Menopause
- In any woman of menopausal age, screen for symptoms of menopause and (e.g., hot flashes, changes in libido, vaginal dryness, incontinence, and psychological changes).
- In a patient with typical symptoms suggestive of menopause, make the diagnosis without ordering any tests. (This diagnosis is clinical and tests are not required.)
- In a patient with atypical symptoms of menopause (e.g., weight loss, blood in stools), rule out serious pathology through the history and selective use of tests, before diagnosing menopause.
- In a patient who presents with symptoms of menopause but whose test results may not support the diagnosis, do not eliminate the possibility of menopause solely because of these results.
- When a patient has contraindications to hormone-replacement therapy (HRT), or chooses not to take HRT: Explore other therapeutic options and recommend some appropriate choices
- In menopausal or perimenopausal women:
- Specifically inquire about the use of natural or herbal products.
- Advise about potential effects and dangers (i.e., benefits and problems) of natural or herbal products and interactions.
- In a menopausal or perimenopausal women, provide counselling about preventive health measures (e.g., osteoporosis testing, mammography).
- Establish by history a patient’s hormone-replacement therapy risk/benefit status.
General Overview
General Overview
- Diagnosis
- Perimenopause
- Irregular periods and VMS until menopause
- Menopause
- >45yo and no period for 12 consecutive months and not using contraception
- If no uterus, diagnose based on symptoms
- Consider FSH <40-45yo
- If elevated FSH on 2 blood samples 4-6w apart and <40yo, diagnose premature ovarian insufficiency
- >45yo and no period for 12 consecutive months and not using contraception
- Perimenopause
Symptoms of menopause
Symptoms of menopause
- Vasomotor symptoms (VMS)
- Hot flashes, sweats
- Genitourinary syndrome of menopause (GSM) - previously vulvovaginal atrophy
- Urinary frequency/urgency/incontinence, dysuria
- Vaginal dryness/burning/pruritus, post-coital bleeding, sexual dysfunction, dyspareunia
- Mood, irritability
- Sleep changes
- Joint and muscle pain
History
History
- Changes in periods
- Symptoms of menopause
- Hot flashes, sweats
- Vaginal dryness/burning
- Sexual concerns (desire, arousal, pain, or orgasm)
- Bladder issues / incontinence
- Sleep
- Mood
Treatment
Treatment
- Lifestyle
- Healthy weight
- Diet (low sodium, low sugars - increase vegetables/fibers)
- Avoid VMS triggers (hot drinks, alcohol, caffeine)
- Exercise >150mins moderate-vigorous per week
- Routine Vitamin D +/- calcium
- STOP Smoking, alcohol
- Optimize sleep, relationship, mood
- Assess for HTN/DM/DLP
- VMS
- Hormone replacement therapy first-line if <60yo or <10y past menopause (can be continued beyond 65yo in cases where risk>benefit)
- Contraindicated in unexplained vaginal bleeding, pregnancy, history of breast cancer, coronary heart disease, a previous venous thromboembolic event or stroke, or active liver disease
- Risks per 1000 women with five years of hormone use
- Coronary heart disease (CHD) – 2.5 additional cases
- Invasive breast cancer – 3 additional cases
- Stroke – 2.5 additional cases
- Pulmonary embolism – 3 additional cases
- Colorectal cancer – 0.5 fewer cases
- Endometrial cancer – no difference
- Hip fracture – 1.5 fewer cases
- All-cause mortality – 5 fewer events
- Review at three months then annually (use up to 5y or longer)
- Unscheduled vaginal bleeding may happen in first 3 months
- Vaginal bleeding should be investigated to r/o endometrial cancer
- May consider waiting for 6 months before endometrial biopsy
- Unscheduled vaginal bleeding may happen in first 3 months
- Risks per 1000 women with five years of hormone use
- Contraindicated in unexplained vaginal bleeding, pregnancy, history of breast cancer, coronary heart disease, a previous venous thromboembolic event or stroke, or active liver disease
- Offer choice of preparations
- Estrogen-progesterone (EP) or tissue-selective estrogen complex (eg. Duavive)
- Transdermal
- Climara Pro (matrix patch) 45mcg Estradiol + 15mcg LNG once weekly
- Estalis 50mcg Estradiol + 140mcg NETA (or 250mcg NETA) twice weekly
- Oral
- FemHRT 2.5mcg EE + 0.5mg NETA once daily
- Premplus continuous 0.625mg CE + 2.5mg MPA (or 5mg MPA) once daily
- Premplus cycle 0.625mg CE + 10mg MPA 2 tabs once daily
- Transdermal
- If post-hysterectomy (no need for endometrial protection), estrogen only
- If comorbidities (Diabetes mellitus, HTN, smoking, obesity, DLP/CVD risk, gallstones), Transdermal preparation recommended
- Estrogen-progesterone (EP) or tissue-selective estrogen complex (eg. Duavive)
- Consider off-label transdermal testosterone therapy for menopausal women with low sexual desire if HRT alone is not effective
- Consider tissue-selective estrogen complexes (eg. Duavive) for breast/endometrial safety
- Non-hormonal (Clonidine, Pregabalin, SSRI, SNRI) are second-line, if failed HRT or contraindicated
- Hormone replacement therapy first-line if <60yo or <10y past menopause (can be continued beyond 65yo in cases where risk>benefit)
- GSM
- Water-based lubricants/moisturizer (equivalent to vaginal estrogen in a recent RCT)
- Vaginal estrogen (even if on systemic HRT)
- Estradiol 10mcg intravaginal tablet (Vagifem) daily x 2 weeks, then twice per week
- Estradiol 2mg intravaginal ring (Estring) in place for 90 days
- Estradiol 0.1mg/g cream (Estrace) 2-4g daily x 1-2w, then half dose 1-2 weeks, then maintenance dose of 1g 1-3x/week
- Conjugated estrogens 0.625mg/g cream (Premarin), dose 0.5-2g cream twice weekly (or cyclic 21 days on, 7 days off)
- CBT for mood and anxiety
- Limited evidence (efficacy and safety) for complementary and alternative medicine
References:
- NAMS 2017. http://www.menopause.org/docs/default-source/2017/nams-2017-hormone-therapy-position-statement.pdf
- CFP 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5389763/
- NICE 2015. https://www.nice.org.uk/guidance/ng23/chapter/Recommendations
- SOGC 2014. https://sogc.org/wp-content/uploads/2014/09/gui311CPG1505Erev.pdf
- Santen Richard J, Stuenkel Cynthia A, Burger Henry G, and Manson JoAnn E. Competency in menopause management: whither goest the internist? J Womens Health (Larchmt). 2014 Apr;23(4):281-5. http://online.liebertpub.com.proxy3.library.mcgill.ca/doi/full/10.1089/jwh.2014.4746