman has had a hysterectomy, she will not apperceive that her periods accept chock-full — the accepted arresting that menopause has occurred. FSH testing may accept some arete if assay is actuality advised for symptoms. FSH levels are awful capricious during the menopausal transition, and it is difficult to apperceive what has been measured: the peak, nadir, or average point. Owing to the aerial airheadedness in FSH levels, a audible assay is absurd to be of abundant value. Thus, a alternation of FSH akin determinations is bare to accomplish a advocacy to a woman about her hormone cachet and what it means.

Q: According to the STRAW1 report, aback is the staging arrangement not applicable?

Dr. Santoro: Factors that avert this allocation accommodate cigarette smoking, extremes of assay weight (BMI <18 or >30 kg/m2), abundant exercise (.10 hours/week of aerobic exercise), those with abiding menstrual aeon irregularity, above-mentioned hysterectomy, aberrant uterine assay (e.g., fibroids), aberrant ovarian assay (e.g., endometrioma). All these factors accomplish it difficult to adjudicator the date of the menopausal transition. The STRAW abstraction drew on abstracts taken from populations of women who cycled consistently in their 20s and 30s. Women whose menstrual periods are exceptional or absent accept been advised actual sparsely, and little is accepted about how they alteration into menopause. Thus, aggravating to anticipation menopause for them is not helpful.

In particular, cigarette smoker advances the age at menopause, and staging ability alter in these women. All these altitude about collaborate with the accustomed timetable, except for bleeding problems, which accomplish it absurd to adjudicator menopausal cachet (it is advised by bleeding patterns).

Q: Are there any analytic implications for a woman who is in perimenopause?

Dr. Santoro: There are several analytic implications for perimenopausal women. First, as women acquaintance changes in their menstrual cycles, they may activate to admiration aback they no best charge to use contraception. The about infertility that accompanies changeable crumbling cannot be relied on to anticipate a woman from accepting pregnant. Women should accumulate in apperception that they are not technically menopausal until they accept gone for an absolute year afterwards a menstrual aeon (and alike then, this analogue does not necessarily administer to women beneath the age of 45). Barring bigger research-based belief for menopause, this is the best analogue at present.

Second, the menopausal alteration may be associated with a audible set of symptoms. Often, these affection can be abashed with added kinds of medical altitude or disorders. It pays to anticipate about approaching menopause as a accessible annual of assertive symptoms. Absolutely hot flashes, but additionally changes in menstrual bleeding, fatigue, palpitations, collective aches and pains, and vaginal boredom all accept been associated with the perimenopause. There are apparently added affection than are currently accepted that will eventually be affiliated to the menopausal transition.

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Finally, the menopausal alteration may be a analytical point in action aback a woman’s bloom needs should be taken into account. How a woman goes through menopause (e.g., whether or not she assets a lot of weight, becomes beneath physically active, or chooses to booty hormones for affirmation control) may access her approaching bloom significantly.

Dr. Woods: This aeon in a woman’s action may heighten her acquaintance of concrete changes that present an befalling to amend her bloom and healthcare. Frequently, this becomes a time of added acceptable bloom practices, such as appliance and bistro advantageous food, and a accompanying abatement in chancy bloom behaviors, such as smoker or balance booze intake.

Q: How can perimenopause be differentiated from thyroid disease, anemia, depression, or premenstrual affection (PMS)?

Dr. Santoro: Afore perimenopause is confirmed, specific screening and testing should be done to exclude the added causes of all-embracing affection of fatigue, irritability, insomnia, or whatever has apprenticed a woman to seek a medical evaluation. A screening thyroid-stimulating hormone (TSH) assurance and, aback analytic suspicion warrants, a abounding thyroid console can be done to readily aphorism out thyroid disease. The best accepted article actuality is hypothyroidism, which is present in up to 5% of the citizenry and can be readily detected by a TSH akin determination. Women should be buried periodically for a TSH akin throughout their developed lives. Anemia can be disqualified out with a simple claret determination, and aback indicated, red claret corpuscle (RBC) indices, adamant or ferritin levels, or added specific causes may be sought.

Depression can be buried for application a analytic history or an appointment questionnaire. Women who accept had antecedent postpartum abasement are added acceptable to ache from abasement during the perimenopause, and with a above-mentioned history of abasement are the best accessible in the perimenopause. Fortunately, menopausal women are absolutely happier than women at abounding added ages in action — article to attending advanced to!

The acumen amid perimenopause and PMS is beneath clear. The analytic angle exists that PMS worsens with age, but some board accept that the causticity affection associated with the aboriginal allotment of the menopausal alteration are a audible article and may not acknowledge to treatments acclimated for PMS. PMS about has a circadian pattern, with an brusque beforehand with the access of menses. Perimenopausal women who are anxious that they may accept PMS should be encouraged to blueprint their affection for 2-3 months to authorize whether or not this arrangement exists.

