Menopause — Diagnosis, HRT & Care
Menopause is the permanent end of menstruation, diagnosed after 12 months without a period (when she is not on hormonal contraception)
The transition (perimenopause) can last several years, with irregular periods and symptoms such as hot flushes, night sweats, poor sleep, low mood and vaginal dryness
In women over 45, diagnose perimenopause from the symptoms and the irregular periods; blood tests are not needed
Hormone therapy (HT or HRT) is the most effective treatment for hot flushes and night sweats, and for vaginal symptoms and bone loss
For most healthy symptomatic women under 60 or within 10 years of menopause, the benefits of HT outweigh the risks
Women over 45: diagnose perimenopause clinically from vasomotor symptoms and irregular periods; do not use AMH, inhibin, oestradiol or ovarian scans
Women aged 40–45 with symptoms, or under 40 where menopause is suspected: consider an FSH test
Do not use FSH when she is on a combined hormonal contraceptive or high-dose progestogen; hormonal treatment can mask the picture
After hysterectomy without removal of the ovaries, diagnose from symptoms, since periods cannot be used
Premature ovarian insufficiency (under 40): symptoms with a raised FSH on two samples 4–6 weeks apart; offer hormone replacement until at least the natural age of menopause unless contraindicated
Hot flushes
Night sweats
Palpitations
Vaginal dryness and soreness
Pain with sex
Urinary urgency and recurrent infections
Low mood and anxiety
Poor sleep and tiredness
Poor concentration (“brain fog”)
Joint and muscle pain
Low sexual desire
Bone loss, later fractures
History: symptoms, last period, bleeding pattern, personal and family history of breast cancer, clots, stroke, heart disease, liver disease (from memory)
Examine: blood pressure, weight (BMI), breasts and pelvis as due, and check cervical screening is up to date (from memory)
Contraception: she can still conceive in perimenopause; offer advice on contraception until the menopause is confirmed
Bone health: calcium, vitamin D, weight-bearing exercise, no smoking, little alcohol; consider a bone scan when risk factors are present (from memory)
Lifestyle for symptoms: regular exercise, cool clothing, avoiding triggers such as spicy food, alcohol and caffeine (from memory)
| Situation | What to offer | Points to remember |
|---|---|---|
| Has a uterus | Oestrogen plus a progestogen (sequential if still having periods, continuous when postmenopausal) | The progestogen protects the endometrium; oestrogen alone is not given |
| No uterus | Oestrogen alone | No progestogen needed after hysterectomy (unless she had endometriosis, from memory) |
| Vaginal symptoms only | Vaginal oestrogen; moisturisers and lubricants | Safe to use alongside systemic HT; symptoms return when it stops; routine endometrial thickness checks are not advised |
| Raised risk of blood clots (for example BMI over 30) | Transdermal (patch or gel) rather than oral | Standard-dose transdermal HT carries no greater risk than baseline; refer high-risk women for haematology advice |
| Premature ovarian insufficiency | HT or a combined hormonal contraceptive until at least the age of natural menopause | Protects bone, heart and mood |
| Low sexual desire despite HT | Consider testosterone | Specialist-led; unlicensed in many places |
| Outcome | What the guidance says |
|---|---|
| Hot flushes and night sweats | HT is the most effective treatment |
| Bone | Lowers the risk of fracture while taken; the benefit fades after stopping |
| Heart disease | Does not raise the risk when started under 60; heart risk factors are not a bar when well managed |
| Stroke | Oral oestrogen gives a small increase; transdermal does not |
| Blood clots (VTE) | Oral HT raises the risk; standard-dose transdermal does not |
| Breast cancer | Oestrogen alone: little or no effect. Oestrogen with a progestogen: the risk may rise with duration and falls after stopping |
| Dementia | The effect is unknown |
| Diabetes | Does not raise the risk of type 2 diabetes |
Cognitive behavioural therapy can help hot flushes, low mood and sleep
Drugs such as SSRIs, SNRIs (for example venlafaxine) and clonidine are not first-line for flushes alone, but are options when hormones are unsuitable; do not give paroxetine or fluoxetine with tamoxifen
Newer non-hormonal drugs and gabapentin exist for hot flushes; follow your local guidance (from memory)
Herbal products such as isoflavones and black cohosh may help, but their safety is uncertain and they can interact with other medicines; St John’s wort has interaction risks
Vaginal symptoms: moisturisers and lubricants; local oestrogen may be used after specialist advice even in women who cannot take systemic HT
After breast cancer: give information on all options and refer to a menopause specialist
Review at 3 months for effect and side effects, then every year
Irregular bleeding is common in the first 3 months of HT; tell her to report it at the review, or promptly if it starts later
Refer if symptoms do not improve, side effects persist, or the choice is uncertain
She need not stop HT at age 60 or 65; review the risks and benefits regularly and continue while the benefit is clear
Stopping: she can stop gradually or at once; gradual stopping may limit a short-term return of symptoms
Keep up cervical and breast screening as for her age, and check blood pressure, weight and bone health (from memory)
Sending blood tests to diagnose menopause in a woman over 45
Giving oestrogen alone to a woman with a uterus
Forgetting contraception during the transition
Missing premature ovarian insufficiency in a young woman with irregular periods
Using oral HT in a woman at high clot risk, when a patch or gel would do
Not offering vaginal oestrogen, or stopping it when she has improved
Labelling every symptom as menopause without looking for other causes
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