Menopause

Definition
Menopause is the permanent cessation of menstruation resulting from the loss of ovarian follicular activity. It is a natural biological process that marks the end of a woman's reproductive years. The diagnosis is made retrospectively after 12 consecutive months of amenorrhoea without any other pathological or physiological cause.

Epidemiology

The average age of menopause is 50–52 years.
It usually occurs between ages 45 and 55.
Premature menopause: before age 40.
Early menopause: between ages 40 and 45.

Pathophysiology

Menopause occurs due to depletion of ovarian follicles and reduced estrogen and progesterone production. This leads to:

Elevated follicle-stimulating hormone (FSH) and luteinising hormone (LH) levels due to loss of negative feedback.
Decreased estrogen levels causing vasomotor symptoms, urogenital atrophy, and bone loss.

Stages of Menopause

Perimenopause
- Transitional period with irregular cycles and onset of menopausal symptoms.
Menopause
- Final menstrual period, confirmed after 12 months without menstruation.
Postmenopause
- Time after menopause, with continued low estrogen levels and increased long-term health risks.

Symptoms

Vasomotor Symptoms

Hot flushes (sudden feelings of heat, flushing, sweating).
Night sweats.

Genitourinary Symptoms

Vaginal dryness, itching, burning.
Dyspareunia (painful intercourse).
Recurrent urinary tract infections.
Urinary urgency and frequency.

Psychological Symptoms

Mood swings, irritability.
Anxiety, depression.
Poor concentration, memory changes.

Other Symptoms

Sleep disturbances.
Joint and muscle aches.
Skin and hair changes.

Complications

Osteoporosis: due to reduced bone mineral density.
Cardiovascular disease: loss of estrogen increases risk.
Urogenital atrophy: progressive thinning and inflammation of vaginal and urinary tract tissues.

Diagnosis

Clinical diagnosis: based on history and 12 months of amenorrhoea in women over 45 years.
Laboratory tests: not routinely needed, but FSH may be measured in women <45 years or when diagnosis is uncertain (FSH usually >40 IU/L).

Management

1. Lifestyle Modifications

Maintain healthy weight.
Regular exercise (weight-bearing for bone health).
Balanced diet rich in calcium and vitamin D.
Avoid triggers for hot flushes (alcohol, caffeine, spicy foods).
Smoking cessation.

2. Pharmacological Treatment

Hormone Replacement Therapy (HRT)

Most effective treatment for vasomotor symptoms.
Choice depends on presence of uterus:
- With uterus: Combined estrogen + progestogen to prevent endometrial hyperplasia.
- Without uterus: Estrogen alone.

Common HRT Options and Doses

Estradiol (oral): 1–2 mg once daily.
Conjugated estrogens (oral): 0.3–0.625 mg once daily.
Estradiol (transdermal patch): 25–100 micrograms/day, changed twice weekly.
Progesterone (micronised, oral): 100 mg daily or 200 mg nightly for 12–14 days each month.
Medroxyprogesterone acetate: 5–10 mg daily for 12–14 days/month.

Non-hormonal Options for Vasomotor Symptoms (for women who cannot take HRT)

Venlafaxine: 37.5–75 mg daily.
Paroxetine: 10–20 mg daily.
Gabapentin: 300 mg at night, increasing to 300 mg three times daily as tolerated.
Clonidine: 25–50 micrograms twice daily.

3. Urogenital Symptoms

Local Estrogen Therapy

Estriol vaginal cream: 0.5 mg nightly for 2–3 weeks, then twice weekly.
Estradiol vaginal tablet: 10 micrograms daily for 2 weeks, then twice weekly.
Estradiol vaginal ring: releases 7.5 micrograms/day for 90 days.

4. Osteoporosis Prevention and Treatment

Calcium: 1000–1200 mg/day.
Vitamin D: 800–1000 IU/day.
Bisphosphonates (if indicated): e.g., Alendronic acid 70 mg once weekly.
Selective estrogen receptor modulators (SERMs): e.g., Raloxifene 60 mg daily.

Contraindications to HRT

History of breast or endometrial cancer.
Active or recent thromboembolic disease.
Undiagnosed vaginal bleeding.
Severe liver disease.

Monitoring

Annual review of symptom control, side effects, and risk factors.
Regular breast screening.
Blood pressure and cardiovascular risk assessment.

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