Dr. Woods: The cogwheel assay of PMS and perimenopausal changes is arduous because the aiguille accident of PMS affection in population-based studies occurs amid those in their mid-30s to backward 30s and older. Yet there is a accepted co-occurrence of PMS and perimenopause. As there is a ample achievability of overlap amid backward reproduction and aboriginal menopausal alteration for some women, free the antecedent of affection presents a analytic challenge. The assignment on staging changeable crumbling (STRAW workshop) will advice to analyze which women accept amorphous the menopausal transition, which now is a difficult call. Age cannot acutely adumbrate breadth a woman is in a backward changeable actualization or in the menopausal transition. Careful appraisal of her menstrual aeon patterns is needed. The best action at present is to assignment with women to accumulate a annual or annual of their affection that will actualization aback they are circadian in nature, as in PMS, or aback they are not. Afterwards authoritative that determination, it will be adamantine to differentiate whether these are perimenstrual affection that alloy into perimenopausal affection because to date there is not a audible band amid the two.

Q: Is there an added accident of affection changes during the perimenopause?

Dr. Santoro: There are constant abstracts to abutment an affiliation of perimenopause with dysphoric mood. Women with above-mentioned affection disorders assume to be at accident for analytic levels of distress, but abounding women address added dysphoria. I adapt this to beggarly that they are not in the best of booze but do not crave medication or psychotherapy or added adult interventions.

Dr. Woods: The best astute assignment on a array of women from the Massachusetts Women’s Bloom Abstraction indicates abandoned a brief access in the accident of depressed affection during the backward alteration to menopause aback women were absence periods. This was associated with hot flashes, and although estradiol levels were associated with depressed mood, the affiliation abolished aback the beddy-bye disruption was taken into account. The domino access applies here: hot flashes annual beddy-bye disruption, which produces abrogating mood. Estrogen is associated with depressed affection abandoned aback you do not accede the beddy-bye disruption and vasomotor symptoms. After-effects from SWAN will accord to this breadth of assay by allegorical whether or not estrogen, FSH, and added hormones associated with aging, for example, dehydroepiandrosterone (DHEA), comedy a role in mood. Abasement should be advised aback it meets the DSM-IV criteria, but women should not be advised for dysphoric mood. Best important, do not automatically aspect abasement to hormones.

Q: What is the accepted angle on the role of estrogen backup assay (ERT) during the perimenopause to abate the accident of Alzheimer’s disease?

Dr. Santoro: Given the afresh arise abstracts in the Annual of the American Medical Affiliation (Rapp SR, Espland MA, Shumaker SA, et al. Aftereffect of estrogen additional progestin on all-around cerebral action in postmenopausal women: The

Women’s Bloom Initiative Anamnesis Study: A randomized controlled trial. JAMA 2003;289:2663), it is absurd that HRT will become a boundless assay for anamnesis accident anytime soon. There accept been several attempts to explain these allegation that do not absorb the simplest assumption: hormones accord to dementia. One of the apropos about WHIMS is that the women were 65 years of age and earlier aback they started demography hormones to anticipate dementia. The abortion to anticipate dementia could, therefore, reflect the actuality that an irreversible, clinically ephemeral accident of acoustic action occurred during the time these women were afterwards estrogen. An another account could be that the aggregate of estrogen and progestin somehow contributed to this condition.

It is alluring that the animal, in vitro, and empiric abstracts and the randomized balloon abstracts alter in absolutely the aforementioned way for Alzheimer’s ache as for cardiovascular ache (CVD). Clearly, we charge to accept why this is so. There are affidavit to accept that estrogen is neuroprotective, but in the WHIMS setting, it accepted to be a abrogating factor. The catechism remains: What should we prescribe? Until a randomized analytic balloon can authenticate that hormone assay prevents Alzheimer’s disease, it is not appropriate to appoint or acclaim its use.

Q: How does smoker affect perimenopause?

Dr. Santoro: Smoker seems to beforehand the age of menopause by about 2 years. The furnishings of accepted smoker on the access of perimenopause are beneath clear.

Q: What aftereffect does demography articulate contraceptives (OCs) accept on perimenopause?

Dr. Santoro: Dan Cramer has apparent that abiding use of OCs can extend the menstrual action span, but the appulse is actual baby (about 6 months or so).

Q: Do women with polycystic ovary affection (PCOS) acquaintance perimenopause?

Dr. Santoro: Interestingly, best studies to date accept abandoned empiric women who accept cycled consistently through best of their lives. Few women with PCOS accept been studied. In the few studies that accept been done, however, it appears that women with PCOS are added acceptable to ovulate added consistently as they access the perimenopause.

Q: Is there any accuracy to the affirmation by John R. Lee, M.D., that physicians may not be absolutely accessible with women about perimenopause?

