Overview
Menopause is defined as the permanent cessation of menses for at least 12 months, following the loss of ovarian activity. Symptoms of menopause are due to low oestrogen levels, and these are mainly psychological symptoms, vasomotor symptoms and urogenital symptoms. Urogenital symptoms worsen with age while vasomotor symptoms resolve with time. Diagnosis is clinical. No specific investigations are required.
One of the main pathological consequences of menopause is osteoporosis. Peak bone mass is usually achieved at 30 – 35 years. Common fractures include femoral neck, vertebral and distal radial fractures.
The mean age of menopause is 51 years (45-55 years). 80% of women experience some symptoms. 50% of women experince symptoms for at least 7 years.
Definition of terms
| Term | Definition |
|---|---|
| Premature menopause (1%) | Menopause that occurs in women ≤ 40 years. |
| Iatrogenic menopause (5%) | Cessation of menses due to oophorectomy (surgical menopause) or iatrogenic ablation by chemotherapy or pelvic irradiation |
| Perimenopause | Transition phase leading to menopause characterized by irregular menstrual cycles, fluctuating oestrogen levels and onset of menopausal symptoms. May last 4 – 8 years. |
| Post-menopause | 12 months after cessation of ovarian activity |
| Premature ovarian failure | Hypergonadotropic, hypoestrogenic amenorrhoea in women ≤ 40 years old. Permanent causes include autoimmune disease, toxins, and genetics. Reversible causes include exercising, eating disorders, and high stress levels (not equivalent to premature menopause) |
- Pathophysiology of menopause
- Decline in primary follicles → reduced production of oestrogen and progesterone → Increased FSH and LH (predominantly FSH)
- Conseqeunce of oestrogen loss include vasomotor symptoms and osteoporosis
Signs and symptoms of menopause
| Category | Signs and symptoms |
|---|---|
| Vasomotor | Hot flashes (80%), night sweats (70%), palpitaitons (30%) |
| Psychological | Irritability, depression, anxiety, poor short-term memory, sleep disturbance, low libido |
| Urogenital | Vaginal dryness (45%), atrophic vaginitis, dyspareunia, reduced libido, bladder dysfunction, stress incontinence, pelvic organ prolapse |
| Dermatological | Dry skin, formication, facial hair, breast atrophy |
| Muskuloskeletal | Joint soreness and stiffness, back pain |
| Systemic | Weight gain, dizziness, lethargy |
- Investigations
- Serum FSH and oestradiol: for early menopause (< 45 years) to confirm diagnosis
- Elevated FSH (> 25 U/L)
- Low oestradiol (< 100 pmol/L)
- Fasting lipid profile: assess cardiovascular risk
- Mammography: 3 months after starting HRT
- Hysteroscopy: if there is abnormal uterine bleeding
- DEXA scan: if there is risk of fractures
- Serum FSH and oestradiol: for early menopause (< 45 years) to confirm diagnosis
- Patient education
- Emphasize that menopause is a natural, physiological process
- Avoid lifestyle factors that can trigger vasomotor episodes e.g. caffeine, alcohol and spicy foods
- Encourage healthy diet and regular exercise to reduce symptoms severity and maintain cardiovascular and bone health
- Screen for anxiety and depression and treat if present
- Advice on bone health and supplement calcium and vitamin
- Continue contraception for 12 months after last period in women > 50 and 2 years in women < 50. COCPs low-dose preparation can be used up to 50 years if no contraindications. After 50 years condoms and progesterone preparations are recommended
- Advise that it is normal to need additional vaginal lubrication
- Complications of premature or iatrogenic menopause
- Early loss of fertility
- More severe symptoms
- Greater risk of osteoporosis
Hormone Replacement Therapy
Hormone replacement therapy (HRT) is used to relieve moderate to severe vasomotor symptoms (and urogenital symptoms + prevention of osteoporosis) ****by replacing hormones that are no longer being produced (oestrogen +/- progesterone). Since unopposed oestrogen therapy causes an 5 – 10 x increased risk of endometrial carcinoma, women on hormone replacement therapy (still with uterus) should also be on a progestin to prevent endometrial hypertrophy.
HRT should be lmited to less than 5 years to reduce the risk fo adverse effects, and the dose should be tapered over 2 -3 months when stopping treatment. The risks of HRT are greates in women > 60 years.
- Principles of HRT
- Combine oral contraceptive pill or IUD if perimenopausal
- Combined oestrogen and progesterone therapy for all women with a uterus
- Oestrogen only therapy for woemen without a uterus
- Start with a small dose and titrate upwards
- Mammography 3 months after starting treatment
- Review at 6 month intervals
- Aim to cease treatment at 2 years, and if unable to tolerate symptoms continue for up to 5 years
- HRT Preparations
- Combined HRT: Estrogen + progesterone for women with intact uterus
- Cyclical HRT: estrogen taken daily and progestin taken for part of the month. Best in perimenopausal women
- Non-cyclical (continuous) HRT: both oestrogen and progesterone are taken daily without interruption. Best in post-menopasual women
- Oestorgen only HRT: for women with hysterectomy
- Combined HRT: Estrogen + progesterone for women with intact uterus
- HRT options
- Topical vaginal preparations for 6 – 8 weeks for urogenital symptoms
- Trandermal oestrogen patches applied weekly
- Transdermal topicl gel
- Implant given every 3 – 12 months
- Cyclical or Continuous oral preparations
- Synthetic steroids e.g. tibolone (has oestrogen, progestin and testosterone effects)
- Testosterone implant to improve libido
- Non-hormonal options
- SSRIs: second-line for vasomotor symptoms
- Gabapentin
- Clonidin
- Caution
- Added progestins to topical vaginal preparations can increased the risk of endometrial cancer
- Unopposed oestrogen therapy carries a 5 – 10 times increased risk of endometrial cancer
- Benefits of oestrogen containing oral HRT preparations
- Reduces vasomotor symptoms
- Reduced risk of bowel cancer
- Reduced risk of osteoporosis and fractures
- Disadvantages of oestrogen containing oral HRT
- Increases the risk of breast cancer
- Increases the risk of coronary artery disease
- Increases the risk of stroke
- Increases the risk of pulmonary embolism