Menopause

Introduction

Menopause is a physiologic event characterized by loss of ovarian activity and permanent cessation of menses, diagnosed after 12 consecutive months of amenorrhea.

  • The median age at which menopause occurs is 51 years, with a normal range of 45 to 55 years.



Symptoms

Symptoms of menopause occur in 75% of females and are moderate to severe in 28%.

  • Symptoms may start during perimenopause (menopausal transition) and last, on average, 7 to 10 years.
  • Vasomotor symptoms (hot flushes and night sweats) predominate in perimenopause, but urogenital symptoms become more common with age.

Symptoms of Menopause

Hot flashes

  • Typically begin as the sudden sensation of heat centred on the upper chest and face that rapidly becomes generalized. The sensation of heat lasts from 2 to 4 minutes, is often associated with profuse perspiration and occasionally palpitations, and is sometimes followed by chills and shivering, and a feeling of anxiety.
  • Hot flashes usually occur several times per day, although the range may be from only 1 or 2 each day to as many as 1 per hour during the day and night. Hot flashes are particularly common at night.
  • It had been thought that vasomotor symptoms diminish and stop within a few years of onset in most women. However, vasomotor symptoms can persist for as long as 20 years past the final menstrual period.



Management

The goals of managing menopause are to alleviate symptoms and reduce the risk of osteoporosis.

Systemic menopausal hormone therapies is the most effective treatment for vasomotor symptoms and can also aid sleep. Standard recommendations for duration of use are 3 to 5 years. However, extended use is sometimes necessary for women with persistent, severe hot flashes.

  • Oestrogen-only
    • For women who have undergone hysterectomy
  • Combined oestrogen plus progestogen
    • In either cyclical or continuous regimen.
    • For women with an intact uterus who needs a progestin to prevent oestrogen-associated endometrial hyperplasia and endometrial cancer
  • Other forms, such as tibolone.
    • Tibolone should only be prescribed to women who are more than one year after menopause as it can cause vaginal bleeding. It is also associated with increased risk of stroke in women older than 60 years of age.

Generally, hormone replacement therapy should not be prescribed for women with

  • Current, past or suspected breast cancer
  • Personal history or known high risk of thromboembolic disease
  • Untreated endometrial hyperplasia
  • History of endometrial or ovarian cancer
  • Untreated hypertension
  • Active liver disease
  • High-risk gall bladder disease

NOTE: Many women wish to stop menopausal hormone therapy after some time to assess whether their symptoms still warrant treatment. Some may elect to continue menopausal hormone therapy indefinitely.

Intravaginal oestrogen therapy is the most effective therapy of vulvovaginal atrophy. It can also reduce the risk of recurrent urinary tract infections and improve some urinary symptoms (including urinary urge incontinence).

Nonhormonal therapies include drug and nondrug approaches.

  • Lifestyle modifications, e.g. diet and exercise
  • Layering of clothing, maintaining a lower ambient temperature, and consumption of cool drinks may help improve vasomotor symptoms associated with menopause
  • Cognitive behavioural therapy
  • Drugs for alleviation of vasomotor symptoms include SSRIs (such as paroxetine), SNRIs, clonidine and gabapentin.
  • Nonestrogen water-based or silicone-based vaginal lubricants and moisturizers may alleviate vaginal symptoms



Complementary Therapies

Placebo-controlled clinical studies of complementary medicines or supplements to treat menopausal hot flushes found:

Inconsistent evidence of efficacy for

  • Vitamin E supplements (although safe to use)
  • Soy extracts (and safety in breast cancer has not been established)
  • Red clover isoflavones
  • Black cohosh (lack of long-term safety data and cases of liver toxicity have been reported)

No evidence of efficacy for



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