Menopause

Dr ZharifHussein
O&G Specialist MetroIVF
-Special interest in infertility-
Background and prevalence

Definition : when menstruation ceases permanently owing to the loss of ovarian follicular activity. It is diagnosed with certainty after 12
months of spontaneous amenorrhoea.

The average age of menopause is 52 years.

Peri-menopause is the period before the menopause when the endocrinological, biological, and clinical features of approaching
menopause commence because of decreasing oestrogen Levels.

Premature ovarian insufficiency (POI) is less than 40 years old & Early menopause - 40 till 45 years old

Hot flushes occur in 70–80% of peri-menopausal women. They are most common in the first year after the final menstrual period.
Vaginal symptoms occur in about 30% of women during the early post-menopausal period and in up to 47% of women during the later
post-menopausal period.
Only 10% seek medical advice.
Risks or complications

Affect Quality of life

Vasomotor symptoms( Hot flushes) and vaginal symptoms( dryness, discomfort, itching, and dyspareunia) - up to 2-
5 years.

Risk of chronic disease:

* Risk of osteoporosis,Uv prolapse ,urogenital atrophy, cardiovascular disease, and stroke all increase.

* Dementia(unclear)
Assessment at primary care

• Assess the stage of menopause

• Assess the symptoms
• Determine severity of the symptoms and the extent to which they are affecting
the woman’s QOL.
• Discuss woman’s expectations.
• Assess the risk of cardiovascular disease and of osteoporosis.
• Rule out any contraindications (history of breast cancer, VTE).
• Discuss the risks and benefits of HRT.
• Record BMI and BP.
Assessment at primary care

Breast examination
Pelvic examination
Investigations are not routinely indicated.
Women who are not suitable for HRT or do not want to use HRT discuss alternatives to
HRT.
Tthe national cervical screening programme.
Discuss the perceived benefits and possible risks for their individual situations,
including consideration of alternative therapies.
Discuss the risk of VTE and the signs and symptoms of VTE.
Advise to access medical help if suspect thrombosis.
History &symptoms

• Menstrual cycle change.

• Most common symptoms are hot flushes, night sweats, vaginal dryness, and sleep disturbance.
• Urinary and vaginal symptoms, such as vaginal discomfort and dryness, dyspareunia, and
recurrent lower urinary tract infection, are common in the menopause.
Contraindications to starting HRT

• Hormone-dependent cancer
• Active or recent arterial thromboembolic disease
• VTE, PE.
• Severe active liver disease.
• Undiagnosed breast mass.
• Uninvestigated abnormal vaginal bleeding
Investigations

Do not offer routine investigations before starting HRT unless:

• Change in menstrual pattern, IMB, PCB, or PMB: consider an endometrial assessment.
• Personal or family history of VTE: consider a thrombophilia screen.
• High risk of breast cancer: mammography or MRI as appropriate for the woman’s age.
• Woman has arterial disease or other risk markers for arterial disease: a lipid profile may be useful.
FSH & LH level

• Measurement of FSH may be useful in (≥ 2 occasions at least 1–2 months apart):

1. * Women < 45 years of age with suspected POI.
2. * Women who have had a hysterectomy with ovarian conservation before 40 years of age.
3. * Women using hormonal contraception. As the COC suppresses gonadotrophins, a low
level may be impossible to interpret.
Routes and regimens

• Oestrogen
• Progestogen
Progestonic side effects

Non-hysterectomized women require 12–14 days of progestogen to avoid endometrial hyperplasia

and
minimize the risk of endometrial cancer with unopposed oestrogen.
• One of the main factors for reduced compliance with HRT is that of progestogen intolerance.
• Progestogens – symptoms of fluid retention are produced by the sodium-retaining effect of the
renin–aldosterone system, triggered by stimulation of the aldosterone receptors.
• Androgenic side effects such as acne and hirsuitism are a problem of the testosterone-derived
progestogens owing to stimulation of the androgen receptors.
• Mood swings and PMS-like side effects result from adverse stimulation of the central nervous
system progesterone receptors.
• Dose can be halved and duration of progestogen can be reduced to 7–10 days to minimize
progestogenic side effects. This may result in bleeding problems and hyperplasia, so keep a low
threshold for ultrasound scanning and endometrial sampling if clinically indicated.
Benefits of HRT – immediate effects of HRT

