Menopause refers to the point in time when permanent cessation of menstruation occurs usually due to loss of ovarian function. The age of onset is usually between 45 and 55 years. It may however occur earlier. A woman is considered to be postmenopausal if there is no menstruation for a period of at least 6 months and she is not pregnant.

It is associated with physical, emotional and psychological upheaval of varying intensity in the affected individual.

CAUSES

• Natural onset due to the age of the individual
• Due to surgical extirpation of the ovaries (bilateral oophorectomy)
• Pelvic irradiation
• Premature

• Ovarian failure
• Pituitary damage from primary post-partum haemorrhage (PPH) (Sheehan’s syndrome)

• Cytotoxic (anticancer) therapy

SYMPTOMS

Sixty percent of menopausal women may be asymptomatic. When symptoms occur they can be mild or severe. The following symptoms may be particularly distressing:

• Hot flushes (heat or burning in the face, neck and chest with resultant sweating. The flushes may be associated with palpitations, faintness, dizziness, fatigue and weakness)

• Vaginal dryness

• Emotional and psychological problems include:

• Mood changes

• Depression
• Anxiety
• Nervousness
• Irritability
• Loss of libido

• Atrophic changes in the genital tract may give rise to the following:

• Increased frequency of micturiction and dysuria.
• Stress incontinence (urinary incontinence with coughing or straining).
• Vaginal dryness

Long term problems include:

• Osteoporosis with resultant fractures:

• Vertebral compression fractures in the thoraco-lumbar spine causing backache, reduced body height and kyphosis. (refer to appropriate sections for management)

• Cardiovascular problems:

• Increased cardiac problems including heart attacks. (refer to appropriate sections for management)

INVESTIGATIONS

• FBC, sickling
• Hormone tests if available (serum LH, FSH, Oestradiol)
• Blood chemistry - blood glucose, lipid profile
• Pelvic ultrasound scan
• X-ray long bones and thoraco-lumbar spine
• Mammography

TREATMENT

Therapeutic objectives

• To control symptoms.
• To replace lost calcium.

Non-Pharmacological Treatment

• Patients need counselling and reassurance. Explain the problem and its treatment. For mild symptoms patients may benefit from counselling and reassurance alone.

Pharmacological Treatment

(Evidence rating: A)

1. Severe cases would benefit from hormone replacement therapy.

• Conjugated oestrogens and progestogen - 28 tablets each containing conjugated oestrogens, 625 micrograms and 12 tablets, each containing norgestrel, 150 micrograms

Dose: menopausal symptoms, in women with intact uterus, 1 conjugated oestrogen tablet daily continuously, starting on day 1 of menstruation (or at any time if cycles have ceased or are infrequent), and 1 norgestrel tablet daily on days 17 - 28 of each 28-day treatment cycle; subsequent courses are repeated without any interval

• Conjugated oestrogens - 625 microgram daily. To be given only to patients with previous hysterectomy and NEVER to those with an intact uterus

CAUTION:

Current evidence suggests an increased risk of coronary heart disease and strokes in healthy post-menopausal women who have been given hormone replacement therapy.

2. ADD calcium supplements, oral, 500 mg twice or 3 times daily.

• Indications for treatment include:
• Severe hot flushes
• Atrophic vaginitis
• Premature menopause
• Osteoporosis
• Recurrent cystitis

Contraindications to hormonal treatment include: previous thrombo-embolic phenomena, chronic liver disease, breast cancer and endometrial cancer, hypertension and diabetes mellitus.