What are the symptoms of the menopause❓ 

 Hot flushes 😰

 Night sweats 💤

 Mood changes (low mood/anxiety) 

 Difficulty/disturbances sleeping 💤

 Cognitive disturbances (memory loss/difficulty concentrating) 

 Libido loss (sex drive) 

 Irregular menstruation 

 Dry vagina  

 Urination problems 💧

 Aches and pains of joints/muscles 

How is the menopause diagnosed❓ 

1. Usually based on the clinical symptoms & age; but beware the following;
   
2. Abnormal bleeding needs investigating 
3. Consider differential diagnosis 
4. Arrange Follicle Stimulating Hormone for patients if: 
5. < 40: premature menopause (2 separate results, > 30 IU/L, between 4 and 8 weeks apart) 
6. < 45: early menopause (2 separate results, >30 IU/L, between 4 and 8 weeks apart) 
7. > 50: wants to stop taking hormonal contraception (1 > 30 IU/L result – patient can stop taking hormonal contraception in 12 months) 

How is the menopause treated❓ 

Lifestyle changes: 

 Regular exercise 🚴

 Relaxation exercise 

 Stress reduction ⬇ 

 Decrease alcohol intake 

 Smoking cessation 🚬

 Healthy BMI 

 Improve sleep hygiene 💤

 Avoid vasomotor symptoms (e.g. spicy food) 

HRT (Hormone Replacement Therapy): 

 Fist line therapy for low mood and vasomotor symptoms 

 Also beneficial for musculoskeletal symptoms, low sex drive, bone mineral density and urogenital atrophy 

HRT alternative options: 

 CBT – beneficial for low mood and anxiety symptoms 😢

 Isoflavones – can be beneficial for hot flushes 😰

 Avoid SSRIs, SNRIs and clonidine as first line therapy 

Are there any contraindications to HRT❓ 

 History of breast cancer or oestrogen-rich tumour 

 Bleeding of vagina which is undiagnosed 

 Arterial thromboembolic disease 

 Thrombophillia  

 Endometrial hyperplasia which is untreated 

 Current/recurrent VTE 

 Liver disease 

What are the risks of HRT❓ 

Breast cancer:  

 Risk from lifestyle choices likely greater than from HRT 🚬

 Greater risk with combined HRT than oestrogen only HRT 

 Micronised progesterone likely safest progestogen 

VTE:  

 Risk increased by HRT ⬆ 

 Oral HRT preparations increase risk ⬆ 

 Micronised progesterone likely safest progestogen 

CVD (Cardiovascular disease):  

 Post-menopausal women most commonly die of CVD 

In women <65, HRT does NOT increase risk 

 HRT may be cardioprotective in younger women 

Stroke (CVA):  

 Oral HRT increases risk (transdermal HRT preparations are safest) ⬆ 

Ovarian Cancer: 

 Risk slightly increased by HRT ⬆ 

What are the different types of HRT❓ 

What type of HRT should I offer my patient❓ 

When should I review menopause treatment❓ 

 3 months after you start treatment 📅

 Annually thereafter 

What should I look for when reviewing a patient❓ 

1. Ask the patient about any side effects, symptoms and indications 
2. Check patient’s blood pressure, BMI and screening 

What if I identify problems when reviewing a patient❓ 

 Heavy bleeding on sequential HRT – increase progestogen dose/duration 

 Bleeding on combined HRT – if remains after 3 to 6 months of it, try sequential HRT instead 

 Persistent bleeding more than 6 months after starting HRT – investigate the reason for this 

 Side effects caused by progestogen – try alternative progestogen or IUS 

Summary:

1. There are many symptoms of menopause which you should be aware of
2. Menopause is usually diagnosed based on clinical symptoms and age
3. Treatments: lifestyle changes, HRT or alternatives 
4. HRT risks: breast cancer, VTE, cardiovascular disease, stroke, ovarian cancer
5. There are 3 types of HRT: oestrogen only, sequential combined and continuous combined 
6. You should review treatment 3 months after starting and annually thereafter