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.
One of the main pathological consequences of menopause is osteoporosis. Peak bone mass is usually achieved between 30 and 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 patients experience some symptoms. 50% of patients experience 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. It 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) |
Clinical features 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 |
- 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
- 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 to 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 and 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