Menopause Management
[!WARNING] Medical Disclaimer: This content is for educational and informational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional for diagnosis and treatment. Medical guidelines and best practices change rapidly; users should verify information with current local protocols.
Menopause is a biological stage defined retrospectively as 12 months of amenorrhoea due to ovarian follicular depletion. The average age in the UK is 51.
Perimenopause is the transition period (vasomotor symptoms + irregular periods) leading up to the final period.
Clinical Scenario: The Confused Prescriber
A 52-year-old woman requests HRT for severe hot flushes. Her last period was 4 months ago. She has a BMI of 32 and well-controlled hypertension.
Key Teaching Points
- **Diagnosis**: Perimenopause (periods not stopped for >12m).
- **Regimen**: She needs **Sequential Combined HRT** (Monthly bleed). If you give continuous HRT too early, she will get nuisance breakthrough bleeding.
- **Route**: **Transdermal** (Patch/Gel) is preferred because obesity (BMI >30) increases VTE risk, and oral Oestrogen increases it further, whereas Transdermal does not.
Image Integration Plan
| Image Type | Source | Status |
|---|---|---|
| Management Algorithm | AI-generated | PENDING |
| Pathophysiology (HPA Axis) | AI-generated | PENDING |
| Osteoporosis (DEXA) | Web Source | PENDING |
| HRT Risks Chart | Web Source | PENDING |
[!NOTE] Image Generation Status: Diagrams illustrating the 'Estrogen Withdrawal' effect are queued.
HRT Golden Rules
- Uterus Present? You MUST give Progesterone to prevent Endometrial Cancer.
- LMP < 1 year? Give Sequential HRT (Daily Oestrogen + Progesterone for 14 days).
- LMP > 1 year? Give Continuous HRT (Daily Oestrogen + Daily Progesterone).
- No Uterus? Give Oestrogen Only (Unopposed).
- Average Age: 51 years.
- Early Menopause: 40-45 years.
- Premature Ovarian Insufficiency (POI): < 40 years (1% of women). requires HRT until age 51 for bone/heart protection.
- Follicular Depletion: Ovaries run out of eggs.
- Hormone Crash: Oestrogen and Progesterone levels fall.
- Feedback Loop: Pituitary tries to stimulate ovaries -> High FSH and LH.
- Consequences:
- Vasomotor: Thermoregulatory zone narrows -> Hot flushes.
- Bone: Increased osteoclast activity -> Osteoporosis.
- Urogenital: Epithelial atrophy -> Dryness/Infection.
Vasomotor (75%)
Genito-Urinary Syndrome of Menopause (GSM)
Psychological
Musculoskeletal
- Blood Pressure: Check before starting HRT.
- BMI: Influences choice of route.
- Breast Exam: Screening up to date?
Diagnosis is Clinical in women > 45 years.
- Do NOT measure FSH if >45 with typical symptoms. It fluctuates wildly.
Indications for FSH testing:
- Women under 40 (Suspected POI).
- Women 40-45 with atypical symptoms.
- (Ideally done outcome of oral contraceptive pill for 6 weeks, or on day 2-5 of cycle).
A. Non-Hormonal / Lifestyle
- Diet: Calcium/Vitamin D.
- Exercise: Weight-bearing (Bone density).
- CBT: Effective for mood and flushes.
- Drugs: SSRIs (Venlafaxine), Clonidine, Gabapentin (for flushes - off label).
B. Hormone Replacement Therapy (HRT)
The most effective treatment for symptoms.
1. Route
- Transdermal (Patch/Gel/Spray): Safest. No First Pass metabolism. No increased VTE risk. Preferred for BMI >30, Smokers, Migraine, History of VTE.
- Oral (Tablets): Cheap. Convenient. Slight increase in VTE risk.
2. Regimens
- Estrogen Only: For women generally without a uterus.
- Combined Sequential: Estrogen daily + Progesterone 10-14 days/month. (Causes withdrawal bleed). For Perimenopausal women.
- Combined Continuous: Both hormones daily. No bleed. For Postmenopausal women (>1y no period).
3. Progesterone Types
- Micronised Progesterone (Utrogestan): Body identical. Lower breast cancer risk.
- Mirena Coil (IUS): Excellent option. Provides bleeding control + contraception + endometrial protection.
C. Local Oestrogen
- Vaginal Pessaries/Creams.
- Safe for everyone (minimal systemic absorption).
- Treats dryness/UTIs effectively. Can be used alongside systemic HRT.
The Million Women Study vs Modern Evidence:
- Breast Cancer:
- Estrogen Only: Little/No increased risk.
- Combined: Small increased risk (4 extra cases per 1000 women over 5 years). Risk reduces after stopping.
- Obesity/Alcohol increase risk more than HRT.
- VTE (Clots):
- Oral HRT doubles risk.
- Transdermal HRT has NO increased risk.
- Cardiovascular: "Timing Hypothesis" - HRT started early (<60) is protective. Started late (>60) may increase stroke risk slightly.
- Symptoms average duration: 7 years. (Some women have them for decades).
- HRT significantly improves Quality of Life and prevents Osteoporosis.
- NICE NG23: Menopause: diagnosis and management (2015).
- British Menopause Society (BMS): Consensus statements.
Do I need need hormone therapy? If your symptoms (hot flushes, brain fog, poor sleep) are affecting your life, HRT is the best treatment. It is very safe for most women under 60.
What about the cancer risk? The media scared many women in the past. The truth is:
- The risk of breast cancer is very small (less than the risk of being overweight or drinking 2 glasses of wine a night).
- If you don't have a womb, the risk is almost zero.
Will I gain weight? There is no evidence HRT causes weight gain. Menopause itself slows metabolism, so weight gain happens anyway, but HRT doesn't add to it.
Which type should I take?
- Patches/Gel: Are safest (no risk of blood clots).
- Tablets: Are easy to take but have a tiny clot risk.
- Mirena Coil: Great if you also need contraception or have heavy periods.
Can I take it forever? There is no arbitrary limit. You can take it as long as the benefits outweigh the risks for you.
- NICE. Menopause: diagnosis and management [NG23]. 2015.
- British Menopause Society. BMS & WHC's 2020 recommendations on hormone replacement therapy in menopausal women.
- Rossouw JE, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women. (WHI Study - controversial but landmark). JAMA. 2002.