Menopause

Question 1

Define menopause

Answer 1

Cessation of menses for at least 12 months, without a clear reason, due to loss of ovarian follicular activity and therefore oestrogen release.

Question 2

Define perimenopause

Answer 2

Period before menopause when the endocrinological, biological, and clinical features of approaching menopause starts. Characterised by irregular cycles of ovulation and menstruation and ends 12 months after the last menstrual period.

Question 3

What are the symptoms of menopause

Answer 3

Amenorrhoea
Hot flushes (sudden feeling of heat in the upper body that spreads) ± palpitations, anxiety
Night sweats
Vaginal symptoms: Dryness, Itching, Dyspareunia, Burning/irritation/discomfort
Reduced libido
Mood changes: Irritability, Mood swings
Recurrent UTIs
Sleep disturbance
Poor concentration and memory

Question 4

What are the signs of menopause on examination

Answer 4

Height, weight, Blood pressure
Vaginal exam ( do NOT routinely do): Pale, dry vaginal mucosa

Question 5

What are the differentials for menopause

Answer 5

Secondary amenorrhoea
Irregular bleeding: Endometrial polyps, fibroids, adenomyosis, endometrial hyperplasia
Hot flushes: hyperthyroidism, phaeochromocytoma, carcinoid syndrome, pancreatic cancer
Vaginal atrophy: trauma, infection, lichen sclerosis
Urinary incontinence: UTI, multiparity

Question 6

What investigations should be done for menopause

Answer 6

Clinical diagnosis: if the woman (>45yo) has not had a period for at least 12 months (and is not using hormonal contraception)

Bedside: urine pregnancy test
Bloods: FSH (raised >30 2x 4-6 weeks apart), LH, oestradiol <110, androgens, TFTs, cortisol, HbA1c
Other: pelvic USS (endometrium <5mm)

Question 7

When are investigations indicated for menopausal symptoms

Answer 7

NOT Taking contraception:
- Aged over 45 years with atypical symptoms.
- Aged between 40–45 years with menopausal symptoms, including a change in menstrual cycle.
- Younger than 40 years with a suspected diagnosis of premature ovarian insufficiency (POI)
- Over 50 years of age using progestogen-only contraception, including depot medroxyprogesterone acetate (DMPA).
If the FSH level is in the premenopausal range, the woman should continue contraception and the FSH level should be rechecked in 1 year.

Question 8

What is the management for menopause

Answer 8

Assess treatment goals and refer to menopause clinic

Conservative
Non-hormonal
Hormonal

± contraception

+ follow up 3 months later

Question 9

Describe the conservative measures for menopause

Answer 9

Hot flushes and night sweats: regular exercise, weight loss (if applicable), wearing lighter clothing/layers of clothing, turning down central heating, sleeping in a cooler room, using fans, reducing stress, and avoiding possible triggers (such as spicy foods, caffeine, smoking, and alcohol).
Sleep disturbances: avoiding exercise late in the day and maintaining a regular bedtime. Sleep hygiene
Low mood and anxiety: adequate sleep, regular physical activity, and relaxation exercises.
Cognitive symptoms: exercise and good sleep hygiene
CBT

Question 10

What are the non-hormonal pharmacological measures for menopause

Answer 10

SSSRIs e.g. citalopram, fluoxetine, venlafaxine (Increases serotonin → improves Vasomotor symptoms)
Clonidine (alpha adrenergic receptor agonist)
Gabapentin
Evening primrose oil

Question 11

What are the hormonal pharmacological measures for menopause

Answer 11

Oestrogen or progesterone or combined
- Hysterectomy → oestrogen only
- Uterus present → combined
Continuous or cyclical (perimenopause - oestrogen daily and progesterone for the last 10-14 days)

Oestrogen: oral, transdermal (gel or patch - BMI >30, VTE risk), implant
Progesterone: oral, pessary/gel, mirena coil

Women on HRT may get unscheduled bleeding within the first 4-6 months
Amenorrhoea desired → tibolone (oestrogen and androgen properties)

Question 12

How long should contraception be used to women with menopause

Answer 12

12 months after the last period in women > 50 years
24 months after the last period in women < 50 years

Question 13

What are the complications of the oestrogen-only HRT

Answer 13

Metabolised by the liver into its active form → affects cholesterol metabolism (lipidaemia) and clotting (increased DVT risk)
VTE (increased if oral, not if transdermal)
Stroke
coronary heart disease
Ovarian cancer
Breast tenderness/swelling, nausea, leg gramps, headache

Question 14

What are the side effects of combined HRT

Answer 14

Increased risk of breast cancer (5 extra cases per 1000 women)
VTE → Increased stroke risk
Breast tenderness, coronary heart disease
Ovarian cancer (1 extra case per 1000)
Acne

Question 15

What are the complications of menopause

Answer 15

Osteoporosis and fracture
CVD
Stroke
Cognitive decline
Parkinsonism
Vaginal atrophy, sexual dysfunction
Genitourinary syndrome of menopause, due to oestrogen depletement + natural ageing process

Question 16

What is the prognosis for menopause

Answer 16

The duration and severity of symptoms experienced in menopause vary markedly between different women
Symptoms typically last for 5–7 years, but some women continue to experience symptoms for at least 10–15 years
Perimenopause can last for several years, and menopause can last a few years to more than 13 years

Risk factors for worsened outcome:
- Ethnicity (Caucasian, Hispanic, Afro-Caribbean)
- Younger age at menopause.
- Current smoking.
- Weight gain.
- Lower educational level.

Question 17

What are the absolute contraindications for HRT

Answer 17

Suspected pregnancy
Breast cancer- current, past or suspected
Known or suspected oestrogen-sensitive cancer (e.g. endometrial cancer)
Untreated endometrial hyperplasia
Active liver disease
Uncontrolled hypertension
Previous idiopathic or current VTE unless already on anticoagulants
Active or recent arterial thromboembolic disease (e.g. angina, MI)
Known thrombophilia (e.g. Factor V Leiden)
Otosclerosis