Recognition
- Perimenopause: irregular cycles, vasomotor symptoms, sleep and mood disturbance, from the mid-40s. Menopause is a retrospective diagnosis after 12 months of amenorrhoea; FSH is not needed over 45 with typical symptoms.
- Premature ovarian insufficiency: menopause before 40; needs investigation (karyotype, fragile X, autoimmune screen) and hormone replacement until the average age of menopause for bone and cardiovascular protection.
- Symptoms: vasomotor (hot flushes, night sweats), genitourinary syndrome (dryness, dyspareunia, urinary symptoms), sleep, mood, joint pain, cognitive complaints.
Menopausal hormone therapy and alternatives
- The most effective treatment for vasomotor symptoms. Oestrogen alone after hysterectomy; oestrogen with a progestogen (or the levonorgestrel IUD) to protect the endometrium in those with a uterus.
- Transdermal oestrogen avoids the first-pass effect and carries a lower VTE risk than oral; preferred with obesity, VTE risk factors or hypertension.
- Risks depend on age and timing: started under 60 or within 10 years of menopause, benefits generally outweigh risks for symptomatic women. Breast cancer risk rises with combined therapy over years of use; VTE and stroke risk with oral oestrogen. Contraindications: current or past breast cancer, unexplained bleeding, active liver disease, prior VTE (oral), recent cardiovascular event.
- Vaginal oestrogen for genitourinary symptoms is low-dose, local and safe for most, including many breast cancer survivors after discussion.
- Non-hormonal: SSRIs and SNRIs, gabapentin, fezolinetant (a neurokinin-3 antagonist), cognitive behavioural therapy, lifestyle.
- Bone health: calcium, vitamin D, weight-bearing exercise, bone density assessment by risk; hormone therapy prevents bone loss while used.