Menopause

Menopause is the permanent cessation of menstruation for > 12 months. It typically occurs between 45-55 years, with an average age of 51 years. It's caused by Ovarian failure, which leads to an oestrogen deficiency. There are different terms used, which include:

Pathophysiology

In menopause, the reduced follicular count causes ↓Oestrogen levels and less negative feedback, therefore leading to a ↑LH/FSH. This ↓Oestrogen has 2 main effects:

• Causes the symptoms

• Becomes too low to stimulate the endometrium → Amenorrhoea

Post-menopausal women will eventually have a hormonal state of ↓Oestrogen and ↑LH/FSH.

Presentation

• Vasomotor – Hot flushes, Night sweats (Sleep disturbance)

• Genitourinary Syndrome

  • Sexual dysfunction – Atrophic Vaginitis (Dryness, Itchiness, Atrophy, Burning, Painful sex, PCB)

  • Urinary tract disorders (Dysuria, Frequency, Urgency, Recurrent UTI)

• Psychological – Anxiety and mood disorders, Fatigue, Cognitive impairment

Long-term effects - Heart (CVD, Stroke, TIA), Bone (Osteoporosis, Fracture)

N.B. Oestrogen is bone-protective.

Investigations

If < 45 years, take a history and do bloods:

• FSH - Repeat at least 4 weeks apart - should be >30 iu/L

  • Make sure they’re not on COCP or HRT

  • If level is pre-menopausal (low), repeat in a year

If > 45 years, check their periods and symptoms. FSH isn't tested here as clinical features are often more than enough for a diagnosis in this age group.

Management

The mainstay is HRT, which is given either:

• Cyclically for pre-menopausal women OR

• Continuously for post-menopausal women

Benefits of HRT are:

• Relief of Vasomotor and Urogenital symptoms

• Reduces the risk of osteoporosis

Risks of HRT are:

• VTE

• Breast cancer

• Endometrial cancer (if oestrogen alone)

Alongside the HRT, you can give:

• Testosterone for sexual dysfunction

• SSRI, CBT for anxiety and mood disorders

Premature Ovarian Insufficiency

This is when menopause occurs < 40 years. Causes of this are Idiopathic, Iatrogenic, Genetic, Autoimmune.

Investigations will show a raised FSH, but this should be repeated more than once.

Managed with HRT until around 51 years. If the patient has had a bilateral oophorectomy, testosterone should be added.

Hormone Replacement Therapy

Contains:

• Oestrogen for symptoms

• Progesterone for endometrial protection

Can be given:

• Cyclical if pre-menopausal

  • Give this monthly if they continue to have regular periods

  • Give this every 3 months if they continue to have irregular periods

• Continuous if post-menopausal

Most common side-effects are breast tenderness, and headache.