Menopause

Last reviewed: December 2018

Last updated: September 2018

Summary

The diagnosis is clinical, based on the absence of menses for 12 months, and does not require further testing for appropriately presenting patients.

Oestrogen therapy is an effective treatment for the management of menopausal symptoms including hot flushes, night sweats, and urogenital symptoms.

For women with an intact uterus, a progestin must be co-administered with an oestrogen to protect against endometrial hyperplasia and cancer.

Arbitrary limits should not be placed on the duration of use of hormone therapy (HT); all patients require individualised decision-making. Reassessment should occur at least annually. Transdermal administration of estradiol is associated with a lower risk of stroke and venous thromboembolism than oral administration of estradiol, and is unlikely to increase the risk of stroke or venous thrombosis above that of non-users.

Non-hormonal interventions may help women who have a contraindication to, or cannot tolerate, HT. However, they are less effective than HT in controlling menopausal symptoms.

Definition

Onset of the menopause is heralded by the cessation of menses for at least 12 consecutive months, without some other reason for amenorrhoea (such as pregnancy, hormone therapy, or other medical condition). No further testing is indicated for amenorrhoea in an appropriate clinical context or symptoms of the menopause in a woman without a uterus. [1]

Permanent cessation of ovarian function may occur surgically by removal of both ovaries (surgical menopause) or medically, usually due to chemotherapy or radiotherapy (treatment-induced menopause).

The perimenopause includes the years before and after the cessation of menses in an ovulating woman and is marked by irregular menses and menopausal symptoms. Management of menopause symptoms requires individualisation based on each woman’s clinical circumstance.

History and exam

Key diagnostic factors

presence of risk factors
amenorrhoea
irregular menstrual cycle
hot flushes and night sweats
vaginal symptoms
mood changes

Full details

Other diagnostic factors

sleep disturbance
mild memory impairment
menorrhagia

Full details

Risk factors

age 40 to 60 years
cancer treatment
smoking
ovarian surgery
mother's age at the menopause

Full details

Diagnostic investigations

1st investigations to order

pregnancy test

Full details

Investigations to consider

follicle-stimulating hormone (FSH)
serum estradiol

Full details

Treatment algorithm

ACUTE

initial presentation with mild vasomotor symptoms

ONGOING

women with a uterus, moderate to severe hot flushes, with/without reduced libido

women without a uterus or with levonorgestrel-releasing intrauterine device fitted in the last 5 years, moderate to severe hot flushes, with/without reduced libido

urogenital atrophy only

reduced libido only

urinary stress incontinence only

Contributors

Authors VIEW ALL 

Heather Currie, MB BS, FRCOG, DRCOG, MRCGP

Clinical Director Women and Sexual Health

NHS Dumfries and Galloway

Dumfries and Galloway Royal Infirmary

Scotland

Disclosures

HC declares that she has received sponsorship, educational grants, speaker fees, funding for attendance at meetings, and advisory board fees from several pharmaceutical and non-pharmaceutical companies, which supports the running and development of Menopause Matters Ltd.

Haitham Hamoda, MBChB, MD, FRCO

Consultant Gynaecologist

Clinical Lead for Menopause Service

King's College Hospital NHS Trust

London

Disclosures

HH declares that he has acted in an advisory capacity for Bayer. HH received a research grant to support a clinical trial and support to attend academic conferences from Besins.

Bradford W. Fenton, MD, PhD, FACOG

Independence Park Medical Services

Anchorage

Disclosures

BWF is a consultant for Advance Medical and Kevin Trangle Associates and is on the Speakers Bureau for Abbvie.

Acknowledgements

Dr Heather Currie, Dr Haitham Hamoda, and Dr Bradford W. Fenton would like to gratefully acknowledge Dr Rebekah Wang-Cheng, a previous contributor to this topic. RWC declares that she has no competing interests.

Peer reviewers VIEW ALL 

Nan Gillespie O’Connell, MD

Assistant Professor

Department of Obstetrics and Gynecology

Virginia Commonwealth University

Richmond

Disclosures

NGOC declares that she has no competing interests.

Carolyn Simpkins, MD, PhD

Internist

Daniel Island

Disclosures

CS declares that she has no competing interests.

Edward Morris, MD

Consultant

Honorary Senior Lecturer and Clinical Director

Department of Obstetrics and Gynaecology

Norfolk and Norwich University Hospital

Norwich

Disclosures

EM declares that he has no competing interests.

Michelle Warren, MD

Professor of Medicine and Obstetrics & Gynecology

Obstetrics and Gynecology

Columbia University in New York Medical Center

New York

Disclosures

MW has received research funding from Ferring and Pfizer Wyeth; has acted as an advisory board consultant for Pfizer Wyeth, QuatRx, and Yoplait; and is on the speakers' bureau of Amgen, Upsher Smith, and Warner Chilcott. MW is also an author of a reference cited in this monograph.

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Menopause

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

initial presentation with mild vasomotor symptoms

women with a uterus, moderate to severe hot flushes, with/without reduced libido

women without a uterus or with levonorgestrel-releasing intrauterine device fitted in the last 5 years, moderate to severe hot flushes, with/without reduced libido

urogenital atrophy only

reduced libido only

urinary stress incontinence only

Contributors

Authors VIEW ALL 

Heather Currie, MB BS, FRCOG, DRCOG, MRCGP

Disclosures

Haitham Hamoda, MBChB, MD, FRCO

Disclosures

Bradford W. Fenton, MD, PhD, FACOG

Disclosures

Acknowledgements

Peer reviewers VIEW ALL 

Nan Gillespie O’Connell, MD

Disclosures

Carolyn Simpkins, MD, PhD

Disclosures

Edward Morris, MD

Disclosures

Michelle Warren, MD

Disclosures

Differentials

Guidelines

Patient leaflets

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