Menopause
Definition
* Normal physiological process, average age = 51y (related FHx)
* Cessation of menses after 12 months
* Usually irregular (90%)↑/↓ flow, oligo/polymenorrhoea before stopping completely.
* Earlier = cigarette smoking (3-5 years, increases severity of sx), poor nourishment, high altitudes
Pathogenesis
* Loss of Ovarian activity , oocyte depletion
* ↑ FSH/ LH ↓ oestrogen (testosterone levels same – from adrenal) --> negative feedback inc FSH/LH --> Receptors less sensitive --> less oestrogen
* Oestrogen from androgen conversion in adipose tissue
Clinical Features (menopausal symptoms start before menopause)
Sx:
* Menstrual disturbance
* Vasomotor sx (hot flushes – hallmark!, sweats)
* Hot flushes : acute lowering of hypothalamic set point from estrogen withdrawal
* Psychological (anxiety, ↑ tension, mood swings, depression, irritability)
* Depression: new onset with no previous depression hx
* Atrophy/ dryness (skin, genitourinary tissues)
* Dyspareunia
Increased risk of
* Osteoporosis : hip, vertebral compression fractures
* CVD (for obese, htn, >60y women) – most common cause of death
Investigation
Bloods: inc FSH/LH (diagnostic, but not necessary)
Management
Non-pharm
Lifestyle, relaxation, CBT
Avoid hot environments/ spicy food/ stress
Wt bearing exercise
Pharm
1) HRT
Oral:
* Combined oestrogen and progesterone if intact uterus
* Oestrogen alone if previous hysterectomy, not cardio protective.
- increases risk for stroke (NNH 123) and possibly venous thromboembolism (NNH 217)
* lower dose than OCP
* May cause post menopausal 'withdrawal' bleed (especially if progesterone not used)
* Increase risk of breast cancer, incr risk of recurrent breast cancer (WHI trial)
Topical :
* patches/ dermal gel/ vaginal (tablet/cream)
* Doesn't increase breast cancer risk, good symptom relief.
2) Tibolone (livial)
* Synthetic steroid, Oestrogen receptor agonist - good for bones, not useful for hot flushes
3) Remifemin (Complementary and Alternative Medicine)
4) Testosterone- helps with sexual dysfunction
5) calcium 1,200-1,500 mg/day and vitamin D 400-800 units/day recommended
Differential diagnosis
* Hypothyroidism
* Hyperprolactinaemia
* Primary ovarian insufficiency
Source
* Normal physiological process, average age = 51y (related FHx)
* Cessation of menses after 12 months
* Usually irregular (90%)↑/↓ flow, oligo/polymenorrhoea before stopping completely.
* Earlier = cigarette smoking (3-5 years, increases severity of sx), poor nourishment, high altitudes
Pathogenesis
* Loss of Ovarian activity , oocyte depletion
* ↑ FSH/ LH ↓ oestrogen (testosterone levels same – from adrenal) --> negative feedback inc FSH/LH --> Receptors less sensitive --> less oestrogen
* Oestrogen from androgen conversion in adipose tissue
Clinical Features (menopausal symptoms start before menopause)
Sx:
* Menstrual disturbance
* Vasomotor sx (hot flushes – hallmark!, sweats)
* Hot flushes : acute lowering of hypothalamic set point from estrogen withdrawal
* Psychological (anxiety, ↑ tension, mood swings, depression, irritability)
* Depression: new onset with no previous depression hx
* Atrophy/ dryness (skin, genitourinary tissues)
* Dyspareunia
Increased risk of
* Osteoporosis : hip, vertebral compression fractures
* CVD (for obese, htn, >60y women) – most common cause of death
Investigation
Bloods: inc FSH/LH (diagnostic, but not necessary)
Management
Non-pharm
Lifestyle, relaxation, CBT
Avoid hot environments/ spicy food/ stress
Wt bearing exercise
Pharm
1) HRT
Oral:
* Combined oestrogen and progesterone if intact uterus
* Oestrogen alone if previous hysterectomy, not cardio protective.
- increases risk for stroke (NNH 123) and possibly venous thromboembolism (NNH 217)
* lower dose than OCP
* May cause post menopausal 'withdrawal' bleed (especially if progesterone not used)
* Increase risk of breast cancer, incr risk of recurrent breast cancer (WHI trial)
Topical :
* patches/ dermal gel/ vaginal (tablet/cream)
* Doesn't increase breast cancer risk, good symptom relief.
2) Tibolone (livial)
* Synthetic steroid, Oestrogen receptor agonist - good for bones, not useful for hot flushes
3) Remifemin (Complementary and Alternative Medicine)
4) Testosterone- helps with sexual dysfunction
5) calcium 1,200-1,500 mg/day and vitamin D 400-800 units/day recommended
Differential diagnosis
* Hypothyroidism
* Hyperprolactinaemia
* Primary ovarian insufficiency
Source
- A/Prof Amanda Dennis 2014
- Holmberg L, Anderson H; HABITS steering and data monitoring committees. HABITS (hormonal replacement therapy after breast cancer--is it safe?), a randomised comparison: trial stopped. Lancet. 2004 Feb 7;363(9407):453-5.
- Freeman EW, Sammel MD, Lin H, Nelson DB. Associations of hormones and menopausal status with depressed mood in women with no history of depression. Arch Gen Psychiatry. 2006 Apr;63(4):375-82.
- Rymer J, Morris EP. "Extracts from "Clinical evidence": Menopausal symptoms. BMJ. 2000 Dec 16;321(7275):1516-9