Vasomotor symptoms –
Mood – short-term use of HRT may improve mood and
depressive symptoms
Urogenital symptoms – oestrogen has a proliferative effect
on the bladder and urethral epithelium and may help relieve
symptoms of urinary frequency, urgency, and possibly reduce
the risk of recurrent UTIs in women with urogenital atrophy.
Musculoskeletal effects – Oestrogen therapy has a protective effect against connective
tissue loss and may possibly reverse this process in
menopausal women receiving HRT.
Colorectal cancer – reduced risk of colorectal cancer with the use of oral combined
HRT.
Long-term effects of HRT

Osteoporosis
• HRT is effective in preserving bone density and preventing osteoporosis in both spine and hip, as well as
reducing the risk of osteoporosis-related fractures.

Cardiovascular
• Early cohort studies suggested that HRT is associated with a significant reduction in the incidence of
heart disease, whether oestrogen alone or combined with progestogen.
• WHI – women using CEE 0.625 mg alone or with MPA 2.5mg had a small increase in incidence of
coronary heart disease in the first 12 months.

Cognition
• Observational data show an improvement in cognitive function with HRT started in early menopause and
a possible reduction in the long-term risk of Alzheimer’s
disease and all causes of dementia. Further evidence is needed to confirm this.
Risks of HRT

1. Breast cance
2. Endometrial cancer
3. Venous thromboembolism
4. Stroke
Refer women if:

Poor symptom control

• Review the woman and her expectations.
• There is multiple treatment failure. • Check that the HRT has been used for at least 3 months to
• Pattern of withdrawal bleeding or breakthrough bleeding ensure full
changes while effect.
taking monthly cyclical therapy. • Check that patches are adherent.
• There is breakthrough bleeding that persists for more than 4–6 • Consider an alternative diagnosis.
months or • Treatment options include increasing the oestrogen dose.
does not lessen while taking a 3-monthly regimen. • Adding vaginal oestrogen if urogenital symptoms are not
controlled.
• Switching from oral to a non-oral route (e.g., if absorption is
poor because
of a bowel disorder or if a drug interaction is present).
• Switching delivery system if patch adhesion is poor.
When to stop HRT

• If HRT is being used for symptom control consider a trial withdrawal (if a woman is
symptom-free) after 1–2 years.
• Symptoms may recur for a short time once HRT is stopped.
• Topical oestrogen may be required long term as symptoms can recur once treatment
is stopped.
• Stop treatment at least annually to re-assess the need for continued treatment.
Alternatives to HRT for the management of symptoms of the menopause (RCOG)

Lifestyle measures
• Aerobic exercise – limited evidence. Can improve psychological health, QOL, and can result in significant
improvements in vasomotor symptoms and other menopause-related symptoms (e.g., mood and insomnia).
Low-intensity exercise such as yoga may be beneficial. The best activity appears to be regular sustained
aerobic exercise such as swimming or running.
• Hot flushes and night sweats – take regular exercise, wear lighter clothing, sleep in a cooler room, and
reduce stress. Avoid possible triggers, such as spicy foods, caffeine, smoking, and alcohol. Smoking
cigarettes and having a BMI > 30 kg/m
increases the likelihood of flushing.
• Sleep disturbances – avoiding exercise late in the day and maintaining a regular bedtime.
• Mood and anxiety disturbances – adequate sleep, regular physical activity, and relaxation exercises.
• Cognitive symptoms – exercise and good sleep hygiene may improve subjective cognitive symptoms
 Thank You

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