Menopause and Menopausal Problems 🌸 ✅

Menopause is the permanent cessation of menstruation caused by loss of ovarian follicular activity. In clinical practice it is usually diagnosed retrospectively after 12 months of amenorrhoea in people who are not using hormonal contraception. The transition leading up to this is the perimenopause, during which fluctuating ovarian hormone production causes irregular periods and characteristic symptoms.

📖 Definitions and stages

• Perimenopause: the transitional phase before menopause, often with irregular cycles and vasomotor symptoms.
• Menopause: the final menstrual period, recognised retrospectively after 12 months of amenorrhoea.
• Postmenopause: the phase after menopause, characterised by persistent hypo-oestrogenism.
• Premature ovarian insufficiency (POI): menopause before age 40.
• Early menopause: menopause between ages 40 and 44.

🧬 Pathophysiology

• Ovarian follicle depletion leads to reduced oestrogen and progesterone production.
• Loss of negative feedback causes FSH and LH to rise.
• Oestrogen deficiency affects multiple systems:
• Thermoregulation: hot flushes and night sweats.
• Genitourinary tract: vaginal dryness, dyspareunia, urinary symptoms, recurrent UTIs.
• Bone: accelerated bone loss and increased osteoporosis risk.
• Cardiovascular/metabolic health: adverse lipid changes and redistribution of body fat.
• Sleep, mood, and cognition: poor sleep, low mood, anxiety, irritability, concentration difficulties.

🌡️ Symptoms

• Vasomotor: hot flushes, night sweats.
• Menstrual change: irregular, lighter, or heavier periods in perimenopause.
• Psychological: mood change, anxiety, irritability, poor concentration, low mood.
• Sleep: insomnia or unrefreshing sleep.
• Genitourinary: vaginal dryness, dyspareunia, urinary urgency, recurrent UTIs.
• Sexual: reduced libido, discomfort during sex.
• Musculoskeletal/other: joint aches, fatigue, skin and hair changes.

🩺 Assessment

• Menstrual history: last period, cycle pattern, contraception use.
• Symptom review: vasomotor, psychological, sleep, urogenital, sexual, and musculoskeletal symptoms.
• Past history: VTE, migraine, breast cancer, cardiovascular disease, liver disease, osteoporosis risk, hysterectomy.
• Family history: breast cancer, VTE, osteoporosis, early menopause.
• Medication review: tamoxifen, aromatase inhibitors, SSRIs/SNRIs, antihypertensives, hormonal contraception.
• Lifestyle: smoking, alcohol, caffeine, exercise, weight.

👩‍⚕️ Examination

• Examination is often normal and may not be needed if the diagnosis is clear.
• Consider BP, BMI, mood/affect, and targeted examination depending on symptoms.
• Pelvic examination may be useful if there are vaginal or prolapse symptoms.
• Breast examination is guided by symptoms rather than done routinely for menopause alone.

🔬 Investigations

• Usually a clinical diagnosis in people aged 45 or over with typical menopausal or perimenopausal symptoms.
• Do not routinely measure FSH in otherwise healthy people aged 45 or over with typical symptoms.
• Consider tests for alternative diagnoses if symptoms are atypical, for example pregnancy, thyroid disease, anaemia, or hyperprolactinaemia.
• In suspected POI or early menopause, investigate further — typically with FSH and other causes of amenorrhoea as appropriate.
• DXA is not routine for everyone, but may be appropriate if fracture risk is high or POI is present.

🌿 Genitourinary syndrome of menopause (GSM)

GSM describes the chronic vulvovaginal and lower urinary symptoms caused by oestrogen deficiency. Typical features include vaginal dryness, dyspareunia, itching/irritation, urinary urgency, and recurrent UTIs. Unlike hot flushes, GSM often persists or worsens over time if untreated.

💊 Management principles

• Use a shared decision-making approach.
• Discuss symptom severity, quality of life, personal risk factors, and patient preference.
• Explain that HRT is the most effective treatment for vasomotor symptoms and can also help mood, sleep, and bone health in appropriate patients.
• Explain that HRT is not contraceptive; contraception may still be needed in perimenopause.
• Advise on lifestyle measures: exercise, smoking cessation, healthy weight, sleep optimisation, limiting alcohol excess, and calcium/vitamin D intake where appropriate.

💉 Hormone replacement therapy (HRT)

• Offer HRT for menopausal symptoms after discussing short-term and longer-term benefits and risks.
• Oestrogen-only HRT is used if the person has had a hysterectomy.
• Combined HRT (oestrogen + progestogen) is needed if the uterus is present, to protect the endometrium from unopposed oestrogen.
• For people with a uterus and ongoing periods/perimenopause, sequential HRT is usually used initially; after menopause, continuous combined HRT is usually preferred.
• A levonorgestrel intrauterine system may be used as the progestogen component in some HRT regimens.
• Review response and adverse effects after starting or changing HRT, then continue regular review.

