Menopause

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.