Key Facts

Menopause marks the end of reproductive life and is associated with declining oestrogen levels. Symptoms can significantly impact quality of life. HRT remains the most effective treatment and NICE NG23 supports its use for symptomatic women.

Epidemiology

• Average age of menopause in the UK: 51 years
• Perimenopause (transition): typically begins 4-8 years before menopause
• POI (<40 years): affects 1% of women
• 80% of women experience vasomotor symptoms; 25% describe them as severe

Aetiology

• Natural menopause: progressive depletion of ovarian follicles
• Surgical menopause: bilateral oophorectomy
• Iatrogenic: chemotherapy, pelvic radiotherapy, GnRH analogues
• Premature ovarian insufficiency: autoimmune (most common), genetic (Turner syndrome, fragile X), idiopathic

Pathophysiology

• Declining ovarian oestrogen production leads to loss of negative feedback on hypothalamus/pituitary
• Elevated FSH and LH levels
• Oestrogen deficiency affects multiple systems: thermoregulatory (vasomotor symptoms), urogenital (atrophy), skeletal (osteoporosis), cardiovascular, neurological (mood, cognition)
• Loss of the protective cardiovascular effect of oestrogen increases CVD risk post-menopause

Vasomotor Symptoms

• Hot flushes (75-80% of women; median duration 7 years)
• Night sweats
• Sleep disturbance

Genitourinary Syndrome of Menopause (GSM)

• Vaginal dryness and atrophy
• Dyspareunia
• Recurrent UTIs
• Urinary urgency and frequency

Psychological Symptoms

• Low mood and anxiety
• Irritability
• Reduced concentration and memory (brain fog)
• Reduced libido

Musculoskeletal

• Joint aches and stiffness
• Accelerated bone loss (osteoporosis risk)

Red Flags

• Menopause before age 40 (investigate for POI)
• Postmenopausal bleeding (exclude endometrial pathology)
• Unexplained weight loss or new neurological symptoms (exclude other causes)
• Symptoms not responding to adequate HRT (review diagnosis)

Bedside

• Clinical diagnosis in women >45 with typical symptoms (no blood tests needed per NICE NG23)
• BMI, blood pressure
• Breast examination

Bloods

• FSH: NOT required for diagnosis in women >45 with typical symptoms
• FSH indicated: if age <45, POI suspected, or diagnosis uncertain (FSH >30 IU/L on 2 occasions 4-6 weeks apart confirms menopause)
• TFTs: exclude thyroid dysfunction
• HbA1c, lipid profile: baseline metabolic screening
• Bone density (DEXA): if POI, early menopause, or risk factors for osteoporosis

Imaging

• TVS if postmenopausal bleeding (exclude endometrial pathology)
• DEXA scan for bone density assessment if indicated

Special Tests

• Anti-Müllerian hormone (AMH): low in POI (may support diagnosis)
• Karyotype: if POI age <35 (exclude Turner syndrome)
• Fragile X premutation testing: if POI with family history

Non-pharmacological

• Lifestyle modification: regular exercise, weight management, reduce caffeine and alcohol
• CBT: effective for vasomotor symptoms and low mood (NICE NG23)
• Relaxation techniques, mindfulness
• Vaginal moisturisers and lubricants for GSM

Pharmacological

• HRT (first-line for vasomotor symptoms):
  • Oestrogen-only: for women without a uterus (oestradiol patches 25-100mcg or gel 0.75-1.5mg)
  • Combined (oestrogen + progestogen): for women with a uterus
  • Sequential combined: for perimenopausal women (bleed expected)
  • Continuous combined: for postmenopausal women (≥12 months amenorrhoea)
  • Transdermal oestrogen preferred (no VTE risk increase; NICE NG23)
  • Micronised progesterone (Utrogestan 100mg continuous or 200mg cyclical) preferred over synthetic
• Tibolone 2.5mg OD: synthetic steroid with oestrogenic, progestogenic, and androgenic activity
• Vaginal oestrogen (estriol 0.01% cream or pessaries): safe for GSM; can be used with or without systemic HRT; no endometrial monitoring required
• Non-HRT options: SSRI/SNRI (venlafaxine 37.5-75mg, paroxetine 7.5-10mg), gabapentin 300mg TDS, clonidine 25-75mcg BD (less effective than HRT)
• For POI: HRT or COC recommended until average age of menopause (51) for bone and cardiovascular protection

Surgical/Interventional

• Not applicable for menopause management
• DEXA-guided osteoporosis treatment if indicated

Referral Criteria

• POI diagnosis: specialist menopause clinic
• Complex cases: specialist menopause clinic (e.g. HRT after breast cancer, complex risk assessment)
• Persistent symptoms despite adequate HRT: specialist review
• Suspected endometrial pathology: gynaecology referral

• Vasomotor symptoms: median duration 7 years; 10% of women experience symptoms beyond 12 years
• HRT effectively controls vasomotor symptoms in 80-90% of women
• GSM: progressive without treatment; responds well to vaginal oestrogen
• Bone health: HRT prevents osteoporotic fractures (30-50% reduction)
• Cardiovascular: HRT started within 10 years of menopause reduces coronary heart disease risk (timing hypothesis)
• Breast cancer risk with combined HRT: small increase (4 extra per 1,000 over 5 years at age 50-59); risk returns to baseline within 5 years of stopping

HRT Risks and Benefits Summary

WHI Trial Key Findings