Menopause

Clinical assessment

Diagnosis is usually clinical based on age (>45 years) and characteristic symptoms, especially cessation of menses for 12 consecutive months. In younger women or atypical presentations, hormonal testing (FSH levels) may be considered but is not routinely needed for diagnosis in women >45 yrs.

Differential diagnosis

• Pregnancy (must exclude in perimenopause with irregular cycles).
• Thyroid dysfunction (hyper or hypo).
• Depression/Anxiety disorders.
• Other causes of amenorrhoea.
• Side effects of medications.

Investigations

• Pregnancy test (if irregular bleeding/amenorrhoea <12 months).
• Consider TSH to rule out thyroid disease.
• FSH levels (elevated) - generally NOT needed for diagnosis in women >45yrs with typical symptoms.
• Lipid profile, BP check, Glucose check (assess cardiovascular risk).
• Bone density scan (DXA) - assess osteoporosis risk (less available).

Diagnostic criteria

Clinical diagnosis: Cessation of menstruation for 12 consecutive months in women of typical age range (45-55), often accompanied by characteristic symptoms. Or clinical symptoms in women with bilateral oophorectomy.

Non-pharmacological management

• Patient Education and Reassurance: Explain menopause as a normal physiological process.
• Lifestyle Adjustments:
• - Healthy Diet: Rich in calcium and vitamin D; low fat; high fruit/vegetables.
• - Regular Weight-Bearing Exercise: For bone health and general well-being.
• - Adequate Sleep.
• - Stress Management / Relaxation techniques.
• - Dress in layers, use fans, keep bedroom cool (for hot flushes).
• - Avoid triggers for hot flushes (spicy food, caffeine, alcohol).
• - Smoking Cessation.
• - Moderate alcohol intake.
• - Vaginal Lubricants/Moisturizers (non-hormonal) for vaginal dryness/dyspareunia.

Pharmacological treatment

• Management focuses on symptom relief and long-term health.
• Vasomotor Symptoms (Hot Flushes/Night Sweats):
• - Hormone Replacement Therapy (HRT/MHT): Most effective treatment. Requires careful discussion of risks/benefits with individual patient (specialist guidance often needed). Estrogen +/- Progestogen (progestogen needed if uterus intact). Various routes available. Contraindicated in certain conditions (e.g., history of breast cancer, VTE, liver disease).
• - Non-hormonal options (less effective than HRT): SSRIs (e.g., Fluoxetine 20mg daily - UCG mentions for severe symptoms), SNRIs (Venlafaxine), Gabapentin, Clonidine.
• Urogenital Atrophy:
• - Topical Vaginal Estrogen (creams, pessaries, rings): Low dose, minimal systemic absorption, effective and safe for most women, including some with history of breast cancer (specialist advice).
• - Non-hormonal lubricants/moisturizers.
• Mood Symptoms:
• - HRT may improve mood if related to hormonal changes.
• - Antidepressants (SSRIs like Fluoxetine) if clinical depression present.
• - Counselling/Psychotherapy.
• Osteoporosis Prevention/Treatment:
• - Calcium and Vitamin D supplements (if dietary intake inadequate).
• - HRT (provides bone protection).
• - Bisphosphonates (Alendronate, etc.) - specialist management.
• Cardiovascular Risk Management: Address hypertension, dyslipidemia, diabetes, obesity, smoking.

Monitoring

Monitor symptom control. Monitor side effects if on HRT or other medications. Regular health checks (BP, lipids, glucose, breast awareness/screening, cervical screening).