Menopause

Overview

•Premature ovarian insufficiency (POI) = loss of normal ovarian function before age 40, affecting ~1 in 100 women

•Hormonal signature: FSH >40 IU/L on two occasions at least 4-6 weeks apart + oestradiol <100 pmol/L

•Always exclude: pregnancy, hypothyroidism (TSH), hyperprolactinaemia (prolactin) in secondary amenorrhoea

🎯
Menopause over 45 is a clinical diagnosis - bloods not routinely needed. Investigate when symptoms occur under 45 or diagnosis is unclear.

Presentation

•Vasomotor - hot flushes, night sweats, palpitations, sleep disturbance

•Genitourinary - vaginal dryness, dyspareunia, urinary frequency, recurrent UTIs

•Psychological - low mood, anxiety, poor concentration, reduced libido

•Menstrual - irregular periods progressing to amenorrhoea

Management

HRT formulation choice
SituationHRT choiceRationale
Uterus intactCombined HRT (oestrogen + progestogen)Progestogen prevents endometrial hyperplasia/cancer from unopposed oestrogen
Post-hysterectomyOestrogen-only HRTNo uterus = no endometrial cancer risk
GSM onlyTopical (vaginal) oestrogenLow systemic absorption; safe even in many with breast cancer history
POI with uterusCombined HRT until age ~51Must continue to age of natural menopause to prevent osteoporosis, cardiovascular and cognitive risk

Situation	HRT choice	Rationale
Uterus intact	Combined HRT (oestrogen + progestogen)	Progestogen prevents endometrial hyperplasia/cancer from unopposed oestrogen
Post-hysterectomy	Oestrogen-only HRT	No uterus = no endometrial cancer risk
GSM only	Topical (vaginal) oestrogen	Low systemic absorption; safe even in many with breast cancer history
POI with uterus	Combined HRT until age ~51	Must continue to age of natural menopause to prevent osteoporosis, cardiovascular and cognitive risk

🎯
POI with an intact uterus: combined HRT (not oestrogen alone) continued until approximately age 51 - this is not optional. Treating for only 5 years is insufficient to protect bone mineral density. The combined oral contraceptive pill is an acceptable alternative.

•Sequential (cyclical) HRT - oestrogen daily + progestogen for 12-14 days per cycle; used in perimenopausal women (still having periods); produces regular withdrawal bleed

•Continuous combined HRT - both hormones daily; used in post-menopausal women (>1 year since last period); aims for amenorrhoea

•Transdermal route (patches, gels) preferred in women with elevated VTE risk - bypasses hepatic first-pass metabolism, avoiding increased clotting factor production seen with oral HRT

Complications

•Breast cancer - small increased risk with combined HRT; oestrogen-only carries less risk than combined

•VTE - oral HRT doubles baseline risk; transdermal HRT does not carry this risk

•Endometrial cancer - risk eliminated by adequate progestogen opposition in women with a uterus

•Untreated POI - osteoporosis, cardiovascular disease, cognitive impairment, premature mortality

Alternatives when HRT is contraindicated

•Venlafaxine or SSRIs (e.g. fluoxetine, paroxetine) - vasomotor symptoms; unlicensed, effect often short-lived

•Clonidine - licensed for hot flushes; allow 2-4 week trial; side effects include dry mouth and drowsiness

•CBT - evidence-based for vasomotor and psychological symptoms

⚠️
NICE advises against routinely offering SSRIs, SNRIs, or clonidine as first-line for vasomotor symptoms - reserve for when HRT cannot be used.