Hot flushes, sleep and the years around the menopause
Gynaecology
Family practice or menopause clinic, usually between 45 and 55
The first question
Is this the menopause, what is bothering her most, and is there a reason not to offer hormone therapy?
- 01
Confirm the stage
Over 45 with vasomotor symptoms and changing or absent periods: the diagnosis is clinical and needs no hormone test. Under 45, and especially under 40, test and investigate, because early menopause has consequences.
- 02
Name the symptoms that matter to her
Vasomotor, sleep, mood, joint aches, genitourinary symptoms, sexual function; use a symptom scale to track them.
- 03
Screen for the mimics and the risks
Thyroid disease, anaemia, depression, medication effects; breast cancer history and risk, venous thrombosis, cardiovascular disease, liver disease, unexplained bleeding.
- 04
Discuss the options
Menopausal hormone therapy for those who want it and have no contraindication, transdermal when thrombotic risk is raised, a progestogen whenever the uterus is present; non-hormonal options (cognitive behavioural therapy, SSRI or SNRI, gabapentin, fezolinetant where available); vaginal estrogen for genitourinary symptoms with almost no systemic effect.
- 05
Review
At three months for symptoms and side effects, then yearly; bleeding on hormone therapy after the first months is investigated as postmenopausal bleeding.
Where it is
Each opens the structure on the 3D pelvis.
History that discriminates
- Vasomotor symptoms: frequency, night sweats, effect on sleep and work
- Menstrual pattern over the last year, and any bleeding after 12 months without periods
- Mood, anxiety, cognition, joint and muscle aches, palpitations
- Vaginal dryness, dyspareunia, urinary frequency and infections
- Contraception, which is still needed for a year after the last period over 50 and two years under 50
- Personal and family history of breast cancer, venous thrombosis, stroke, heart disease, osteoporosis and fracture
- Smoking, alcohol, weight, exercise and bone risk factors; a hysterectomy or endometriosis in the past
- What she has tried, what she has read, and what she wants
Examination that discriminates
- Blood pressure, weight and BMI
- Breast examination when symptoms or risk warrant it, and screening status
- Pelvic examination if there is bleeding, pain or genitourinary symptoms: atrophy, an adnexal mass
- Thyroid gland
Investigations
- None to diagnose the menopause over 45
- FSH on two occasions when under 45; under 40, the work-up for premature ovarian insufficiency (karyotype, fragile X premutation, adrenal and thyroid antibodies)
- Thyroid function, full blood count and ferritin when symptoms could be something else
- Lipids, glucose and a cardiovascular risk estimate; a fracture risk assessment and bone density where indicated
- Endometrial assessment for any postmenopausal bleeding or unscheduled bleeding on hormone therapy
The differential
| Diagnosis | Favours | Against | Urgency |
|---|---|---|---|
| Perimenopause and menopause | Over 45, vasomotor symptoms, changing then absent periods | Under 40, a goitre, weight loss, an unexplained bleed | routine |
| Premature ovarian insufficiency | Under 40 with irregular or absent periods and raised FSH on two occasions | Regular cycles, normal FSH | urgent |
| Thyroid disease | Heat intolerance with weight loss, tremor, goitre, or fatigue and weight gain with a raised TSH | Normal thyroid function | routine |
| Depression or anxiety disorder | Persistent low mood, anhedonia, previous episodes; symptoms not tied to hot flushes and sleep | Mood that tracks the night sweats | routine |
| Medication effect or another cause of flushing | Tamoxifen, aromatase inhibitors, SSRIs, alcohol, carcinoid or mastocytosis in the rare case | A typical menopausal pattern | routine |
| Endometrial pathology | Bleeding after 12 months of amenorrhoea, or unscheduled bleeding on hormone therapy beyond the first months | No bleeding | urgent |
Pitfalls this pathway refuses
- Ordering an FSH to diagnose the menopause in a woman over 45
- Withholding hormone therapy from a symptomatic woman under 60 without a contraindication because of a general fear of risk
- Giving estrogen without a progestogen to a woman with a uterus
- Forgetting contraception in the perimenopause
- Treating genitourinary symptoms with systemic therapy alone when vaginal estrogen is what works
- Not investigating bleeding on hormone therapy