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Menopause: Diagnosis and management

By Mindo - 21st Jan 2025


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Module Title
Menopause: Diagnosis and management
Module Author
Dr Genevieve Ferraris
CPD points
2
Module Type
Tutorial

Menopause and perimenopause

What is the menopause?

For most women, menopause is the natural conclusion of her reproductive life cycle. Periods come to a gradual halt as ovarian function declines and hormone production eventually stops. All women will go through menopause, and by age 54 more than 80 per cent of women will be menopausal. Menopause marks an important stage in a woman’s life, with changes in bleeding patterns, hormone levels, body composition and psychosocial wellbeing.

Important definitions:

  • Menopause: The permanent cessation of menstruation due to loss of ovarian follicular activity. It occurs with the final menstrual period but is recognised after 12 consecutive months of amenorrhea for which no other physiological or pathological cause is present. The average age of menopause for women in the UK is 51 years.
  • Perimenopause: The stage leading up to the final menstrual period where a woman experiences menstrual irregularity and menopause symptoms. This is due to ovarian dysfunction and fluctuating hormone levels. Most women start to undergo perimenopausal symptoms from 45.
  • Induced/iatrogenic menopause: Cessation of menstruation due to either surgical removal of ovaries, or ablation of ovarian function due to chemotherapy, radiotherapy or GNRH analogues. Non-surgical induced menopause may be temporary or permanent.
  • Premature ovarian insufficiency (POI): The cessation of ovarian function and onset of menopause in women aged below 40 years. This can have long-term health and psychosocial implications.
  • Early menopause: Menopause which occurs between the ages of 40 and 45 years.

Stages of reproductive ageing:

The Stages of Reproductive Ageing Workshop (STRAW) staging system is considered to be the gold standard for characterising reproductive ageing from menarche through to menopause. It was established in 2001 as a way to characterise the last 10-15 years of a women’s reproductive ageing. It divides this into seven stages; five preceding and two following the final menstrual period. Stages -5 to -3 encompass the reproductive interval, stages -2 and -1 are the menopausal transition and stages 1 and 2 are post menopause. This is shown in the table below:

StagePhaseDurationPrincipal criteriaSupportive criteriaDescriptive characteristics
-5 to -3bEarly to late reproductive stageVariableRegular menstrual cycles with subtle changes in flow/lengthLow antral follicle count, FSH and AMH levels vary, low inhibin BMinimal symptoms
-3a to -2Early to late perimenopause transition1-3 yearsCycle length variability (≥7-day variation)Low antral follicle count, increasing FSH (>25 IU/L during late transition), low AMH and inhibin BVasomotor symptoms likely
-1Late perimenopause transition~1 yearInterval of ≥60 days of amenorrhoeaFSH levels elevated, AMH very low, inhibin B lowVasomotor symptoms most likely
0Final menstrual periodDetermined retrospectively after 12 months of no menses
+1a to +1cEarly post-menopause2-6 yearsAmenorrhoea persists, menstrual cycles ceaseFSH stabilises at high levels, AMH very low, inhibin B lowVasomotor symptoms, increasing urogenital atrophy symptoms
+2Late post-menopauseRemainder of lifeStable FSH at high levels, very low AMH and inhibin BPredominance of urogenital atrophy symptoms

Table 1: The Stages of Reproductive Ageing Workshop (STRAW) +10 Staging System

Key features:

  • FSH (follicle-stimulating hormone): Elevated during menopause transition.
  • AMH (anti-Müllerian hormone): Declines consistently as ovarian reserve diminishes.
  • Symptoms: Vasomotor symptoms (eg, hot flashes) occur most frequently during menopause transition and early post-menopause, while urogenital atrophy becomes prominent in later stages.

Although this approach provides a reproducible, evidence-based, standardised classification system there are certain limitations. It does not apply to women who have had a hysterectomy, have polycystic ovarian syndrome (PCOS), hypothalamic amenorrhoea or iatrogenic menopause.

Symptoms

Acute menopausal symptoms, which occur in up to 90 per cent of women, occur due to declining oestrogen levels. Women may experience both physical and psychological symptoms, starting from perimenopause.

Interestingly, menopausal symptom reporting varies between cultures. Japanese women, for example, report fewer and less severe vasomotor symptoms than their North American counterparts. The reasons behind variations in symptom prevalence are not well understood, but evidence suggests factors such as diet, smoking, exercise, reproductive history, genetics, climate, socioeconomic status and attitudes and beliefs towards menopause may all contribute.

The average duration of menopausal symptoms is seven-to-nine years, although some women may experience symptoms into their 60s.

