Menopause

• Overview:

  • Retrospective diagnosis made after a women has had no periods for 12 months
  • Permanent end to menstruation
  • Average age 51
• Postmenopause describes the period from 12 months after the final menstrual period onwards. 
• Perimenopause:

  • The time around the menopause where the woman may be experiencing vasomotor symptoms and irregular periods
  • Includes the time leading up to the last menstrual period, and the 12 months afterwards
  • Typically in women older than 45 years
  • Symptoms last up to 4 years on average (but can be up to 12)
  • Vasomotor symptoms = hot flushes, night sweats
• Premature menopause is menopause before the age of 40 years. It is the result of premature ovarian insufficiency.
• Menopause is caused by a lack of ovarian follicular function, resulting in changes in the sex hormones associated with the menstrual cycle:

  • Oestrogen and progesterone levels are low
  • LH and FSH levels are high, in response to an absence of negative feedback from oestrogen
• Features:

  • Characterised by menstrual irregularity and vasomotor symptoms
  • Irregular cycles often last several years - cycles become longer, shorter or variable. May become heavier for a time. In some women periods abruptly stop
  • Vasomotor symptoms - hot flushes, night sweats
  • Urogenital - vaginal dryness, dyspareunia (pain during sex), UTI
• Other symptoms:

  • Anxiety/depression
  • Difficultly concentrating
  • Sleep disturbance
  • Reduced libido
  • Musculoskeletal pains
• NICE guidance advises menopause can be diagnosed in healthy women over the age of 45 with:

  • Perimenopause based on vasomotor symptoms and irregular periods
  • Menopause in women who have not had a period for at least 12 months and are not using hormonal contraception
  • Menopause based on symptoms in women without a uterus
• Blood tests for FSH should be done in patients aged 45 and younger presenting with perimenopausal symptoms - FSH is elevated
• A lack of oestrogen increases the risk of certain conditions:

  • Cardiovascular disease and stroke
  • Osteoporosis
  • Pelvic organ prolapse
  • Urinary incontinence
• Fertility gradually declines after 40 years of age, but women should still consider themselves fertile, women need to use effective contraception for:

  • Two years after the last menstrual period in women under 50
  • One year after the last period in women over 50
• Hormonal contraceptives do not affect the menopause, when it occurs or how long it lasts, although they may suppress and mask the symptoms. This can make diagnosing menopause in women on hormonal contraception more difficult.
• Good contraceptive options (UKMEC 1, meaning no restrictions) for women approaching the menopause are:

  • Barrier methods
  • Mirena or copper coil
  • Progesterone only pill
  • Progesterone implant
  • Progesterone depot injection (under 45 years)
  • Sterilisation
• Management of symptoms:

  • Conservative lifestyle modifications - exercise, sleeping in cool room and loose clothing. Weight loss
  • HRT
  • Non hormonal treatment - clonidine
  • Vaginal oestrogen for atrophy (can be used alongside HRT)
  • Vaginal moisturisers
  • SSRIs to treat vasomotor symptoms
  • Testosterone for reduced libido if HRT not effective
• Clonidine can be used for women experiencing vasomotor symptoms that cannot take HRT

  • Antihypertensive - alpha agonist
  • Vasodilation
• If a woman has had a hysterectomy she will require oestrogen-only HRT as there is no uterus left to protect against endometrial cancer. She does not need any additional protection from endometrial cancer.