- Incidence: 1000.00 cases per 100,000 person-years
- Peak incidence: 40-50 years
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
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
- regular exercise, weight loss and reduce stress
- avoiding late evening exercise and maintaining good sleep hygiene
- sleep, regular exercise and relaxation
- regular exercise and good sleep hygiene
Management with HRT
- 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
- fluoxetine, citalopram or venlafaxine
- vaginal lubricant or moisturiser
- self-help groups, cognitive behaviour therapy or antidepressants
- 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.
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.
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
- increased risk of ischaemic heart disease