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Menopause

Specialties > General practice

Background knowledge 🧠

Definition

  • Permanent cessation of menstruation due to loss of ovarian follicular activity
  • Diagnosed after 12 consecutive months of amenorrhea
  • Occurs usually between 45-55 years of age
  • Marks the end of a woman’s reproductive years

Epidemiology

  • Average age of menopause in the UK is 51 years
  • Around 1% of women experience premature menopause (<40 years)
  • Menopause affects all women globally, but the age of onset can vary based on genetics, lifestyle, and health factors
  • Higher incidence of premature menopause in women who smoke or have certain medical conditions

Aetiology and Pathophysiology

  • Depletion of ovarian follicles leading to reduced oestrogen and progesterone production
  • Decline in oestrogen levels causes many of the symptoms associated with menopause
  • Increased FSH levels due to loss of negative feedback from oestrogen
  • Pathophysiology involves changes in the hypothalamic-pituitary-ovarian axis
  • Premature menopause may be due to genetic factors, autoimmune disorders, or medical treatments like chemotherapy

Types

  • Natural menopause: Occurs gradually due to ageing
  • Premature menopause: Occurs before age 40
  • Induced menopause: Result of medical intervention (e.g., surgery, chemotherapy)
  • Perimenopause: Transitional phase leading up to menopause, characterized by irregular cycles and symptoms

Clinical Features 🌡️

Symptoms

  • Hot flushes and night sweats
  • Vaginal dryness and atrophy
  • Mood swings, anxiety, and depression
  • Fatigue and sleep disturbances
  • Cognitive changes, such as memory problems
  • Decreased libido
  • Weight gain and metabolic changes

Signs

  • Dry, thinning skin
  • Atrophic vaginitis on examination
  • Breast tenderness or atrophy
  • Osteoporosis or decreased bone density (later stages)
  • Elevated FSH and LH levels
  • Low oestrogen levels
  • Urogenital symptoms (e.g., urinary incontinence)

Investigations 🧪

Tests

  • Serum FSH levels: Elevated (>30 IU/L)
  • Serum oestrogen levels: Decreased
  • TSH levels to rule out thyroid dysfunction
  • Bone density scan (DEXA) to assess osteoporosis risk
  • Pelvic ultrasound if there is abnormal bleeding

Management 🥼

Management

  • Hormone replacement therapy (HRT) to alleviate symptoms
  • Non-hormonal treatments (e.g., SSRIs for mood symptoms)
  • Lifestyle changes: Diet, exercise, and smoking cessation
  • Vaginal oestrogen for atrophic vaginitis
  • Bisphosphonates or calcium/vitamin D supplements for bone health
  • Regular monitoring and follow-up for HRT users

Complications

  • Increased risk of osteoporosis and fractures
  • Cardiovascular disease due to loss of oestrogen’s protective effects
  • Vaginal atrophy and urogenital issues
  • Psychological effects: Anxiety, depression
  • Increased risk of Alzheimer’s disease (controversial)

Prognosis

  • Menopause is a natural life event, not a disease
  • Symptom severity varies greatly between individuals
  • Many women adapt well with appropriate management
  • Long-term monitoring required for bone health and cardiovascular risk

Key Points

  • Menopause is a normal physiological process
  • Management should be individualized based on symptoms and risk factors
  • HRT is effective but has associated risks that need to be balanced
  • Non-hormonal options are available for symptom relief
  • Focus on long-term health: Bone density, cardiovascular health

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General practice