Menopause

  • Menopause — when ovaries stop functioning and woman has her last menstrual period. Usually between 45–55 years — if no hysterectomy or medical treatment causing periods to stop

  • Perimenopause — time leading up to menopause when a woman may experience changes in her cycle regularity, length or menstrual flow pattern
  • Early menopause — when menopause occurs naturally between 40-45 years
  • Postmenopause — no periods for at least 12 consecutive months
  • Surgical menopause — when both ovaries have been removed
  • Premature ovarian insufficiency — when menopause occurs under 40 years. May occur spontaneously, due to surgery or medical treatment

Symptoms of menopause

  • Not all women are bothered by symptoms or experience the same symptoms — 20% no symptoms, 60% mild-moderate, 20% severe
  • Symptoms may differ in different stages, last a short time or for years — no way to predict symptom severity or duration
  • Symptoms of menopause may include physical and emotional symptoms 
    • Hot flushes, night sweats
    • Weight gain
    • Aches and pains, headaches/migraines
    • Increased fatigue or wakefulness
    • Bloating
    • Sore breasts
    • Itch, dry skin, crawling feelings under skin
    • New facial hair
    • Joint/muscle aches and pains
    • Urinary symptoms
    • Vaginal dryness
    • Difficulty concentrating, sleeping, coping
    • Anxiety, irritability, low mood, mood swings
    • Low libido
    • Feeling less able to cope
    • Loss of confidence
  •  Not all symptoms can be attributed to menopause. They may be due to a medical problem, normal ageing or psychosocial factors. If concerning symptoms — medical consult 

Ask

  • Menstrual history
  • Symptoms

Do

  • Adult Health Check
  • Mammogram​ if due or if starting Menopausal Replacement Therapy (MRT)
  • Cervical screening if due
  • Serious health problems in postmenopausal women include
  • Explain normal life changes to older women and why they may get symptoms, what can be done to manage them
  • Talk about pelvic floor exercises — to strengthen pelvic floor muscles, improve or maintain continence
  • Talk about emotional wellbeing — may need counselling or support especially if depressed or dealing with loss, grief or loneliness
  • If there is concern that physical or emotional changes are signs of an illness — medical consult
  • If under 40 years with premature ovarian insufficiency — medical consult for assessment and management
  • If there are risk factors for osteoporosis or a fracture — medical consult to initiate treatment or arrange Bone Mineral Density (BMD) testing

Treatment of specific menopause problems

Hot flushes

  • Lifestyle measures — keep cool, reduce intake of coffee/alcohol/spicy foods,  stop smoking, aim for healthy weight, exercise regularly
  • Complementary therapies
    • Hypnosis, cognitive behavioural therapies, Vitamin E
    • Traditional methods used by grandmothers or traditional healers
  • Menopausal replacement therapy (MRT) — patch/gel (transdermal) or oral oestrogen with progesterone if intact uterus
  • Non-hormonal therapy —  SSRIs, SNRIs, Clonidine, Gabapentin/Pregabalin if non-hormonal therapy preferred by woman or if hormonal therapy contraindicated (eg breast cancer, active liver disease, stroke)

Vaginal dryness, pain with sex

  • Water-based lubricants
  • Vaginal moisturisers
  • Topical vaginal oestrogen or MRT

Mood changes

  • Counselling, lifestyle changes, cognitive behavioural therapy
  • Major depression — medical consult  

Reduced libido

  • Often needs a lot of counselling and education
  • Needs support and reassurance, involve partner if appropriate
  • Consider referral to appropriate services. May need MRT

Menopausal Replacement Therapy (MRT)

Do not use MRT due to increased risk of serious side effects if

  • History or increased risk of hormone-dependent cancers — breast, some types of ovarian and uterine cancers
  • Pre-existing or high risk of cardiovascular disease
  • Previous Venous Thromboembolism (VTE) which includes Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) or stroke

MRT is the most effective way to improve quality of life by reducing symptoms and may have other benefits for bone and cardiovascular health

  • Types of MRT include
    • Oestrogen only therapy
    • Combined (oestrogen and progesterone) therapy
    • Selective oestrogen receptor modulators 
    • Tibolone
  • MRT may provide symptomatic relief for symptoms including hot flushes/night sweats, vaginal dryness, joint pain and stiffness
  • Systemic MRT is associated with small increase in risk of breast cancer, this is greater for combined MRT (oestrogen and progesterone) compared with oestrogen only MRT
  • Transdermal (patch or gel) MRT is associated with minimal or no risk of VTE. Oral therapy is associated with low risk
  • If under 60 years or less than 10 years since menopause — quality of life benefits generally outweigh risks
  • Minor side effects include sore breasts, vaginal bleeding, fluid retention, nausea, headache, mood changes
  • MRT is not a contraceptive

Do — Prescribing MRT

  • Medical consult

  • Must be prescribed by doctor — consider individual benefits, risks, side effects

  • Prescribe at lowest effective dose for shortest time, regular (6–12 monthly) review of ongoing need
  • Safest within first 5 years of menopause
  • Use with care if significant risk factors for CVD, diabetes, smoker
    • If increased risk of CVD — patch better than oral MRT
  • If perimenopausal — best period control by using cyclical MRT regimen, oral contraceptive pill, or oestrogen patch plus Levonorgestrel Intra Uterine Device LNG-IUD
  • If postmenopausal — continuous progesterone therapy (patch or LNG-IUD) or cyclical progesterone therapy
  • If women has uterus — endometrial protection with progestogen is essential
  • If women has had hysterectomy — prescribe oestrogen alone
  • If premature ovarian insufficiency — give MRT at least until usual age of menopause. Usually between 45–55 years — if no hysterectomy