Menopause_management (1)

Question 1

What is menopause?

Answer 1

Menopause is defined as the permanent cessation of menstruation. It is caused by the loss of follicular activity. Menopause is a clinical diagnosis usually made in primary care when a woman has not had a period for 12 months.

Question 2

What percentage of postmenopausal women experience menopausal symptoms?

Answer 2

Roughly 75% of postmenopausal women experience menopausal symptoms.

Question 3

How long do menopausal symptoms typically last?

Answer 3

Symptoms typically last for 7 years but may resolve quicker and in some cases take much longer.

Question 4

What are the three categories of menopause management?

Answer 4

Lifestyle modifications, Hormone replacement therapy (HRT), Non-hormone replacement therapy.

Question 5

What lifestyle modifications can help manage hot flushes during menopause?

Answer 5

Regular exercise, weight loss, and stress reduction.

Question 6

What lifestyle modifications can help manage sleep disturbance during menopause?

Answer 6

Avoiding late evening exercise and maintaining good sleep hygiene.

Question 7

What lifestyle modifications can help manage mood during menopause?

Answer 7

Sleep, regular exercise, and relaxation.

Question 8

What lifestyle modifications can help manage cognitive symptoms during menopause?

Answer 8

Regular exercise and good sleep hygiene.

Question 9

What are the contraindications for HRT?

Answer 9

Current or past breast cancer, Any oestrogen-sensitive cancer, Undiagnosed vaginal bleeding, Untreated endometrial hyperplasia.

Question 10

What percentage of women use HRT to treat menopausal symptoms?

Answer 10

Roughly 10% of women.

Question 11

What should be avoided if a woman with a uterus is given HRT?

Answer 11

Unopposed oestrogens as it will increase her risk of endometrial cancer.

Question 12

What are the risks associated with HRT?

Answer 12

Venous thromboembolism, Stroke, Coronary heart disease, Breast cancer, Ovarian cancer.

Question 13

What medications can be used to manage vasomotor symptoms if not using HRT?

Answer 13

Fluoxetine, citalopram, or venlafaxine.

Question 14

What can be used to manage vaginal dryness during menopause?

Answer 14

Vaginal lubricant or moisturiser.

Question 15

What can be used to manage psychological symptoms during menopause?

Answer 15

Self-help groups, cognitive behavior therapy, or antidepressants.

Question 16

What can be prescribed for urogenital atrophy during menopause?

Answer 16

Vaginal oestrogen.

Question 17

When should HRT treatment be stopped for vasomotor symptoms?

Answer 17

After 2-5 years, with regular attempts to discontinue treatment.

Question 18

When should a woman be referred to secondary care for menopausal symptoms?

Answer 18

If treatment has been ineffective, if there are ongoing side effects, or if there is unexplained bleeding.

Question 19

summarise menopause management

Answer 19

Menopause: management

Menopause is defined as the permanent cessation of menstruation. It is caused by the loss of follicular activity. Menopause is a clinical diagnosis usually made in primary care when a woman has not had a period for 12 months.

Menopausal symptoms are very common and affect roughly 75% of postmenopausal women. Symptoms typically last for 7 years but may resolve quicker and in some cases take much longer. The duration and severity are also variable and may develop before the start of the menopause and in some cases may start years after the onset of menopause.

The CKS has very thorough and clear guidance on the management of menopause and is summarised below.

The management of menopause can be split into three categories:
Lifestyle modifications
Hormone replacement therapy (HRT)
Non-hormone replacement therapy

Management with lifestyle modifications

Hot flushes
regular exercise, weight loss and reduce stress

Sleep disturbance
avoiding late evening exercise and maintaining good sleep hygiene

Mood
sleep, regular exercise and relaxation

Cognitive symptoms
regular exercise and good sleep hygiene

Management with HRT

Contraindications:
Current or past breast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia

Roughly 10% of women will have some form of HRT to treat their menopausal symptoms. There is a current drive by NICE to increase this number as they have found that women were previously being undertreated due to worries about increased cancer risk. If the woman has a uterus then it is important not to give unopposed oestrogens as this will increase her risk of endometrial cancer. Therefore oral or transdermal combined HRT is given.

If the woman does not have a uterus then oestrogen alone can be given either orally or in a transdermal patch.

Women should be advised that the symptoms of menopause typically last for 2-5 years and that treatment with HRT brings certain risks:
Venous thromboembolism: a slight increase in risk with all forms of oral HRT. No increased risk with transdermal HRT.
Stroke: slightly increased risk with oral oestrogen HRT.
Coronary heart disease: combined HRT may be associated with a slight increase in risk.
Breast cancer: there is an increased risk with all combined HRT although the risk of dying from breast cancer is not raised.
Ovarian cancer: increased risk with all HRT.

Management with non-HRT

Vasomotor symptoms
fluoxetine, citalopram or venlafaxine

Vaginal dryness
vaginal lubricant or moisturiser

Psychological symptoms
self-help groups, cognitive behaviour therapy or antidepressants

Urogenital symptoms
if suffering from urogenital atrophy vaginal oestrogen can be prescribed. This is appropriate if they are taking HRT or not
vaginal dryness can be treated with moisturisers and lubricants. These can be offered alongside vaginal oestrogens if required.

Stopping treatment

For vasomotor symptoms, 2-5 years of HRT may be required with regular attempts made to discontinue treatment. Vaginal oestrogen may be required long term. When stopping HRT it is important to tell women that gradually reducing HRT is effective at limiting recurrence only in the short term. In the long term, there is no difference in symptom control.

Although menopausal symptoms can be managed mainly in primary care, there are some instances when a woman should be referred to secondary care. She should be referred to secondary care if treatment has been ineffective, if there are ongoing side effects or if there is unexplained bleeding.

Textbooks

Links
Clinical Knowledge Summaries32
Menopause guidelines
Report broken link
Media
YouTube
Menopause
MedFlix - YouTube61

YouTube
Premature ovarian failure
Osmosis - YouTube51

YouTube
Menopause
Osmosis - YouTube42

Question 20

A 55-year-old lady comes to see you as she is suffering from hot flushes. She finds these come on randomly and are interfering with her work as a barrister, particularly if she gets them whilst she is in court.

She is reluctant to try hormone replace therapy due to the side effects but was wondering if there is anything else that could help her. Which one of the following medications can she be prescribed?

Evening primrose oil
Fluoxetine
Pregabalin
Folic acid
Oestrogen cream

Answer 20

Fluoxetine

NICE guidelines advise that menopausal women suffering from vasomotor symptoms can be given a selective serotonin uptake inhibitor (SSRI) such as fluoxetine. Clonidine is also licensed for the treatment of vasomotor symptoms in menopause, however, there is limited evidence of its efficacy, and it is associated with side effects including dry mouth, sedation, depression and fluid retention. Gabapentin may also be effective for reducing hot flushes, however, further research is currently being done on this.