Background

The permanent cessation of menstruation, due to the depletion of the oocyte store, and resultant loss of ovarian follicular activity 

  • A diagnosis can be made after amenorrhoea for 12 months 
  • Early menopause - menopause occurring between ages of 40-45 years
  • Premature menopause - menopause at < 40 years 

The perimenopause is the time before the menopause, characterised by oligomenorrhea and vasomotor symptoms (hot flushes/night sweats)

 

Clinical Features

  • A change in menstrual cycle in the perimenopause - e.g. lengthening or shortening of the cycle length
  • Vasomotor symptoms 
    • Hot flushes
    • Night sweats
  • Mood disorders
    • Mood swings, anxiety, irritability or low mood
  • Genitourinary syndrome of menopause:
    • Oestrogen deficiency in post-menopausal women causes atrophy of the vaginal lining.
    • Clinical features:
      • vaginal irritation and soreness, commonly worsened by sex
      • Post-coital bleeding - trauma to fragile vaginal skin.
      • Vaginal dryness, itching or discomfort
        • Associated dyspareunia 
      • On examination: smooth, pale, dry vaginal walls with contact bleeding.
    • Reduced libido

 

Diagnosis

  • If there are typical symptoms a diagnosis can be made. 
  • In some cases, measurement of FSH can aid diagnosis of menopause:
    • Age > 45 with atypical symptoms
    • Possible early menopause - age 40-45 with symptoms as above
    • Age < 40 with suspected premature menopause 
  • If the FSH level is > 30 this indicates ovarian insufficiency (2 x samples 6 weeks apart to confirm). 

 

Contraception

  • Inform women that they may remain fertile for up to 2 years after their last menstrual cycle if < 50 years of age (or 1 year if > 50 years of age) and so should continue to use contraception during this… period. 
    • Progestogen only contraception can be used alongside cyclical HRT
    • Combined hormonal contraception (e.g.COCP) can be used as an alternative to HRT in women who are < 50 years of age, for the relief of menopausal symptoms (but should switch to progestogen-only contraception once > 50yrs) 


 

Hormone replacement therapy (HRT)

 

The management of menopause and HRT in particular is a common topic in the MSRA (i.e. which is the most appropriate HRT regimen for X patient? etc.)

 

The most appropriate type of HRT depends on:

  

  1. Uterus or no uterus (hysterectomy)
    1. In women without a uterus (hysterectomy) - offer oestrogen only HRT
    2. In women with a uterus - offer a combined HRT (oestradiol + progesterone)
      1. The progestogen provides endometrial protection - unopposed oestrogen would cause endometrial hyperplasia and increase risk of cancer. 
      2. Next consider sequential vs continuous combined...

 

  1. For COMBINED HRT - Timing of LMP
    1. Perimenopausal - periods ongoing or stopped < 1 year ago  - Sequential (cyclical) combined HRT  
      1. Oestrogen is taken every day, and the progesterone is taken for aprox. half of the month
        1. Results in a monthly withdrawal bleed 
    2. Post-menopausal - LMP was > 1 year ago - Continuous combined HRT 
      1. Continuous = oestrogen and progesterone are taken together every day
      2. Continuous is preferred - advantage is NO withdrawal bleeding 

 

To summarise..

  • Hysterectomy/no uterus - oestrogen only
  • Uterus intact 
    • LMP < 1 year ago - sequential combined
    • LMP > 1 year ago - continuous combined 

 

Duration of treatment

  • HRT should be continued as long as required until no longer necessary for symptom relief (i.e. the symptomatic benefits are outweighed by risks of HRT). 
  • Women with premature menopause/premature ovarian insufficiency should continue HRT until at least age 51 (average age of menopause). 

 

Routes

  • Systemic oestrogen can be taken orally or transdermally (patch, gel, spray)
  • Importanlty, transdermal oestrogen is NOT associated with increased risk of VTE (PO oestrogen only!)

 

Contraindications to HRT 

(1) Breast/Endometrial Cancer (2) Clots (3) Liver disease (4) Pregnancy 

  • History of breast cancer or endometrial cancer
    • By the same logic - undiagnosed breast lump/ PV bleeding/untreated endometrial hyperplasia
  • History of VTE (PE/DVT), thromboembolic disease (angina/MI) or thrombophilic disorder
  • Active liver disease
  • Pregnancy 

  

Side effects of HRT

  • Oestrogen - breast tenderness, bloating, fluid retention 
  • Progestogen - breast tenderness, low mood, acne vulgaris 
  • Vaginal bleeding - common within 1st 3/12 especially  
    • Continuous combined HRT common SE - irregular bleeding/spotting for 4-6 months 

 

Combined hormonal contraception

Combined hormonal contraception (e.g.COCP) can be used as an alternative to HRT in women who are < 50 years of age, for the relief of menopausal symptoms 

 

 

Non-hormonal alternatives

 

Vasomotor symptoms

  • SSRI or SNRI - fluoxetine, citalopram, paroxetine, venlafaxine
  • Clonidine (alpha-2 R agonist - also used in rosacea) 
  • Gabapentin 
    • CBT

 

Mood disorders

  • Antidepressant treatment

 

Management of Genitourinary Syndrome of Menopause

Hormonal

  • 1st Line: Low dose vaginal oestrogen (can also be added to systemic HRT if severe symptom)
  • 2nd line: Trial oral ospemifene (SERM) if mod-severe symptoms. 

Non-hormonal

  • Vaginal moisturisers