🩸 Route of HRT and NICE risk points

• Transdermal oestrogen (patch/gel/spray) is often preferred if VTE risk is a concern.
• VTE risk is not increased with transdermal HRT.
• Oral HRT increases VTE risk, and the VTE risk is greater with oral than transdermal treatment.
• Stroke risk is unlikely to increase with transdermal HRT, but oral oestrogen-containing HRT increases stroke risk, especially with higher dose, longer use, and older age at starting.

🧠 HRT benefits and risks: key counselling points

• Benefits: best treatment for hot flushes and night sweats; helps GSM if systemic symptoms are also present; reduces menopause-related bone loss while taken.
• Breast cancer: oestrogen-only HRT is associated with little or no change in breast cancer risk; combined HRT is associated with an increase in breast cancer risk, which is related to duration and regimen.
• Endometrium: unopposed oestrogen is unsafe in someone with a uterus because it increases endometrial cancer risk.
• VTE/stroke: lower with transdermal than oral oestrogen.
• Cardiovascular disease: HRT should not be used solely for primary prevention of cardiovascular disease, but current NICE guidance does not state that HRT increases coronary heart disease risk in the general menopausal population.
• Diabetes: HRT does not increase the risk of developing type 2 diabetes and generally does not worsen glycaemic control.

🌸 Vaginal oestrogen

• Offer a choice of vaginal oestrogen for GSM, for example cream, gel, tablet, pessary, or ring.
• Vaginal oestrogen may be used alone or with systemic HRT.
• It can be continued for as long as needed to relieve symptoms.
• Lubricants and moisturisers can be used alone or alongside vaginal oestrogen.

🎗️ Menopause symptoms in people with a history of breast cancer

• For GSM, start with non-hormonal moisturisers or lubricants.
• If symptoms persist, consider vaginal oestrogen.
• If the person is currently taking an aromatase inhibitor, work with a breast cancer specialist to decide treatment.
• Systemic HRT is generally avoided in people with current, past, or suspected breast cancer unless specialist advice supports otherwise.

🚫 Non-hormonal options

• CBT may help vasomotor symptoms, sleep, and mood-related distress.
• For hot flushes where HRT is contraindicated or declined, consider non-hormonal options in line with current prescribing guidance and comorbidity.
• Lubricants/moisturisers are useful for GSM, especially when hormonal treatment is not wanted or is unsuitable.
• Treat co-existing depression, anxiety, insomnia, osteoporosis risk, or urinary symptoms on their own merits.

⏳ Premature ovarian insufficiency (POI) and early menopause

• POI and early menopause carry greater long-term risks, especially for bone and possibly cardiovascular health.
• Offer hormonal treatment unless contraindicated.
• For POI, continue hormonal treatment until at least the usual age of natural menopause unless contraindicated.
• Explain that both HRT and the combined oral contraceptive pill can provide symptom control and bone protection, but HRT is not contraceptive.

🚨 Red flags

• Postmenopausal bleeding is abnormal and requires urgent assessment.
• Persistent unscheduled bleeding on HRT needs review.
• Breast lump, unilateral bloody nipple discharge, or unexplained weight loss needs prompt assessment.
• Do not assume all symptoms in midlife are due to menopause; consider other diagnoses where appropriate.

🩺 Cases - Menopause

• Case 1 - Typical vasomotor symptoms 🔥: A 52-year-old reports hot flushes, night sweats, poor sleep, and mood change. Periods stopped 14 months ago. Diagnosis: natural menopause. Management: discuss HRT, especially if symptoms affect quality of life, plus lifestyle advice and review.
• Case 2 - Premature ovarian insufficiency ⏳: A 36-year-old has amenorrhoea, flushes, and vaginal dryness. Diagnosis: POI after appropriate assessment. Management: offer hormonal treatment unless contraindicated, usually until at least the average age of natural menopause.
• Case 3 - Postmenopausal bleeding 🚨: A 61-year-old presents with vaginal bleeding 8 years after menopause. This is endometrial cancer until proven otherwise and needs urgent investigation.

💡 Clinical pearls

Menopause is usually a clinical diagnosis in people aged 45 or over with typical symptoms, so routine FSH testing is usually unnecessary. HRT is the most effective treatment for vasomotor symptoms. Transdermal HRT is safer than oral HRT for VTE risk. People with a uterus need endometrial protection. Vaginal oestrogen can be continued long term for GSM. HRT is not a contraceptive. Postmenopausal bleeding is always abnormal.