Menopause

1. 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). 

2. 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.) 

3. 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. 

4. 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. 

5. 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 

6. In menopausal or perimenopausal women: 

   1. Specifically inquire about the use of natural or herbal products. 

   2. Advise about potential effects and dangers (i.e., benefits and problems) of natural or herbal products and interactions. 

7. In a menopausal or perimenopausal women, provide counselling about preventive health measures (e.g., osteoporosis testing, mammography). 

8. Establish by history a patient’s hormone-replacement therapy risk/benefit status. 

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

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

• • 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

• • 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

    • Offer choice of preparations

      • Transdermal combination estrogen and progestogen 

        • Estalis: 50mcg Estradiol + 140mcg NETA (or 50mcg Estradiol + 250mcg NETA) twice weekly application

      • Oral combination estrogen and progestogen 

        • Activelle: 1 mg estradiol + 0.5 mg norethindrone, one tablet daily

        • Activelle LD (low-dose): 0.5 mg estradiol + 0.1 mg norethindrone, one tablet daily

        • Angeliq: 1 mg estradiol + 1 mg drospirenone, one tablet daily

      • Tissue-selective estrogen complex

        • Duavive: 0.45 mg conjugated estrogen + 20 mg bazedoxifene, one tablet daily

      • Selective Tissue Estrogenic Activity Regular (STEAR)

        • Tibella: 2.5mg tibolone one tablet daily

      • If post-hysterectomy (no need for endometrial protection), estrogen only

        • Oral (Premarin, Estrace)

        • Transdermal (Estradot, Sandoz Estradiol Derm, Oesclim, Climara)

        • Transdermal gel (Estrogel, Divigel)

      • If comorbidities (Diabetes mellitus, HTN, smoking, obesity, DLP/CVD risk, gallstones), Transdermal preparation recommended

    • 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

  • 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