The diagnosis of menopause is clinical, based on the absence of menses for 12 months, and does not require further testing for appropriately presenting patients.
Estrogen therapy is an effective treatment for the management of menopausal symptoms including hot flashes, night sweats, and urogenital symptoms.
For women with an intact uterus, a progestin must be co-administered with an estrogen 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 individualized 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 and venous thrombosis above that of non-users.
Nonhormonal interventions may help women who have a contraindication to, or cannot tolerate, HT. However, they are less effective than HT in controlling menopausal symptoms.
Onset of menopause is heralded by the cessation of menses for at least 12 consecutive months, without some other reason for amenorrhea (such as pregnancy, hormone therapy, or other medical condition). No further testing is indicated for amenorrhea in an appropriate clinical context or symptoms of menopause in a woman without a uterus.
Permanent cessation of ovarian function may occur surgically by removal of both ovaries (surgical menopause) or medically, usually due to chemotherapy or radiation therapy (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 individualization based on each woman’s clinical circumstance.
History and exam
Key diagnostic factors
- irregular menstrual cycle
- hot flashes and night sweats
- vaginal symptoms
- mood changes
Other diagnostic factors
- sleep disturbance
- mild memory impairment
- heavy menstrual bleeding
- age 40 to 60 years
- cancer treatment
- ovarian surgery
- mother's age at menopause
1st investigations to order
- pregnancy test
Investigations to consider
- follicle-stimulating hormone (FSH)
- serum estradiol
initial presentation with mild vasomotor symptoms
women with a uterus, moderate to severe hot flashes, with/without reduced libido
women without a uterus or with levonorgestrel-releasing intrauterine device fitted in the last 5 years, moderate to severe hot flashes, with/without reduced libido
urogenital atrophy only
urinary stress incontinence only
Heather Currie, MB BS, FRCOG, DRCOG, MRCGP
Clinical Director Women and Sexual Health
NHS Dumfries and Galloway
Dumfries and Galloway Royal Infirmary
HC declares that she has no competing interests.
Haitham Hamoda, MBChB, MD, FRCO
Clinical Lead for Menopause Service
King's College Hospital NHS Trust
HH declares that he has no competing interests.
Bradford W. Fenton, MD, PhD, FACOG
Independence Park Medical Services
BWF declares that he has no competing interests.
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.
Nan Gillespie O’Connell, MD
Department of Obstetrics and Gynecology
Virginia Commonwealth University
NGOC declares that she has no competing interests.
Carolyn Simpkins, MD, PhD
CS declares that she has no competing interests.
Edward Morris, MD
Honorary Senior Lecturer and Clinical Director
Department of Obstetrics and Gynaecology
Norfolk and Norwich University Hospital
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
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 topic.
- Polycystic ovary syndrome
- Management of osteoporosis in postmenopausal women: the 2021 position statement of the North American Menopause Society
- Menopause: guidance for nurses, midwives and health visitors
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Menopause: what is it?More Patient leaflets
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