Menopause

Last updated 20.09.12

 

Definition

-  Cessation of menstrual periods (amenorrhoea) for 6 months in a women >40yrs

-  Premature = <40yrs old

-  Perimenopause = changes in pattern of menstruation, can last 2yrs+/-

-  Post menopause = amenorrhoea for 12 months

 

Features

-  Average age at 51yrs

-  1% women prior to 40yrs

-  Smoking & malnutrition may speed process

-  Abrupt decline in oestrogen producing S/S

-  Slow concurrent decrease in testosterone

-  Assocaited with

-  Increased serum cholesterol & LDL

-  Decrease in HDL

-  Insulin sensitivity

-  20% women asymptomatic

-  20% women severe S/S

-  20% women S/S for 5yrs+

-  For healthy women with severe S/S benefits outweigh risks for first 5yrs

 

Associated S/S

-  Menstrual irregularities

-  Short or long cycles

-  Irregular bleeding

-  Abdominal obesity

-  Hot flushes

-  Morning sweats

-  Poor memory & concentration

-  Mood swings

-  Irritability

-  Nervousness

-  Depression

-  Anxiety

-  Insomnia

-  Vaginal dryness, dyspareunia

-  Decreased libido

-  Pruritis vulvae

-  Urinery frequency or urgency

-  Recurrent cystitis

 

Complications

-  Osteoporosis

-  Loss of 1-2% BMD per year after menopause

-  Cardiovascular disease

-  Risk approaches male risk after menopause

-  Stroke

-  Dementia

-  Alzhiemers disease

-  Breast & Colon Ca

-  PMB

 

DDx

-  Hyperthyroidism

-  IDA

-  Depression, anxiety

 

Ix

-  FSH

-  +/- TFT: exclude Hyperthyroidism

-  +/- BMD: Osteoporosis

-  +/- Fasting Glucose: exclude DM2

-  +/- Iron Studies: exclude IDA

 

Mx

Continue Pap smears

-  Until 70yrs old then cease if normal for last 5yrs

-  If Hysterectmoy only need if never screened, still have cervix or previous changes

-  Lifestyle

-  Regular exercise

-  Quit smoking

-  Reduce EtOH

-  Psychosocial support

-  Stress management

-  Premature Menopause

-  Specialist referral

-  Will generally require ongoing HRT until 50yrs+/-

-  At higher risk of complications

-  Perimenopausal

-  COC

-  Mirena

-  Early post menopausal (<12/12 amenorrhoea)

-  +/- COC

-  Cyclical HRT

-  Postmenopausal

-  HRT

-  Tibolone

-  Oestrogen only

-  Combined Oestrogen & Progesterone (cyclical or continuous)

Urogenital atrophy: topical oestrogen

-  Contraindicated if breast Ca

-  Does not need opposition with PG

-  If breast Ca use OTC moisturiser Replense

-  HRT alternatives for hot flushes

-  SNRI

-  Venlafaxine 37.5-75mg PO Daily (may paradoxically cause flushes)

-  SSRI

-  Some are contraindicated if on Tamoxifen (enzyme inducing)

-  Paroxetine

-  Gabapentin 100mg PO Daily 3/7, to BD, TDS (900mg/day max)

-  Clonidine 25mcg PO BD 2 weeks up to 75mcg BD (max)

-  Testosterone cream (not TGA approved)

Osteroporosis

-  Weight bearing exercise

-  +/- Bisphosphanates

-  +/- Raloxifene

-  HRT

Cardiovascular disease risk prevention

-  Healthy lifestyle

-  Control HTN, DM, lipids

-  +/- HRT (controversial)

-  Increased risk if commenced 70yrs+

-  Likely decreases risk if used in 50s

F/U

-  2-3/12 post commencemt of Rx: side effects

-  6 monthly to annual R/V: dose titration

-  Annual breast exam if on E+P & 2yearly mammography

 

 

 

References

 

  Australian Menopause Society

Jean Hailes Menopause Management Algorithm