Menopause

Question 1

Menopause timeline

Answer 1

-Reproductive
-Menopausal transition (perimenopause)
=Menstrual changes
=Fluctuating oestrogen levels
=Intermittent symptoms
=Early: fluctuating FSH
=Menopausal symptoms likely

Final period (average age 50-52)

-Postmenopausal (including perimenopausal)
=Amenorrhoea
=Low oestrogen levels
=Persistent symptoms (median 5 years)
=Persistently raised FSH then increasing urogenital symptoms

Question 2

Menopausal symptoms

Answer 2

-Vasomotor (sweating, hot flushes)
-Mood change
-Musculoskeletal pain
-Urogenital atrophic symptoms
-Weight gain
-Loss of libido

Question 3

Causes of menopause in younger people

Answer 3

-Early menopause (40-45 years)
-Premature ovarian insufficiency(<40 years): suddenly completely stop, less symptoms
-Surgery (oophorectomy)
-Chemotherapy/ radiotherapy/GnRHa

Question 4

Diagnosing menopause

Answer 4

-Diagnose the following without laboratory tests in otherwise healthy women aged over 45 years with menopausal symptoms: perimenopause based on vasomotor symptoms and irregular periods

-Consider checking a serum FSH
=in women aged 40 to 45 years with menopausal symptoms, including a change in their menstrual cycle
=in women aged under 40 years in whom menopause is suspected

Question 5

Interpreting serum FSH

Answer 5

-Serum FSH >30 iU/L is consistent with perimenopause……BUT DOES NOT confirm that the individual has had their final period
-Serum FSH <30 iU/L DOES NOT exclude perimenopause

Question 6

Management of menopause

Answer 6

-HRT/MHT (oestrogen for symptoms, progestogen to protect endometrium from oestrogen)
=Estradiol and progestogen
=improved QOL, bone and cardiovascular protection/ side effects, some don’t respond, symptoms return when stopped

Question 7

Health risks associated with HRT and contraindication

Answer 7

-Breast cancer
-Ovarian cancer
-Thrombosis (oral)

Contraindicated after breast cancer, E2 receptor positive gynae cancer, and oral HRT if risks for thrombosis

Question 8

HRT regimens

Answer 8

-Without uterus (and no endometriosis)
=Unopposed oestrogen

-With uterus and recent menstruation
=Oestrogen and progestogen with gaps
=Or oestrogen with Mirena/ Levosert/ Benilexa

-With uterus and longer since menstruation
=Oestrogen and progestogen/ Mirena etc

Question 9

Managing loss of libido

Answer 9

-Low dose transdermal testosterone
=Often ineffective
=Side effects (acne/ hirsutism/ alopecia/ irritability)
=Unknown long-term safety

Question 10

Managing urogenital atrophy

Answer 10

-Local vaginal oestrogen

Question 11

Methods other than HRT

Answer 11

-Self help
=Avoid vasomotor triggers (caffeine, hot drinks, alcohol)
=Layer clothing and bedding
=Mindfulness/ CBT
=Exercise
=Sleep apps

-Non-hormonal drugs
=SSRI/SNRI/gabapentin/ oxybutynin (off label)
=Lubricant and vaginal moisturiser

Question 12

Contraception in the perimenopausal

Answer 12

-HRT is not contraceptive
-Difficult to be sure when the final menstrual period has happened
-Contraception can be stopped by everyone at age 55
-Hormonal IUDs offer contraception and endometrial protection for HRT
-Can add progestogen-only contraception or a copper IUD to HRT
-Combined hormonal contraception (CHC) not recommended after age 50
-Consider CHC (used continuously without a hormone-free interval) for both contraception and HRT in premature ovarian insufficiency