The menopause is the last spontaneous menstrual period and is due to the
permanent cessation of ovarian function. The diagnosis is made in retrospect
permanent cessation of ovarian function. The diagnosis is made in retrospect
after 12 months of amenorrhoea. The fluctuations in hormonal levels associated
with declining ovarian function usually begin in the fourth decade and last
several years. This reproductive phase is called the climacteric, perimenopause
or more recently the menopausal transition.
- The average age of the menopause is 52 years and by age 54 years, 80% of
women will have stopped having menses. - Menstrual bleeding patterns change during the menopausal transition, with
regular menses being replaced by erratic anovulatory cycles and episodes of
amenorrhoea until the final menstrual period occurs
Consequences of the menopause - Physical, sexual and psychological symptoms are frequently reported in the
early stages of menopausal transition. - Although psychological symptoms are reported by many women, there is a
lack of evidence to support a causal relationship with the menopause. - Depression and anxiety may be related more to psychosocial issues such as
relationship or family problems, retirement or caring for elderly parents. - Mood changes can be secondary to sleep deprivation caused by night
sweats. - The aging process itself may be responsible for some of the symptoms
around the time of the menopause, e.g. decline in cognitive function
Symptoms - Occur due to the fluctuating and declining levels of hormones, and in
the decreasing estrogen levels; 70–80% of women in the UK will
experience menopausal symptoms. - Are usually self-limiting and resolve within 2–5 years, although vasomotor
symptoms persist for many years after the menopause in 10% of women
Can be debilitating in some women and severely impact on their quality of
life. - Long-term consequences of the menopause are osteoporosis, urogenital
atrophy and cardiovascular disease
Osteoporosis - Estrogen plays a central role in maintaining the skeleton and there is a rapid
decline in bone mineral density (BMD) following the menopause. - Almost 50% of women will have osteoporosis at 80 years of age and more
than one in three women will sustain an osteoporotic fracture in their
lifetime. The distal radius, neck of femur and thoracic spine (vertebral
compression fracture) are the commonest sites of fragility fractures. - Osteoporosis is often asymptomatic and only diagnosed when a fracture
occurs
Cardiovascular disease (CVD) - Following the menopause, there is a marked increase in CVD. The exact
mechanisms are still under debate as aging itself plays an influential role,
however menopause is associated with an increase in body weight,
redistribution of body fat and adverse changes to the lipid profile
Diagnosis of the menopause - The diagnosis is made clinically. Investigations are rarely required and
usually unhelpful. An exception would be FSH measurement in women
using hormonal contraception
Management of the menopause
- Hormone replacement therapy (HRT) aims to replace estrogen after the
menopause. Non-hysterectomized women require the addition of a
progestogen to provide endometrial protection. Following a decade of
uncertainty (primarily due to findings from the Women’s Health Initiative
(WHI) and Heart and Estrogen/Progestin Replacement Study (HERS))
regarding the safety and benefits of HRT, a global consensus statement was
produced in 2013 which has provided clarity around the role of HRT. - For symptomatic menopausal women who are under 60 years of age or
within 10 years of the menopause the benefits generally outweigh the risks. - HRT is the most effective treatment for vasomotor symptoms.
- Urogenital symptoms: estrogen treatment is effective in treating vaginal and
urinary symptoms related to atrophy. Low-dose vaginal preparations can be
used long term with no requirement for added progestogen as there is no
significant systemic absorption. - Osteoporosis: HRT prevents early postmenopausal bone loss and reduces
fractures in postmenopausal women. The bone protective effect is estrogen
dose related. - CVD: There appears to be a ‘window of opportunity’ whereby HRT
commenced below the age of 60 years or within 10 years of the menopause
reduces the incidence of coronary heart disease. - Stroke: the incidence of stroke (especially ischaemic strokes) is increased in
some studies but the evidence is conflicting and the HERS study found no
increased incidence of stroke with HRT. - VTE: oral HRT increases the risk of VTE 2-to 4-fold however the absolute
risk is small and appears to be associated with oral rather than transdermal
routes. - Breast cancer: The risk may be increased with use of combined HRT
preparations for more than 5years. The risk is related to many other factors
including family history and BMI and decreases after treatment is stopped. - Ovarian cancer: risk is uncertain although there may be a small increase
with use of HRT. - Cognition: evidence of the benefits of HRT is conflicting although some
studies have shown an improvement in cognitive function with HRT started
early in menopause
Routes
Oral, transdermal (patch, nasal spray, gel, cream) topical/intravaginal, the
intrauterine system; implants
Alternatives to HRT
Premature Ovarian Failure (POF) - POF occurs in 1% of women under 40 years and 0.1% under 30 years of
age. HRT is indicated until at least the average age of the natural
menopause and is simply replacing the hormones which would have been
produced at this age with no additional risks. HRT is necessary to control
symptoms and reduce the risk of long-term health consequences e.g.
osteoporosis
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