Physical symptomsPsychological symptomsGenitourinary symptoms
Vasomotor symptoms (hot flushes and night sweats), insomnia and poor sleep, arthralgia, lethargy and fatigue, brain fog, dry skin, hair and nails, headaches, change in menstrual cycleLow mood, anxiety, irritability, mood swings, worsening PMSVaginal dryness, dyspareunia, urinary frequency and/or urgency, recurrent UTIs

Table 2Menopausal symptoms

It is important to note that women in perimenopause can be as symptomatic as women in menopause even though they are still menstruating. Of note though is that vasomotor symptoms tend to be more prevalent in the first year after the last menstrual period.

Diagnosis of perimenopause and menopause in otherwise healthy women over the age of 45 years should be based on symptoms alone. This would include change in menstrual cycle or cessation of periods, and symptoms listed above. Blood tests, including FSH, AMH and oestradiol (oestrogen) levels should not routinely be used to diagnose menopause unless you suspect the patient to have early menopause or POI. The diagnosis of POI should be made based on the presence of oligo-/amenorrhea PLUS elevated FSH levels on two occasions, taken four-to-six weeks apart.

Long-term health impact

Due to changes in population dynamics and longer life expectancy, it is now estimated that women will spend at least a third of their life beyond the menopause transition. Long-term consequences of both ageing and oestrogen deficiency can have significant impact on women’s wellbeing and may increase their risk of certain diseases.

Cardiovascular disease

Cardiovascular disease (CVD) is the leading cause of death worldwide in both men and women. Oestrogen is known to have a beneficial effect on cardiovascular health in women, and as a result pre-menopausal women have a lower risk of heart disease compared to age-controlled men. However, the rate of CVD increases after the menopause, which is believed to be due to the drop in circulating oestrogen levels.

Other cardiovascular risk factors, which may also increase around the menopause transition, include:

  • Smoking
  • Hypertension
  • Dyslipidaemia
  • Abdominal obesity and elevated BMI
  • Diabetes and insulin resistance
  • Sedentary lifestyle
  • Psychosocial factors

Observational studies have shown that oestrogen has a protective effect against coronary heart disease in pre-menopausal women, however these findings were not replicated in the Women’s Health Initiative (WHI) trial. More recent studies including the KEEPS, DOPS and ELITE trials have showed a lower rate of atherosclerosis progression in early pre-menopausal women with the use of HRT, but not in the late postmenopausal group. These findings support the ‘window of opportunity’ theory that the positive effect of oestrogen may have on CVD is influenced by the timing of when HRT is initiated. It is important to note however that the use of oestrogen therapy is not indicated for the primary prevention of CVD. Lifestyle modification and risk-reduction strategies, like statin-therapy, should be considered over HRT.

Osteoporosis

Osteoporosis is a generalised skeletal disorder characterised by low bone mass and architectural deterioration, resulting in bone fragility and increased risk of fractures. The risk of osteoporosis increases with age, although genetics, nutrition status, BMI, certain medication and medical conditions, smoking and alcohol use also influence that risk. Men tend to have a higher peak bone mass compared to women, and as a result generally develop osteoporosis at a later stage in life. Women also experience an accelerated decline in bone mass during menopause, at a rate of approximately 2 per cent per year. Post menopause this rate slows to about 1 per cent per year.

The best strategy therefore for prevention of osteoporosis is to maximise peak bone mass and reduce the rate of bone loss. This can be achieved through a diet with adequate calcium and protein, adequate sun exposure for vitamin D formation, maintaining a normal BMI and regular exercise.

Hormone replacement therapy (HRT) has been shown to be effective at preserving bone density and reducing the risk of spine, hip and other osteoporotic fractures. HRT should be considered as first-line therapeutic intervention in women under the age of 60 who have osteoporosis and symptoms of menopause.

Cognition

Cognitive symptoms, often referred to as ‘brain fog’, are common in perimenopause and menopause. They can impact work and relationships, and many women may be concerned that they are developing dementia due to difficulties in remembering and concentrating.

However, menopausal cognitive symptoms tend to be subtle and fluctuating – obvious and concerning changes should be investigated.

Menopause symptoms themselves can also contribute to cognitive difficulties – anxiety and depression are linked with lower processing speeds; insomnia is associated with poorer memory and attention; and there appears to be a link between hot flushes and memory performance.

Observational data show that some activities and lifestyle changes may benefit memory or help protect against dementia. These include physical activity, stopping smoking and reducing alcohol intake, managing high blood pressure, hyperlipidaemia and diabetes, and maintaining a wide social network.

On the basis of current evidence, HRT should not be prescribed to treat cognitive symptoms alone, nor should it be initiated for the primary purpose of prevention of dementia.

