Menopause

Overview – Menopause

Menopause refers to the permanent cessation of menstruation, confirmed after 12 months of amenorrhoea without another identifiable cause. It marks the end of a woman’s reproductive years and is associated with significant hormonal, physical, and psychological changes. Understanding the clinical features, risks, and management strategies is essential for recognising and supporting patients through this transitional phase.

Definition

• Menopause: ≥12 months of amenorrhoea after the last menstrual period, not due to another cause
• Pre-menopause: Early symptoms of menstrual irregularity
• Perimenopause: Time from the onset of irregular cycles (>2 missed periods) to 12 months after the last period

Aetiology

Types of Menopause

• Physiological: Spontaneous menopause, typically between 45–55 years
• Premature: Occurs before age 40, due to premature ovarian failure
• Iatrogenic: Medically induced via chemotherapy, radiotherapy, or surgical oophorectomy

Pathophysiology

• ↓ Follicle responsiveness to follicle-stimulating hormone (FSH)
  → ↓ follicular recruitment
  → ↓ oestrogen production
  → progressive oligomenorrhoea
  → eventual amenorrhoea
• The entire transition typically spans 3–5 years

Clinical Features

Epidemiology

• Average onset between 45–55 years

Menstrual Symptoms

• Oligomenorrhoea (lighter, irregular periods)
• Possible intermittent menorrhagia (dysfunctional uterine bleeding)

Hormonal Symptoms

May persist for several years post-menopause

• Hot flushes and night sweats (75% of women)
  • Begin ~2 years before menopause, lasting up to 2 years after
• Mood disturbance
  • Irritability, depression, anxiety
  • Poor concentration, memory issues
  • Insomnia, ↓ libido
• Palpitations, dizziness, headaches

Genitourinary Changes

• Vaginal dryness → itching, burning, dyspareunia
• Urethral atrophy → ↑ urinary tract infections
• Infertility due to anovulation

Anatomical & Structural Changes

• Uterus/Cervix: atrophy; fibroids tend to shrink
• Vagina: mucosal atrophy, ↓ elasticity, ↑ pH, ↓ lactobacilli
• Vulva: atrophy
• Pelvic floor: ↓ muscle tone → uterovaginal prolapse
• Ovaries: cease follicular activity and undergo atrophy

Complications

• Osteoporosis
  • Due to oestrogen’s role in calcium deposition and bone maintenance
• Cardiovascular disease
  • Loss of oestrogen’s protective effects → ↑ risk of coronary artery disease

Diagnosis

Clinical

• History: symptoms, menstrual pattern, lifestyle impact
• Examination: complete physical including breast and pelvic exams

Confirmatory

• ↑ FSH and ↓ estradiol → consistent with ovarian failure

Investigations

• Blood tests: FBC, LFTs, TFTs, lipids, coagulation profile
• Bone health: Bone mineral density scan (DEXA)
• Cancer screening:
  • Mammogram (annually)
  • Pap smear (every 2 years)
  • FOBT (annually); colonoscopy every 5 years

Management

Non-Pharmacological

• Lifestyle modification: healthy diet, weight loss, weight-bearing exercise
• Calcium and vitamin D supplementation
• Encourage regular screening: mammogram, Pap smear, colonoscopy

Pharmacological

Hormone Replacement Therapy (HRT)

Goals:

• Short-term symptom relief (ideally ≤2–3 years)
• Use lowest effective dose, taper gradually to avoid rebound symptoms

Regimens:

• Combined oestrogen + progesterone
  • Indicated for women with an intact uterus
  • Cyclical for perimenopausal; continuous for postmenopausal
• Oestrogen-only therapy
  • Used if uterus absent or Mirena coil in situ

Benefits:

• Relief from hot flushes, mood swings, and vaginal dryness
• Prevention of osteoporosis

Risks / Side Effects:

• Breakthrough bleeding, breast tenderness
• Headaches, nausea, mood changes
• Small ↑ risk of:
  • Cardiovascular disease
  • Breast and colorectal cancer
  • Endometrial and ovarian cancer (only with unopposed oestrogen)
  • Venous thromboembolism and stroke

Contraindications to HRT:

• History of thromboembolism (DVT, PE, stroke)
• Active or past breast cancer
• Unexplained postmenopausal bleeding
• Acute liver disease
• Uncontrolled hypertension or cardiovascular disease
• Migraine sufferers

Bisphosphonates

• Used to prevent or treat osteoporosis
• Example: Alendronate (Fosamax)

Summary – Menopause

Menopause marks the end of female reproductive capacity and is defined by 12 months of amenorrhoea. It presents with menstrual irregularities, vasomotor symptoms, mood disturbances, and anatomical changes. Management includes lifestyle changes, screening, and short-term hormone replacement therapy. For a broader context, see our Reproductive Health Overview page.