Menopause is defined as the permanent cessation of menstruation. It is caused by the loss of follicular activity. Menopause is a clinical diagnosis usually made in primary care when a woman has not had a period for 12 months.

The symptoms seen in the climacteric period are caused by reduced levels of female hormones, principally oestrogen

Change in periods

• change in length of menstrual cycles
• dysfunctional uterine bleeding may occur

Vasomotor symptoms - affects around 80% of women. Usually occur daily and may continue for up to 5 years

• hot flushes
• night sweats

Urogenital changes - affects around 35% of women

• vaginal dryness and atrophy
• urinary frequency

Psychological

• anxiety and depression may be seen - around 10% of women
• short-term memory impairment

Menopausal symptoms are very common and affect roughly 75% of postmenopausal women. Symptoms typically last for 7 years but may resolve quicker and in some cases take much longer. The duration and severity are also variable and may develop before the start of the menopause and in some cases may start years after the onset of menopause.

The CKS has very thorough and clear guidance on the management of menopause and is summarised below.

The management of menopause can be split into three categories:

• Lifestyle modifications
• Hormone replacement therapy (HRT)
• Non-hormone replacement therapy

Management with lifestyle modifications

Hot flushes

• regular exercise, weight loss and reduce stress

Sleep disturbance

• avoiding late evening exercise and maintaining good sleep hygiene

Mood

• sleep, regular exercise and relaxation

Cognitive symptoms

• regular exercise and good sleep hygiene

Management with HRT

Contraindications:

• Current or past breast cancer
• Any oestrogen-sensitive cancer
• Undiagnosed vaginal bleeding
• Untreated endometrial hyperplasia

Roughly 10% of women will have some form of HRT to treat their menopausal symptoms. There is a current drive by NICE to increase this number as they have found that women were previously being undertreated due to worries about increased cancer risk. If the woman has a uterus then it is important not to give unopposed oestrogens as this will increase her risk of endometrial cancer. Therefore oral or transdermal combined HRT is given.

If the woman does not have a uterus then oestrogen alone can be given either orally or in a transdermal patch.

Women should be advised that the symptoms of menopause typically last for 2-5 years and that treatment with HRT brings certain risks:

• Venous thromboembolism: a slight increase in risk with all forms of oral HRT. No increased risk with transdermal HRT.
• Stroke: slightly increased risk with oral oestrogen HRT.
• Coronary heart disease: combined HRT may be associated with a slight increase in risk.
• Breast cancer: there is an increased risk with all combined HRT although the risk of dying from breast cancer is not raised.
• Ovarian cancer: increased risk with all HRT.

Management with non-HRT

Vasomotor symptoms

• fluoxetine, citalopram or venlafaxine

Vaginal dryness

• vaginal lubricant or moisturiser

Psychological symptoms

• self-help groups, cognitive behaviour therapy or antidepressants

Urogenital symptoms

• if suffering from urogenital atrophy vaginal oestrogen can be prescribed. This is appropriate if they are taking HRT or not
• vaginal dryness can be treated with moisturisers and lubricants. These can be offered alongside vaginal oestrogens if required.

Stopping treatment

For vasomotor symptoms, 2-5 years of HRT may be required with regular attempts made to discontinue treatment. Vaginal oestrogen may be required long term. When stopping HRT it is important to tell women that gradually reducing HRT is effective at limiting recurrence only in the short term. In the long term, there is no difference in symptom control.

Although menopausal symptoms can be managed mainly in primary care, there are some instances when a woman should be referred to secondary care. She should be referred to secondary care if treatment has been ineffective, if there are ongoing side effects or if there is unexplained bleeding.

Contraception

It is recommended to use effective contraception until the following time:

• 12 months after the last period in women > 50 years
• 24 months after the last period in women < 50 years

Longer-term complications

• osteoporosis
• increased risk of ischaemic heart disease