Menopause

Menopause refers to the natural halting of the menstrual cycle due to depletion of ovarian follicles.
– It is defined as amenorrhoea for 2 years below the age of 50 or 12 months over the age of 50.
– The average age of menopause in the UK is 51.
– Perimenopause refers to the period before the menopause in which the woman begins to experience symptoms of the approaching menopause.

Each woman is born with a finite number of oocytes and over time the supply in the ovaries depletes:
– In the perimenopausal period, declining follicle numbers leads to fewer available binding sites for LH + FSH – Reduced binding of LH and FSH results in a reduction in follicular oestrogen production
– Declining levels of oestrogen gives more anovulatory cycles, giving irregular periods + menopausal symptoms – There is reduced pituitary inhibition, causing erratic secretion of FSH, LH, GnRH
– Eventually follicular development stops altogether and amenorrhoea occurs
– Menopause is characterised by low oestrogen and high FSH/LH

Symptoms:
– Menstrual changes -> change in length, frequency and amount of blood loss
– Hot flushes and night sweats
– Joint and muscle aches

– Atrophic vaginitis -> vaginal dryness/discomfort, superficial dyspareunia, recurrent UTIs
– Mood changes
– Sleep problems

Complications:
i) Osteoporosis 
➔ as oestrogen protects bone mass by reducing osteoclast activity
ii) Increased risk of ischaemic heart disease 
➔ as oestrogen is protective against IHD iii) Increased risk of dementia

Diagnosis:
– Perimenopause –> diagnose if the woman has irregular periods and hot flushes/night sweats
– Menopause –> diagnosis when periods have been absent for at least 12 months
– Can measure FSH levels (tend to be high), which gives you estimate of ovarian reserve

Management (according to NICE Guidelines1):
i) Lifestyle modification 
➔ exercise, weight loss, sleep + stress reduction

ii) Hormone replacement therapy:

– If vaginal symptoms only ➔ prescribe oestrogen topical gel

– If no uterus or IUS (coil) ➔ can prescribe oestrogen only HRT
– If they have a uterus 
➔ combined oestrogen and progesterone HRT

   –> if perimenopausal (last period <1 year ago) –> cyclical regime
   –> if postmenopausal (last period >1 year ago) –> continuous

If HRT is rejected or contraindicated, offer symptomatic management:
– Vasomotor symptoms 
➔ fluoxetine, citalopram or venlafaxine
– Vaginal dryness 
➔ lubricant or moisturiser
– Mood disturbance 
➔ self-help groups, CBT, antidepressants

N.B. HRT (except the progesterone coil) does not work as a contraceptive. Therefore, to avoid pregnancy, contraception is still required until a woman is no longer considered fertile:
– Women <50yrs –> considered potentially fertile for 2 years after their last menstrual period
– Women >50yrs –> considered potentially fertile for 1 year after their last menstrual period

  • Premature Ovarian Failure

This is when menopause occurs before the age of 40yrs

Causes
– Idiopathic, autoimmune, iatrogenic (e.g. chemotherapy, radiotherapy)

Symptoms
– Gives similar symptoms to menopause

Diagnosis
– Must have menopausal symptoms + High FSH (on 2 blood samples taken 4-6 weeks apart)
– If doubt, AMH (Anti-Mullerian hormone) levels may be used ➔ direct measure of ovarian reserve

Management – HRT

 

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