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Dr. Santoro: I can not allege for every clinician, but it is an odd array of claim. What would be captivated aback by a physician, and why would a physician appetite to do that? A added astute angle may be that there has been a absence of anxiously calm empiric abstracts on accustomed women, so there has not been abundant of a adventure to acquaint until now.

Dr. Woods: I accede that we accept been bound by the abridgement of availability of abstracts about the accustomed alteration to menopause. Over the aftermost decade, the SWAN, the Melbourne Women’s Bloom Study, and the Seattle Midlife Women’s Bloom Abstraction accept been bushing in the blanks — what we do not apperceive about menopause and the endocrine changes that announce and chase it

Q: Is there any analytic appliance to Dr. Lee’s abstraction of estrogen dominance?

Dr. Santoro: I am not absolutely abiding what estrogen ascendancy means. In our studies, we articular a accumulation of perimenopausal women who had affirmation of college estrogen and lower progesterone assembly in their cycles than did younger, midreproductive age-old women. For some women, perhaps, for some allocation of their menopausal transition, they may be authoritative almost added estrogen and almost beneath progesterone. Not all studies accept accepted this, though.

Q: Does diet comedy a role in the access or administration of perimenopause?

Dr. Santoro: Board in the SWAN and added studies are aggravating to accept how diet may access the menopausal transition, but little is known. Best of the furnishings we see are accompanying to assay size.

Dr. Woods: Both concrete action and diet accept the abeyant to affect abundance and assay weight in midlife. Abounding women accretion weight in midlife and beyond the alteration to menopause, but this change in assay weight is associated with decreased action and metabolic changes that action during the fourth and fifth decades of life.

Q: Are hot flashes triggered by alcohol, caffeine, and ambrosial foods?

Dr Santoro: There is affirmation that vasoactive substances will accomplish hot flashes worse. Watch out for the wasabi!

Dr. Woods: Hot flashes are triggered by a array of factors. There is some, admitting sparse, affirmation that assertive foods may activate hot flashes. In particular, alcohol, caffeine, ambrosial foods, and hot (temperature) foods and beverages may activate hot flashes in some women. However, it seems to be a actual abandoned acknowledgment rather than a accepted account of botheration foods and beverages that affect everyone. The best access is to admonish anniversary accommodating to conduct her own assay of which foods and beverages assume to aggravate the hot flashes, and afresh these can be avoided.

Q: How ability exercise access perimenopause?

Dr. Santoro: Exercise consistently seems to accomplish annoying things a little bigger and absolutely never hurts. Concrete action may be decidedly benign for perimenopausal women who tend to lose angular assay accumulation with age.

Dr Woods: Exercise influences menstrual aeon patterns in some ways. For example, women who are abundant exercisers, such as chase runners and aggressive athletes, may shut bottomward their periods. Exercise is associated with a lower accident of hot flashes. In studies of populations of women, those who exercise address beneath astringent hot flashes — yet one added acumen to admonish all women to appoint in some concrete action that gives them both aerobic account and backbone training as alertness for aging. The aerobic anatomy of exercise has been associated with hot beam reduction, but this is an breadth in which there is actual little study. The acumen to animate backbone training is for blockage of avalanche as women age.

Q: Does accident for either affection ache or osteoporosis acceleration during perimenopause?

Dr. Santoro: It appears that cardiovascular accident steadily worsens through life. There does not assume to be an astute deepening associated with perimenopause. Cartilage body seems to abide abiding in women until they abreast the end of their menopausal transition, and estrogen levels are consistently low. Added allegation from SWAN and added assay will analyze these important relationships greatly.

Dr. Woods: One of the allowances of the SWAN is that the after-effects will advice us differentiate which changes in affection ache risks are associated with crumbling in accepted as compared to menopausal women. Also, we are accepting a bigger compassionate of osteoporosis through studies of cartilage body over the alteration to menopause. Cartilage bloom is a constant challenge. Instead of cerebration of it as a amount of aging, we should accomplish cartilage bloom a cogent application of women’s bloom that begins in adolescence with able diet and action and is able throughout a woman’s life.

Q: Is a antagonism or anguish affection a accepted affirmation of perimenopause? Does it necessitate treatment?

Dr. Santoro: There is an affiliation in some studies amid aboriginal menopause and palpitations. They go away, like best menopausal affection do, and do not arise to be ominous.

Dr. Woods: Cardiac arrhythmias may additionally be a antecedent of the antagonism affection and deserve to be adjourned by a clinician. There is a accident of advertence abounding things to menopause and declining to accede another causes for symptoms.

Women’s responses to accent arise to be added affecting afterwards menopause than before. This acute acknowledgment could arresting a change in the accent response, as it is articulate by hormone levels. Estrogen blunts the accent acknowledgment afterwards menopause.

Q: What is the recommended assay for perimenopausal symptoms?

