Managing menopause

(Notes from BMJ module)

From 45 yrs onwards, menopause/perimenopause can be diagnosed on history only. FSH or other blood tests are not actually helpful in diagnosis in the >40s because of the wide fluctuation in levels in the perimenopause. FSH can, however, be helpful in showing when women >50 can stop progestagen-only contraception; if FSH is >30 in a woman >50, she can stop one year after that. Don’t use it for this purpose in women on combined hormonal contraceptive (or on high-dose progestagen, but the doses used for progestagen-only contraception don’t count).

Note that women over 55 can stop contraception anyway even if still getting periods, as conception so rare at this point. CHC can be used in >50s, and is considered a UKMEC 2, but it’s also considered worth advising against it (note that it can mask the date at which menopause arrives). Women using HRT and requiring contraception can use CHC instead if age-appropriate; can use an IUS as the progestagen component; or can use any type of progestagenic contraception alongside HRT (note that the progestagen part of HRT has to  be used in that case, as only the Mirena is licenced to provide uterine protection in HRT).

When discussing menopause, discuss lifestyle factors for bone health, and also take the time for other health promotion (smoking cessation, exercise promotion, review alcohol consumption). Note that regular aerobic exercise seems to reduce menopausal symptoms (occasional high-impact exercise, on the other hand, can worsen them). Reducing/eliminating alcohol and caffeine can also help.

First-line treatment for vasomotor symptoms should be HRT if no contraindications; other methods are less effective and have a high rate of side-effects, so don’t offer them as first-line.

Women with a history of breast cancer obviously can’t be offered HRT as first-line; when offering SSRIs, be aware that fluoxetine and paroxetine might interact with tamoxifen, reducing its effectiveness, and thus those combinations are contraindicated. Citalopram or Venlafaxine are OK to use.

In terms of VTE risk, note the following:

  • Inform women of the small extra risk with HRT. This, however, only appears to apply to oral HRT; I can’t help feeling this creates some ethical problems.
  • If women are at increased baseline risk – e.g., BMI >30 – offer transdermal instead of oral. I guess women who have a normal starting risk just have to (literally) suck up the extra risk with oral HRT.
  • If the risk is on the ‘strong family history’ or ‘known hereditary thrombophilia’ level, consider referral to a haematologist for advice prior to starting HRT.
  • Women with a past history of unprovoked VTE should avoid HRT altogether.

In terms of cardiovascular risk, note that it only appears to exist in women starting HRT over the age of 60 years. (Also, it only appears to be for non-fatal cardiovascular disease; the risk of dying of an MI doesn’t appear to be increased.) In women under 60 who have no previous history of cardiovascular problems, it might even be cardioprotective. Any existing risk seems to be with the combined types, not the oestrogen-only. Cardiovascular risk factors aren’t a contraindication to HRT if well managed.

There’s a small increase in stroke risk with oral HRT, but not with transdermal.

After starting HRT, review in 3/12 and then annually.

Non-prescription therapies with some evidence of effectiveness include CBT, relaxation, acupuncture and St John’s Wort. However, with regard to the latter, bear in mind that it does have clinically significant interactions; also, the dosage isn’t clear, and potency of preparations can vary.

Remember that topical oestrogen can be helpful for urogenital symptoms, and can be needed to supplement systemic HRT.

Cognitive symptoms don’t seem to be caused directly by the menopause, although they can be caused by sleep deprivation from hot flushes.

Mood changes sometimes respond well to HRT, and can also respond to CBT. SSRIs might not be helpful for mood changes that don’t fit the clinical criteria for depression.

Premature ovarian failure refers to menopause prior to 40 yrs, and is diagnosed by taking two FSH levels 4 – 6 weeks apart in a woman with the typical symptoms and signs. Note that FSH cut-off in this case should be >40 iu/L, not >30 as in checking contraceptive need in the 50 – 55 yr age group. POI can, in occasional cases, reverse spontaneously, so specialist advice should be obtained on contraception. (It is reasonable to use the COC for bone protection, though HRT can also be used.)

Note that if women go through POI secondary to medical/surgical treatment, they’re getting a triple whammy; not only are they going through menopause early, they’re also likely to get very severe symptoms, and to have all this to deal with on top of whatever they were having treatment for in the first place. They might well come in with the menopausal symptoms only some months later when things have settled down regarding whatever the initial problem was. Specialist referral is likely to be indicated.

Note also that women with POI are at increased risk of cardiovascular disease unless on HRT.

Bleeding in the first three to six months of continuous combined HRT is common; if happening or persisting after that, treat as a PMB. If gynaecological pathology and non-compliance have both been excluded and bleeding is persisting, try changing to a different progestagen.

About Dr Sarah

I'm a GP with a husband and two young children.
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