The menopause

Definitions and prevalence

• Menopause is a single day 12 months after last menstrual period (unless periods are suppressed by contraception)
  • • Average age in UK is 51 (45-55 is the normal range)
    • Can be difficult to identify in those on long term hormonal treatment
• Perimenopause
  • • Involves irregular cycles of ovulation and menstruation
    • Symptoms can last 7-9 years (but longer in some)
    • 75% of women experience symptoms, and in 25% they are severe
• Early menopause is menopause <45 years
  • • Increased risk of early menarche, nulliparity, smoking, being underweight
    • Occurs in 12% of women
• Premature ovarian insufficiency
  • • The loss of ovarian function before age 40
    • Affects 3% of women (and may be increasing)
    • Can occur naturally or due to medical interventions/treatments, autoimmunity, infections, genetic conditions
• Hormonal changes
  • • In the perimenopause – oestrogen levels fall, FSH and LH rise (FSH can fluctuate a lot)
    • Post menopause – high levels of FSH and LH, low levels of progesterone and oestrogen

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Symptoms

• Some symptoms very tightly linked to menopause
  • • Menstrual changes
      • • Cycles can shorten or lengthen
        • Blood loss may increase a bit
    • Vasomotor symptoms
      • • Hot flushes, night sweats, palpitations
        • Tend to peak around the final menstrual period but fluctuate a lot
        • Then tend to subside (but continue in a small number)
    • Vaginal symptoms (genitourinary syndrome of menopause)
      • • Vulvovaginal atrophy, atrophic vaginitis, urogenital atrophy
        • Can be dyspareunia
        • Can continue into post menopause
• Other symptoms have very low specificity – therefore consider what other causes may be contributing
  • • Sleep disturbance
    • Fatigue or cognitive issues
    • Mood changes or anxiety
    • Joint aches, headache
    • Weight gain
    • Skin and hair changes
    • UTIs
• Risks of early menopause
  • • Osteoporosis
    • CV and cerebrovascular disease
    • Premature Ovarian Insufficiency is associated with increased all-cause mortality (mostly due to CV disease), diabetes, depression and cognitive decline

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Assessment

• Consider other causes of amenorrhea (including pregnancy!)
• If sudden changes, consider cancer as differential
• Assess CV and cancer risk
• Consider testing FSH
• FSH levels
  • • Not required to diagnose perimenoapse (and usually not sent)
    • Never send if taking combianed oral contraception, and levels are unreliable if taking tamoxifen
    • Consider sending if a person is aged <45
    • If taking – send 2 samples, 6 weeks apart
    • In POI, FSH is typically >30IU/L
• Consider differentials
  • • Any cause of secondary amenorrhea
    • Any cause of irregular vaginal bleeding including polyps, fibroids, adenomyosis, cancer, infections
    • Hyperthyroidism, phaeochromocytoma, carcinoid
    • Anxiety / depression
    • Medication side effects

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Management

• Self-management lifestyle strategies
• Reduce CV risk
• Hormone Replacement Therapy (HRT)
  • • First line
    • Given orally or transdermal. Lots of different types. Tailor to patient.
    • Contraindicated if personal history of oestrogen dependent malignancy (and stop if breast cancer diagnosed)
    • It’s not a mimic of previous hormonal changes
    • Does not provide contraception (can use progesterone-only methods of contraception alongside, or use the combined oral contraceptive instead of HRT in women aged <50)
    • Also give progesterone to patients with a uterus – as unopposed oestrogen increases risk of endometrial cancer
    • Oestrogen only HRT can be used in patients who have had a total hysterectomy
    • Benefits include
      • • Symptom-relief
        • Bone protection (during therapy not afterwards).
        • May also reduce risk of CV disease, Alzheimer’s, colorectal cancer and T2DM
        • HRT is unlikely to impact life expectancy
    • Side effects include breast tenderness, mood swings, fluid retention, irregular bleeding
    • Risks
      • After 5 years of use, small increased risk in breast cancer (it’s the progesterone that does this, not the oestrogen).
      • Obesity or >2 units of ETOH daily increases risk of cancer more than HRT
      • Some regimens have small risk of VTE (not with transdermal), CVA (again not transdermal) and endometrial cancer (if oestrogen-only, but this is not standard)
• Testosterone sometimes used
  • • Can increase libido if this is an issue (but doesn’t help general wellbeing despite all the publicity and pseudoscience)
    • Monitoring testosterone levels is required
    • Can cause hair growth, acne, weight gain (all usually reversible).
    • Sometimes causes alopecia, voice change, clitoral enlargement if dose too high
    • Takes > 3 months to evaluate efficacy
• CBT used for mood and sleep issues
• Vaginal oestrogen – quite safe
• For severe vasomotor symptoms – consider Fezolinetant and Elinzanetant