MENOPAUSE
Definitions
MENOPAUSE, defined by the WHO as the permanent cessation of menstruation resulting from the loss of ovarian
follicular activity, is diagnosed retrospectively after 12 months of amenorrhoea.
In Western populations, spontaneous menopause occurs at an average age of 51 (range 45-55).
Terms associated with the menopause
Menopausal- Period of time leading up to the final menses, transition characterised by menstrual irregularity
Peri menopause -Time period beginning with the first symptoms of the approaching menopause and ending 12
months after the final menses
Premature Menopause- occurring before age 40; it may occur spontaneously (premature ovarian failure) or as a
result of therapeutic intervention
Early menopause- Menopause occurring before age 45
Surgical Menopause -Menopause as a result of bilateral oophorectomy
Changes from premenopause to postmenopause
Late Early menopausal Post-menopaus
Late Post-menopausal
premenopausal transition menopausal
age >35 years transition
Menstrual Regular ovulatory Irregular increasing Irregular Amenorrhoea
Cycles Cycles anovulatory cycles increasing
Amenorrhoea
Hormonal Rising FSH but still Normal to Raised Raised FSH,Variable Raised FSH,decreased oestradiol and
Changes within normal FSH,Variable oestradiol oestradiol and decreased inhibin B
range,normal and decreased inhibin decreased inhibin B
oestradiol and inhibin B
B levels
Ovarian Increased rate of About 100 Declining 0-10
follicle decline
numbers
Menopausal symptoms
Vasomotor instability:• Hot flushes• Night sweats
Urogenital atrophy:• Vaginal dryness, itching and irritation • Dyspareunia• Micturition disorders
Sleep disturbance/insomnia, Sexual dysfunction, Mood disturbance/swings, Depression, Arthralgia and myalgia,
Memory and concentration disturbance, Formication, Dry eyes, Palpitations, Headache
Consequences of menopausal symptoms-psychological, physical and long term health issues-like osteoporosis, CVD
and dementia\.
Clinical evaluation
History
Menopausal symptoms — a diary can be helpful
Reproductive history
Sexual history
Osteoporosis and cardiovascular disease risk factors
General current and past medical history
Psychiatric history
Family history
Social history
Lifestyle assessment
Medications, both prescribed and non-prescribed
Allergies, including sensitivities to adhesive tapes
Examination
Height, weight, waist circumference
Vital signs
Thyroid examination
Breast examination
Cardiovascular examination
Pelvic examination
Other examination as dictated by history
Investigations
FSH, oestradiol (of very limited diagnostic use)
Serum androgens, including sensitive total testosterone and sex-hormonebindingbglobulin; free androgen index
when low libido is a leading complaint
Thyroid-stimulating hormone
Fasting lipids, glucose
Baseline chemistry, including electrolytes and LFTs
25-hydroxyvitamin D
Vaginal ultrasound when indicated
Screening mammogram
Pap smear
Bone mineral density determination (DEXA) if osteoporosis risk factors are present
Evaluation of clotting profile when indicated by past or family history of thromboembolism
MANAGEMENT
• Dietary and lifestyle advice.
• Educating the woman with reference to information obtained previously regarding her understanding of menopausal
issues, thereby enabling her to
make informed decisions about treatment, particularly regarding the benefits and risks of HRT.
• Use of HRT and nonhormonal treatments to manage menopausal symptoms.
• Exploring and evaluating psychological issues relevant to the woman, and instituting appropriate therapeutic
measures.
• Preventing and treating the long-term complications of menopause.
HORMONE REPLACEMENT THERAPY
HRT can be considered:
• In the symptomatic early postmenopausal woman.
• In asymptomatic women under 60, for whom risks are minimal.
• For durations of less than five years.
• In the setting of PM.
Potential benefits of HRT
Relief of menopausal symptoms HRT reduces vasomotor symptoms in up to 90% of women, relieves urogenital
symptoms, joint pain and sleeplessness and improves sexual function
Prevention/treatment of osteoporosis 34% reduction in fracture risk in HRT treated women but positive skeletal
effects of oestrogen decrease after therapy is stopped
Colorectal cancer-reduced risk of colorectal cancer in women after five years of EPT but not ET .
Adverse effects associated with HRT use
Endometrial Cancer-associated with unopposed ET. Addition of progestogen either continuously or sequentially reduces the risk.
Sequential Rx should have at least 10 days of progestogen therapy/month
Breast cancer-absolute risk calculated as four additional breast cancers per 1000 women after five years of EPT.Risk
is less with ET only. Risk may vary with the type of progestogen, with increased risk seen with MPA, norethisterone and
intrauterine levonorgestrel but not dydrogesterone.
VTE-oral HRT use doubles the baseline risk of venous thromboembolism. Use of transdermal oestrogen or tibolone in
women with a higher baseline risk of VTE.
Stroke
Minor side effects-Mastalgia. Irregular bleeding or spotting in the first year of use(no need to Ix)
Principles of HRT prescribing
Lowest effective dose to control symptoms
Appropriate regimen:• unopposed oestrogen or oestrogen + progestogen
• sequential or continuous Appropriate route of administration
Appropriate route of administration
Short-term administration
Patient acceptance
TIBOLONE
Synthetic steroid whose metabolites have oestrogenic,progestogenic and androgenic properties, is an alternative to
conventional HRT.
It is available as an oral daily-dose tablet.
Tibolone has positive effects on vasomotor and urogenital symptoms, sexual function, bone density and fracture risk.
Androgen Therapy
A female androgen insufficiency syndrome has been proposed on the basis of clinical symptoms, including diminished
wellbeing, decreased sexual function, dysphoric mood and fatigue in the setting of low serum testosterone
concentration.
Contraindications to testosterone therapy
Severe acne, Moderate to severe hirsutism, Circumstances in which enhanced libido would be undesirable, Androgenic
alopecia, Pregnancy or lactation, Known or suspected oestrogen or androgendependent, neoplasia, Polycythaemia,
Professional singers,Unable to use concurrent oestrogen
Non-hormonal therapies for vasomotor symptoms
Preparation Dose Reduction in
hot flushes
Gabapentin 300-900mg/day in divided 50%
doses
Venlafaxine XR 37.5-75mg/day Up to 60%
Paroxetine* 10-20mg/day Up to 50%
Clonidine 0.1mg/day Up to 26%
Complementary Therapies
Current scientific evidence does not support the use of complementary or alternative therapies in the management of
menopausal symptoms
Management of minor side effects of HRT
Initial heavy withdrawal bleed with sequential EPT- Reassure, as this is usually transient
Initial break-through bleeding on continuous EPT Reassure if within the first 12 months and no indication of other pathology
Persistent mastalgia Reduce oestrogen dose or switch to tibolone
Persistent nausea or headache Reduce oestrogen dose or switch to transdermal therapy
Premenstrual syndrome-type symptoms-Reduce progestogen dose or switch to different progestogen
Persisting vasomotor symptoms Increase oestrogen dose or switch to transdermal oestrogen or screen for alternative
aetiology
Persistent heavy withdrawal bleed-Increase progestogen dose or consider use of intrauterine progestogen system. Vaginal
ultrasound to exclude
uterine pathology
Break-through bleeding on sequential Rx Increase progestogen dose or increase duration of progestogen or switch to
different progestogen. Vaginal ultrasound to r/o uterine pathology
Persistent break-through bleeding on continuous Rx Change to sequential EPT or consider use of intrauterine
progestogen system. Vaginal ultrasound to exclude uterine pathology