Hormone replacement therapy – benefits and risks

HRT, also known as menopause hormone therapy (MHT), is proven to be the most effective treatment for the symptoms of menopause. It should be considered first-line therapy for the treatment of vasomotor and genitourinary symptoms, and may improve other menopause-related symptoms like mood changes, joint pains, sleep disturbances and sexual dysfunction.

There is also good evidence that HRT reduces the risk of osteoporosis and cardiovascular disease in women who go into an early menopause. These women should be offered HRT at least until the natural age of menopause (51). HRT can be used in perimenopausal and menopausal women, and can be continued for as long as the patient derives benefit (and the benefits outweigh risks). There is no longer an arbitrary cut-off time for HRT.

The mainstay of HRT is oestrogen, as this is what is effective at controlling menopausal symptoms. Oestrogen may be administered orally or transdermally, and there are various preparations available. The decision of which product to use depends on both patient preference and risk factors.

As transdermal oestrogen is not metabolised through the liver it has a neutral effect on a woman’s clotting profile, and does not increase her risk of experiencing a venous thromboembolic event (VTE). Therefore, patients who are already at a higher risk of VTE should be offered transdermal oestrogen only. Transdermal oestrogen can be prescribed in women in whom oral oestrogen may be contraindicated (eg, gallbladder disease, obesity, migraine). Oestrogen is administered on a continuous basis, regardless of whether or not a woman is still having periods.

In patients with an intact uterus, progestogen must be given to the patient alongside the oestrogen. This is because oestrogen stimulates the endometrium, and over time unopposed oestrogen is a risk factor for endometrial hyperplasia and endometrial cancer. Progestogens may come in the form of natural microionised progesterone capsules, or synthetic progestogen tablets, patches or the intrauterine progestogen releasing system. Microionised progesterone has some advantage over synthetic progestogens in that it has a lower VTE risk, and slightly lower breast cancer risk.

There are two progestogen regimens – cyclical or continuous. The decision of which regimen to use depends on whether a woman is still having periods. In a perimenopausal patient (ie, still having periods, even if irregular) we should use a cyclical regime for progestogen – this means she will take a progestogen for 14 days out of every 28-day cycle. In women who have been amenorrhoeic for over 12 months or more we use continuous progestogen. The levonorgestrel releasing intrauterine device (Mirena®) is licensed for the use of HRT for five years and is a good progestogen option for women who still require contraception and/or those that experience heavy menstrual bleeding. Of note, continuous progestogen administration confers slightly better endometrial protection compared to cyclical, and so in women over 50 who have been on cyclical HRT for over a year we should consider moving to a continuous regimen even if they are still having periods.

Testosterone may be prescribed alongside oestrogen and progesterone. Levels of testosterone naturally decline in women in menopause, however not all women are symptomatic of low testosterone. Testosterone therapy may be considered for women who are on HRT and continue to experience low libido which causes distress and for which there are no other causes. Some studies have shown benefits on the skeleton, cognition and wellbeing, but these require further assessment and currently testosterone should not be prescribed for these reasons. There are currently no licensed testosterone preparations for women in Ireland and the UK. Irish Medical Council (IMC) guidance on the prescription of unlicensed medication should be consulted when prescribing.

Total testosterone levels should be checked at six-12 weeks from starting testosterone therapy. Levels should be maintained at physiological levels (ie, total testosterone <2). Adverse effects are uncommon if levels are maintained within this. The most common side effects are acne, excess hair growth in areas of gel application and weight gain. These are reversible with discontinuation of product. It can take three-to-six months for women to feel benefit of use with testosterone. If there is no improvement in symptoms beyond six months, testosterone should be discontinued.

What are the benefits of HRT?

HRT is the most effective treatment of menopause symptoms, with significant improvement of those symptoms and better quality of life. It also improves bone density and reduces the risk of osteoporosis, and when started within 10 years of the last menstrual period it reduces the risk of cardiovascular disease and mortality.

It should be also be used in women who experience POI and early menopause, even if they do not have menopausal symptoms, to reduce their risk of osteoporosis and cardiovascular disease, and may be used as treatment of osteoporosis in symptomatic menopausal women below the age of 60.

What are the risks of HRT?

Many women and healthcare professionals may be worried about the risk of breast cancer with HRT use. Current evidence suggests that oestrogen-alone HRT is associated with little or no risk, while combined HRT can be associated with an increased risk but may vary depending on type of progesterone used. Large observational trial data suggest that micro-ionised progesterone and dydrogesterone are likely to be associated with a lower risk of invasive breast cancer compared to other progestogens. It is however worth noting that the risk of breast cancer overall is low in both medical and statistical terms, particularly compared to other modifiable risk factors such as alcohol intake and smoking. The risk should be taken into context of the individual patient and the overall benefits obtained from HRT.