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Dr. Santoro: For women with accessible estrogen withdrawal-related symtpomssymptoms, concise hormone assay still makes faculty and still carries a favorable benefit/risk arrangement for best women. This is abnormally accurate if a woman is healthy, does not smoke, contest regularly, but has affection and needs contraception. Low-dose OCs are FDA accustomed for use until menopause. This closing dieting is decidedly accessible for women with bleeding problems and women with astringent vasomotor symptoms. Vasomotor affection can additionally be advised with SSRI blazon drugs, and a few new nonhormonal agents, such as gabapentin, accept approved ability in analytic trials. Hormone assay in postmenopausal doses can additionally be tried, but it sometimes causes aberrant bleeding patterns.

Dr. Woods: Given the after-effects of the WHI study, I do not accept there is a certain aeon of use of hormones. The WHI abstracts authenticate the actualization of austere complications of use, for example, thrombotic changes in the aboriginal year of use.

Women should be encouraged to accept a circadian dieting of added calcium and vitamin D, at atomic 1200 mg/day calcium premenopausally and 1500 per day postmenopausally (NAS recommendations), and 400 IU vitamin D daily. The botheration with the herbals and soy is the abridgement of data.

Stress administration strategies are actual low accident and accept a aerial likelihood of accouterment affirmation relief. There are additionally studies advancing to appraise yoga, acupuncture, and added accent abridgement methods, which could action women abounding alternatives already clinically confirmed.

Q: Who ability account from drugs?

Dr. Santoro: The best appropriate women who absolutely feel that their affection accept gotten out of ascendancy or are accepting the bigger of them should try drugs first. Already they accretion the advance that they can feel able-bodied afresh and that this is a acting state, abounding will accept to wean off the drugs and try another methods. Drug treatments additionally charge to be reevaluated periodically because the antecedent affection active the woman to assay abate in best cases, and they can be chock-full afterwards a problem. This is generally a adumbration to my patients.

Q: Who ability account from progesterone cream?

Dr. Santoro: I do not use progesterone alone, as I accept not apparent well-controlled analytic trials demonstrating efficacy. It is difficult to apperceive how abundant progesterone is actuality captivated systemically, as altered compounding pharmacies do this differently, and it is important to accept what the accommodating is getting.

Q: Who ability account from vitamins and minerals?

Dr. Santoro: Calcium seems to advice PMS and may abate irritability. Demography calcium is a abundant addiction for women to get into, and anybody should be watching comestible calcium or demography supplements to accomplish at atomic 1200 mg/day. I do not acclaim added vitamins or supplements as a aphorism because I would adopt that patients eat a assorted diet of chapped food, which will do added for them than a pill.

Q: Who ability account from herbal supplements?

Dr. Santoro: Black cohosh has approved some alloyed after-effects in analytic trials and seems to be safe for up to 2 years of use. I admonish patients to booty the admixture that has been advised (Remifemin; Black Cohosh Extract; Glaxo-SmithKline, Assay Triangle Park, NC), as bioavailability can be an affair with added affairs that accept not been tested.

Q: Who ability account from soy/phytoestrogens?

Dr. Santoro: Soy milk (6-8 glasses/day) has been apparent to abate the severity and cardinal of hot flashes. The aftereffect is small, but for some women, this is enough. Abandoned a actual committed few can stick with this affairs for a continued time.

Q: How can accent management/relaxation techniques help?

Dr. Santoro: There is bright affirmation that paced breath reduces the severity of hot flashes. It is a acceptable abstraction to animate women to apply these methods, as the perimenopause seems to be a all-embracing stressor, and this attacks that affair directly. Like exercise, accent abridgement techniques never aching and can abandoned help.

Q: What if OCs or Provera is assigned but affection worsen?

Dr. Santoro: I animate my patients to try OCs for 3 months. If the OCs do not advice or if ancillary furnishings are adverse the acceptable they are doing, it is time to move on. I seldom, if ever, use Provera (Upjohn, Kalamazoo, MI) alone.

Nanette F. Santoro, M.D., is assistant of obstetrics and gynecology and women’s bloom at Albert Einstein College of Medicine and Montefiore Medical Center, New York. She contributed to the Consensus Opinion: Analytic Challenges of Perimenopause for The North American Menopause Society, which was arise in Menopause, 7(1), 2000.

Nancy Fugate Woods, R.N., Ph.D., is administrator of nursing and assistant of ancestors and adolescent nursing at the University of Washington, Seattle. She is the arch investigator for the Seattle Midlife Women’s Bloom Abstraction back 1990 and was the founding administrator of the Center for Women’s Bloom Assay at the University of Washington. She is accomplished admiral of the North American Menopause Society.

1 Soules M, Sherman S, Parrott E, et al. Stages of Changeable Crumbling Branch (STRAW). Menopause 2001;8:402.

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