Introduction
The climacterium is the transition from reproductive to non-reproductive life. Menopause is the last menstrual period, diagnosed after 12 months of amenorrhoea; the average age is about 51. Menopause before 40 is premature ovarian insufficiency.
Hormonal changes
The follicles run out: inhibin and oestradiol fall, so FSH rises (FSH > 30 IU/L on two occasions supports the diagnosis in women under 45; above 45 the diagnosis is clinical). Anovulatory cycles cause irregular, sometimes heavy, bleeding in the perimenopause.
Management
Hormone replacement therapy (HRT)
- Most effective for vasomotor symptoms; prevents osteoporosis.
- Women with a uterus need oestrogen + progestogen (cyclical if periods within the last year, continuous later) to protect the endometrium; after hysterectomy, oestrogen alone.
- Routes: tablets, transdermal patches or gel (no increase in thrombosis risk), vaginal oestrogen for local symptoms (safe long term).
- Risks: small increase in breast cancer with combined HRT (rises with duration, falls after stopping), venous thromboembolism and stroke with oral oestrogen; oestrogen alone does not raise breast cancer risk much.
- Benefits outweigh risks for most women under 60 or within 10 years of menopause. In premature ovarian insufficiency HRT is advised until at least 51.
- Contraindications: oestrogen-dependent cancer (breast, endometrial), undiagnosed vaginal bleeding, active thromboembolism, active liver disease, pregnancy.
Alternatives
- Non-hormonal: SSRIs/SNRIs, gabapentin, clonidine, fezolinetant; cognitive behavioural therapy.
- Bone: calcium, vitamin D, weight-bearing exercise, stop smoking; bisphosphonates if osteoporosis (DEXA T-score ≤ −2.5).
- Contraception is still needed for 1 year after the last period if over 50, 2 years if under 50.
A woman with a uterus must not take oestrogen alone: unopposed oestrogen causes endometrial hyperplasia and cancer.