This document discusses a 52-year-old woman presenting with hot flashes and depression for 14 months without a period. It defines perimenopause, menopause and postmenopause, and lists common menopausal symptoms. It provides guidance on diagnosing and managing menopause, as well as addressing potential risks and benefits of hormone replacement therapy. Laboratory tests are not necessary to diagnose menopause in most women over age 45. Lifestyle changes and short-term hormone therapy are recommended for managing vasomotor symptoms.

1. Fadhila Al-Busaidi
Family medicine resident – R4

2. 52 yrs old lady.
k/c/o feeling hot most of the time ,
No change in her weight , no change in bowel habits,
She does not have peroid for 14months.
Also she feels depressed sometimes
Her husband died 3years back , no sexaul relationship.

3. Definitions.
Perimenopause.
Menopause.
Postmenopause.
Menopausal Symptoms.
Laboratory investigations.
Management.
Take home massage.

4. Perimenopause:
>40yrs, woman has irregular cycles of ovulation and
menstruation leading up to menopause and continuing
until 12 months after her final period.
The perimenopauseis also known as the menopausal
transition or climacteric.

5. Menopause:
12 months amenorrhea, with no other cause in women
>50yrs OR >24 months amenorrhea in women <50 yrs.

6. Postmenopause:
 The time after menopause has occurred, starting when a
woman has not had a period for 12 consecutive months.

7. Last
period
Irregular
period
Change in
period
menopause
12 months

8. vasomotor symptoms (hot flushes and sweats)
musculoskeletal symptoms (joint and muscle pain)
effects on mood (low mood)
urogenital symptoms (vaginal dryness, UTI)
sexual difficulties (low sexual desire).

9.  Diagnose the following without laboratory tests in otherwise
healthy women aged over 45 years with menopausal
symptoms:
 perimenopause based on vasomotor symptoms and irregular
periods
 menopause in women who have not had a period for at least
12 months and are not using hormonal contraception
 menopause based on symptoms in women without a uterus.

10. Don’t use FSH test to diagnose menopause in women
using COC or high-dose progestogen.
Consider using a FSH test to diagnose menopause only:
in women aged 40 to 45 years with menopausal symptoms, including
a change in their menstrual cycle
in women aged < 40 years in whom menopause is suspected

11. it can be difficult to diagnose menopause in women who
are taking hormonal treatments,

12. One small study found that a rise in FSH without a
change in estradiol levels 2wks after stopping COC is
evidence that it is safe to transition to HRT.
Others suggest discontinuation of COC when women are
in their mid-50s because spontaneous conception is rare
at this age.
AAFP

13. Offer women HRT for vasomotor symptoms. short-term
(up to 5 years):
oestrogen and progestogen to women with a uterus.
oestrogen alone to women without a uterus.
Do not routinely offer (SSRIs), (SNRIs) or clonidine as
first-line treatment for vasomotor symptoms alone.

14. Low-dose paroxetine (Brisdelle) is the only non-hormonal
medication approved by the FDA to treat hot flashes.
AAFP

15. clinical hypnosis (five 45-minute sessions weekly) has
been shown to reduce hot flashes by 74%, compared with
a 17% reduction in patients who received only education
and encouragement.

16. there is no high-quality, consistent evidence that black
cohosh, many botanical products, and omega-3 fatty acid
supplements are effective for treating hot flashes.
Yoga, paced respiration, acupuncture, exercise, stress
reduction, and relaxation therapy also have not been
proven to alleviate hot flashes.
AAFP

17. lowering the ambient temperature;
using fans;
exercising;
avoiding triggers, such as alcohol and spicy foods
Although some women may prefer lifestyle modification,
there is no evidence for it to improves hot flashes.
AAFP

18. Consider HRT to alleviate low mood that arises as a result
of the menopause.
 Consider CBT to alleviate low mood or anxiety that arise
as a result of the menopause.
No clear evidence for SSRIs or SNRIs to ease low mood
in menopausal women who have not been diagnosed with
depression

19. Consider testosterone supplementation for menopausal
women with low sexual desire if HRT alone is not
effective.

20. Offer vaginal oestrogen to women with urogenital atrophy
(including those on systemic HRT) and continue treatment
for as long as needed to relieve symptoms.
If vaginal oestrogen does not relieve symptoms of
urogenital atrophy, consider increasing the dose.

21. Explain to women with urogenital atrophy that:
symptoms often come back when treatment is stopped
adverse effects from vaginal oestrogen are very rare
they should report unscheduled vaginal bleeding to their GP.
moisturisers and lubricants can be used alone or in
addition to vaginal oestrogen.

22. Do not offer routine monitoring of endometrial thickness
during treatment for urogenital atrophy. NICE
Clinicians should consider an endometrial biopsy and/or
transvaginal ultrasonography if spotting or bleeding occurs
while using low-dose vaginal estrogen.
AAFP

23. gradually reducing HRT may limit recurrence of symptoms
in the short term
gradually reducing or immediately stopping HRT makes
no difference to their symptoms in the longer term.

24. Cardiovascular disease.
Venous thromboembolism. (oral > transdermal )
Breast cancer. (HRT with oestrogen and progestogen)
Prevent Osteoporosis. (effect decreases once treatment stops)

25. HRT does not increase cardiovascular disease risk when
started in women aged < 60 years.
Be aware that the presence of cardiovascular risk factors
is not a contraindication to HRT as long as they are
optimally managed.

26.  the baseline risk of coronary heart disease and stroke for
women around menopausal age varies from one woman to
another according to the presence of cardiovascular risk
factors
 HRT with oestrogen alone is associated with no, or reduced,
risk of coronary heart disease
 HRT with oestrogen and progestogen is associated with little
or no increase in the risk of coronary heart disease.

27. Women that taking oral (but not transdermal) oestrogen is
associated with a small increase in the risk of stroke.
The baseline population risk of stroke in women aged <
60 years is very low.

28. FSH should not be done routinely in the diagnosis of
menopause in women aged > 45 years.
FSH should not be used to diagnose menopause in those
taking COC or POP because these affect FSH
measurements.

29. NICE. 12 November 2015
RCOG.
AAFP.