🔑 Key Learning

  • Menopause is diagnosed after 12 months of amenorrhoea.
    • Premature menopause = under 40 years
    • Early = 40–45 years.
  • HRT is tailored based on uterus status and timing of last menstrual period. For the exam, the most important thing to remember is:
    • No uterus? Oestrogen only
    • Uterus intact. LMP < 1 year ago - Sequential combined HRT
    • Uterus intact. LMP > 1 year ago - Continuous combined HRT
  • Transdermal oestrogen avoids increased VTE risk.
  • Vaginal oestrogen is 1st line for isolated genitourinary syndrome of menopause (GSM).

🧬 Pathophysiology

  • Permanent cessation of menstruation due to follicular depletion.
  • Perimenopause = time before menopause, with cycle changes and vasomotor symptoms.

👀 Clinical Features

  • Irregular or changing menstrual cycles (lengthening/shortening).
  • Vasomotor symptoms: hot flushes, night sweats.
  • Mood: low mood, irritability, anxiety, mood swings.
  • Genitourinary Syndrome of Menopause:
    • Vaginal dryness, soreness, itching
    • Dyspareunia
    • Post-coital bleeding
    • On exam: pale, dry vaginal walls with contact bleeding
  • Reduced libido

🧪 Diagnosis

  • Clinical diagnosis if classic symptoms in a woman > 45
  • FSH measurement is not essential in typical cases, but can aid diagnosis in specific situations: 
    • Age > 45 with atypical symptoms
    • Age 40–45 if early menopause suspected
    • Age < 40 with suspected premature ovarian insufficiency
  • FSH > 30 IU/L on 2 occasions, 6 weeks apart → ovarian insufficiency

🚫 Contraception

  • Women may remain fertile up to 2 years following their LMP, so contraception counselling is essential:
    • Women < 50: use contraception for 2 years after LMP
    • Women > 50: continue for 1 year after LMP
  • Options:
    • POP can be used alongside cyclical HRT
    • COCP can be used in < 50s as alternative to HRT, but switch to POP after 50

💊 Hormone Replacement Therapy (HRT)

Backgroud

  • Oestrogen replacement treats menopausal symptoms
  • Progesterone protects the uterus - unopposed oestrogen causes endometrial thickening, increasing the risk of endometrial hyperplasia and carcinoma.
    • Hence, no uterus? No need for progesterone. 

Decision Tree

  • Uterus removed (hysterectomy) → oestrogen only HRT
  • Uterus intact → combined oestrogen + progestogen HRT

Based on timing of menopause:

  • LMP < 1 year ago → sequential combined HRT
    • Designed to mimic natural menstrual cycle - periods of oestrogen followed by progestogen.
    • Daily oestrogen, cyclical progestogen
    • Results in monthly bleed
  • LMP > 1 year ago → continuous combined HRT
    • Daily oestrogen and progestogen
    • No withdrawal bleed 

Duration

  • Continue as long as needed for symptom relief
    • Most commonly it's taken for 2 to 5 years
  • Premature menopause: continue until at least age 51 (reduce risk of osteoporosis etc.)

Route

  • Oral or transdermal (gel, spray, patch)
  • Transdermal oestrogen is preferred - unlike oral, it is NOT associated with increased VTE risk

❌ Contraindications to HRT

  • History of breast
  • History of endometrial cancer or untreated endometrial hyperplasia
  • Undiagnosed PV bleeding or breast lump
  • History of VTE or thrombophilia
  • Arterial thromboemolic disease: Ischaemic heart disease, stroke, or angina
  • Active liver disease
  • Pregnancy
  • Caution is recommended with: Porphyria cutanea tarda, diabetes (CVD risk), VTE risk factors, history endometrial hyperplasia, migraines, RFs for breast cancer. 

⚠️ Side Effects

  • Oestrogen: breast tenderness, bloating, fluid retention
  • Progestogen: mood changes, acne, breast pain
  • Irregular bleeding, especially with continuous combined HRT in first 4–6 months

🩸 Unscheduled Bleeding

  •  VERY common - up to 40% of women have unscheduled bleeding in the first 6 months of starting HRT. 
  • However, prolonged, or heavy bleeding, or persistent (e.g. daily) is not normal and may suggest underlying endometrial carcinoma. 
  • Assessment of risk factors is essential and determines risk/ investigation / 2WW referral. 
  • The British Menopause Society have produced the following guidelines.

🌡️ Non-Hormonal Alternatives

Vasomotor symptoms

  • SSRI/SNRI: fluoxetine, paroxetine, venlafaxine
  • Clonidine
  • Gabapentin
  • CBT

Mood symptoms

  • Treat with antidepressants as required

💧 Management of Genitourinary Syndrome of Menopause

  • 1st Line: Low-dose vaginal oestrogen
  • 2nd Line: Oral ospemifene (SERM)
  • Vaginal moisturisers and lubricants can be used alone or with vaginal oestrogen

📝 Exam Clues & Clinchers

  • LMP > 1 year ago + uterus intact → continuous combined HRT
  • LMP < 1 year ago → sequential HRT
  • Hysterectomy → oestrogen only HRT
  • Vaginal symptoms → vaginal oestrogen, safe even with systemic HRT
  • Transdermal oestrogen avoids VTE risk (unlike oral)

🔗 Useful Links and References