Menopause occurs when the ovaries become less responsive to FSH (follicle-stimulating hormone) and ovulation subsequently ceases.
Symptoms of menopause occur before the menopause itself. Oestrogen production gradually declines to a stop, by this time ovarian function has also declined. Symptoms tend to occur when women are in their mid 40s, although the menopause itself generally tends to take place when women are about 50 years old. This can differ quite widely in women with different lifestyles, health status and also genetic factors.
When assessing patients it is important to note the date the patient first encountered symptoms, details of last period, such as flow, duration, anything unusual. If there was abnormal bleeding, this would need to be investigated. It is important at this stage to find out what the patient’s views/concerns regarding menopause are, whether they use herbal remedies, what form of contraception they use (this will need to be continue for 2 years after the last period if the woman is under 50 and for one year after the last period if she is over 50). Current HRT use needs to be noted as does any risk factors for cardiovascular disease and osteoporosis, or any contraindications for HRT.
It is important at this point to check cervical screening is up to date, carry out breast and pelvic examination if necessary, also check BMI, BP and waist/hip ratio.
Common symptoms of menopause include hot flushes/night sweats; these affect about 4/5 of women. There may also be a decrease in libido, palpitations, interrupted sleep patterns, and weight gain.
Because of the changes occurring in the body, increases may occur in LDL and a decrease in HDL which increases the risk of cardiovascular disease.
Diagnostic blood tests can be carried out but hormones will naturally be fluctuating at this time so they may be of limited value.
TFT helps to exclude thyroid disease which can present similar symptoms to the initial stages of menopause.
Lipid levels need to be checked as these may be increased at menopause, increasing the risk of cardiovascular disease.
Hormone tests as mentioned may be of limited use, but include FSH (which is likely to fluctuate). FSH and LH ought to be taken on days 2-4 of the cycle, if known, or if unknown, two blood samples can be taken two weeks apart.
Depending on the symptoms a woman experiences, certain modifications in lifestyle may be in order. Diet assessment and advice may be required as weight is often increased at menopause, increasing the risk of CVD. Exercise needs also to be encouraged as it helps keep weight down, decreases the risk of CVD as well as osteoporosis (by increasing bone density). Weight decrease has also an effect on decreasing hot flushes. Hot flushes can also be minimised by avoiding hot/spicy foods and wearing light clothing.
HRT is generally effective for women who are experiencing urogenital, vasomotor and psychological symptoms of menopause. These may include:
- Urogenital – urinary frequency. urgency, stress and urge incontinence, decreased libido, painful sex or post-coital bleeding, decreased lubrication, itching/irritation.
- Vasomotor – hot flushes, night sweats, palpitations, interrupted sleep patterns, or insomnia, tachycardia, faintness, nausea, shivering.
- Psychological – anxiety, irritability, mood swings, depression, loss of self-esteem, deterioration in memory.
It is best practice to use the lowest strength hormone for the shortest possible period, although withdrawal from HRT can lead to symptoms returning. There are a variety of products available administered via a variety of routes, which requires informed discussion with the patient.
Continuous combined HRT contains oestrogen and progestogen; it is taken orally once daily and after the first 6 months should stop bleeding completely. Transdermal patches are also available.
Women who have had a hysterectomy should be given oestrogen-only HRT which can be given in the form of implants, patches, gel, or tablets.
For women who have a history of endometriosis, progestogen may need to be taken.
Sequential HRT enables a scheduled bleed as it is taken orally for 12-14 days.
A mirena coil can be fitted to provde progestogen, this prevents bleeding and also can be used as a contraceptive. If the coil is used for HRT as well as contraception it will need to be changed 4-yearly rather than 5-yearly.
Vaginal oestrogen can be administered as a cream and this has the added benefit of helping with urogenital symptoms.
Testosterone tends to be used in the form of patches/implants particularly in women experiencing a loss of libido.
There are risks associated with HRT; CHD, DVT/PE, breast cancer and CVA. Therefore all treatment options must be considered prior to commencement.