HRT is contraindicated in women with a personal history of breast cancer, and some types of ovarian cancer. It may also not be suitable in women who have had a clot, cardiovascular event or stroke, or with a strong family history of breast cancer. However, these cases are more nuanced and the decision to prescribe HRT (or not) depends on a variety of factors.

Non-hormonal treatments for menopause symptoms

In women who cannot, or choose not to, take HRT, non-hormonal therapies should be offered and discussed. These include pharmacological and non-pharmacological options as outlined below:

  1. Non-pharmacological therapies

Cognitive behavioural therapy (CBT) has good evidence to support its use. It can reduce vasomotor symptoms, insomnia and depressive symptoms associated with menopause and may be used as a stand-alone intervention or alongside pharmacological therapies.

Mindfulness-based interventions including mindfulness-based stress reduction (MBSR) have been shown to have positive effects on menopause symptoms broadly, with mixed effects on VMS specifically. However, as the studies for this were small there is not enough data currently to recommend it.

While lifestyle measures like exercise, yoga and weight loss have other benefits, their efficacy specifically to treat menopause symptoms has been found to be limited.

  • Pharmacological therapies

There are currently only two US FDA-approved non-hormonal medications to treat vasomotor symptoms – paroxetine mesylate 7.5mg daily (not available in Ireland currently) and fezolinetant 45mg daily (licensed and available in Ireland). Other medications that can reduce VMS include other selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), oxybutynin and gabapentin. Clonidine is no longer recommended due to its side-effect profile and the fact that more effective therapies exist.

Fezolinetant is a relatively new medication. It is an NK3 receptor antagonist and works in the brain to stop the origin of vasomotor symptoms. However, it is not yet licensed for use in women who have had previous breast cancer.

Lifestyle

The menopause transition should be seen as a time to discuss and review healthy lifestyle interventions with patients. The focus should be around protecting bone and cardiovascular health, maintaining a healthy BMI, and reducing exposure to carcinogens.

These include:

  • Exercise
    • 150 mins of moderate intensity exercise per week is recommended. Ideally patients should combine cardiovascular exercise, resistance training, and stretching in order to get bone, cardiovascular, and mental health benefits. However, this may not be achievable for some patients and they should be guided to participate in exercise which is enjoyable and accessible for them.
  • Diet
    • A Mediterranean-type diet has numerous health benefits including reduction in cardiovascular disease, improved lipid and blood sugar profiles, reduced risk of cognitive decline and effective weight management.
    • It is rich in whole, minimally-processed foods and emphasises plenty of fruits, vegetables, whole grains, lean proteins and healthy fats.
  • Reducing alcohol intake
    • Alcohol increases hot flushes and has been shown to increase the risk of breast cancer. Women should try to reduce their intake to two units or less a day, and to keep at least one night a week alcohol free.
  • Stopping smoking
    • Smoking has been shown to increase the risk of an earlier menopause and can also trigger hot flushes.
    • It is also linked to increased risk of osteoporosis and cardiovascular disease, as well as various cancers.
  • Stress management
    • These include mindfulness techniques, yoga and meditation to reduce stress levels and anxiety.

Conclusion

As menopausal awareness increases, more women are seeking assistance from their primary healthcare providers. GPs should feel comfortable discussing menopause with patients, knowing who needs workup as appropriate, and prescribing HRT or non-hormonal therapies where needed. Menopause, whilst a normal part of a woman’s reproductive life, can have significant physical and psychosocial implications and she should be supported appropriately through it. It may also be a time where her risk for other diseases like osteoporosis or CVD increases, and so health education in this population is very important.

Useful resources:

ICGP menopause guidance: https://www.irishcollegeofgps.ie/Home/Clinical-Hub/Clinical-Topics/Sexual-Reproductive-Health

ICGP menopause resources for patients:

Menopause Patient Information

https://icgpnews.ie/menopause-patient-information/embed/#?secret=JcVYYeDGzD#?secret=AaRVnVd57Q

Menopause Patient Information

https://icgpnews.ie/menopause-patient-information/embed/#?secret=JcVYYeDGzD#?secret=AaRVnVd57Q

HSE menopause information for patients:  https://www2.hse.ie/conditions/menopause/ or https://rotunda.ie/menopause-clinic/

British Menopause Society: https://thebms.org.uk/

Start this Module to earn CPD Points today

Click the "Start Module" button below

Module Title
Menopause: Diagnosis and management
Module Author
Dr Genevieve Ferraris
CPD points
2
Module Type
Tutorial

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