Menopause

Introduction to Menopause

Menopause refers to the point in time when permanent cessation of menstruation occurs due to loss of ovarian function.
The cessation of menses is preceded by a peri-menopausal phase during which there may be menstrual irregularity.
The age at onset is usually between 45 and 55 years. A woman is considered to be menopausal if there has not been menstruation for a period of at least 12 months in the absence of pregnancy.
Menopause may be associated with physical, emotional, and psychological upheaval of varying intensity in some women.
Sixty percent of menopausal women however have mild symptoms or are asymptomatic.
The risk of osteoporosis and cardiovascular disease increase after the menopause.

Causes of Menopause

Known causes of menopause include the following:

  1. A natural life event due to the ageing of the individual
  2. Surgical removal of the ovaries (bilateral oophorectomy) Pelvic irradiation
  3. Premature ovarian failure
  4. Pituitary damage from primary post-partum haemorrhage (Sheehan’s syndrome)
  5. Cytotoxic (anticancer) therapy

Symptoms of Menopause

Known symptoms of menopause include the following

  1. Hot flushes (heat or burning in the face, neck and chest with resultant sweating)
  2. The flushes may be associated with
    • Palpitations
    • Faintness
    • Dizziness
    • Fatigue
    • Weakness
  3. Emotional and psychological problems include:
    • Mood changes Depression
    • Anxiety
    • Nervousness
    • Irritability
  4. Loss of libido
  5. Vaginal dryness and dyspareunia
  6. Symptoms due to atrophic changes in the genital tract:
    • Increased frequency of micturition and dysuria.
    • Stress incontinence (urinary incontinence with coughing or straining)

Signs of Menopause

  • Usually none

Investigations

  • Serum LH, FSH, Oestradiol
  • Routine investigations e.g. FBC, blood glucose, lipid profile Urine or blood pregnancy tests (to exclude pregnancy)

Treatment of Menopause

Treatment objectives

The under listed points are the treatment objectives of menopause:

  1. To control bothersome symptoms e.g. severe hot flushes, atrophic vaginitis and recurrent cystitis
  2. To prevent cardiovascular morbidity
  3. To prevent osteoporosis especially in individuals with premature menopause

Non-pharmacological treatment

Non Pharmacological approach to treating menopause include the following:

  1. Counselling and reassurance
  2. Encourage active lifestyles, healthy diet, exercise and regular physical checkups for common medical problems

Pharmacological treatment

A. Hormone Replacement Therapy (HRT) for women with intact uterus

1st Line Treatment
Evidence Rating: [A]
Combined conjugated oestrogens and progestogen, oral, (28 tablets each containing conjugated oestrogens-625 micrograms including 12 tablets containing norgestrel-150 micrograms)

  • One tablet daily

Or

Conjugated oestrogen and norgestrel tablet, oral, (625 microgram and 150 microgram)

  • 1 tablet daily on days 17-28 of each 28-day treatment cycle;

B. Hormone Replacement Therapy (HRT) for women with previous hysterectomy

Evidence Rating: [A]
Conjugated oestrogens, oral, 625 microgram daily

C. For relief of vaginal symptoms only

Evidence Rating: [A]
Oestrogen cream, vaginal, apply topically once daily
Note

Women with intact uterus should never be given oestrogens alone.
Current evidence suggests that hormone replacement therapy in the meno pause does not prevent coronary heart disease or strokes.
HRT increases the risk of venous thrombo-embolic phenomena, breast cancer and endometrial cancer after prolonged use and should therefore be given for the shortest possible time whenever indicated.

Referral Criteria

Refer cases with osteoporosis or severe unremitting symptoms to  the specialist.