Menopause management

Quick Overview

Menopause is permanent cessation of menstruation due to ovarian failure, diagnosed after 12 months amenorrhoea (average age 51 years in UK). NICE NG23 emphasises individualised HRT prescribing, balancing symptom relief against cardiovascular and breast cancer risks. Critical for managing vasomotor symptoms, urogenital atrophy, and osteoporosis prevention.

Core Facts & Concepts

Diagnostic Criteria (NICE NG23)

• Perimenopause: Irregular cycles + vasomotor symptoms in women >45 years - diagnosis clinical, no FSH testing needed
• Premature ovarian insufficiency (POI): Menopause <40 years - requires 2 FSH levels >25 IU/L taken 4-6 weeks apart
• Women 40-45 years with menopausal symptoms: Consider FSH testing if atypical presentation

HRT Formulations

• Oestrogen-only HRT: For women post-hysterectomy (oral, transdermal patch/gel)
• Combined HRT: For women with intact uterus (progestogen protects endometrium)
  • Sequential: For perimenopausal women with periods
  • Continuous combined: For postmenopausal women (>12 months amenorrhoea)
• Transdermal preferred if: BMI >30, migraine, VTE risk, hypertriglyceridaemia

Key Contraindications

• Absolute: Current/past breast cancer, undiagnosed vaginal bleeding, active VTE/ACS, untreated endometrial hyperplasia, acute liver disease
• Caution: History VTE (use transdermal), cardiovascular disease, migraine with aura

📊 Treatment Duration

• Continue HRT as long as symptoms persist - no arbitrary time limit (NICE NG23)
• Review annually: Symptoms, risks/benefits, lifestyle
• POI: Continue until natural menopause age (~51 years)

Problem-Solving Approach

Step-by-Step HRT Initiation

1. Confirm diagnosis: Clinical if >45 years with typical symptoms
2. Risk stratification:
   • 🚩 VTE risk: Personal/family history, BMI >30, thrombophilia → use transdermal oestrogen (avoids first-pass hepatic metabolism)
   • 🚩 Breast cancer: Baseline risk 1:14 lifetime; combined HRT increases risk after 1 year (5 extra cases/1000 women over 5 years)
   • 🚩 CVD: Start <60 years or within 10 years of menopause (cardioprotective window)
3. Select formulation: Uterus present → combined; post-hysterectomy → oestrogen-only
4. Starting doses: Oestradiol 1-2mg oral or 50mcg transdermal
5. Review at 3 months: Symptom control, bleeding patterns, side effects

Red Flags During HRT

• Unscheduled bleeding after 12 months continuous combined HRT → urgent endometrial assessment
• New breast lump → 2-week-wait referral
• Leg swelling/chest pain → stop HRT, investigate VTE

Analysis Framework

Non-Hormonal Alternatives (NICE NG23)

Cardiovascular Risk Thresholds

• Low risk: Start HRT age <60 or within 10 years menopause - no increased MI/stroke risk
• High risk: Age >60 or >10 years post-menopause - relative risk CVD increases (avoid initiation)

Breast Cancer Risk

• Oestrogen-only HRT: Little/no increased risk for 7 years
• Combined HRT: Increased risk after 1 year (Type/duration progestogen-dependent)
• Micronised progesterone: May have lower breast cancer risk than synthetic progestogens

Visual Aid

HRT Risk-Benefit Summary

Key Points Summary

✓ Diagnosis clinical in women >45 years with typical symptoms - no FSH testing required (NICE NG23)

✓ HRT no arbitrary time limit - continue as long as benefits outweigh risks; review annually

✓ Transdermal oestrogen preferred for VTE risk, BMI >30, migraine, hypertriglyceridaemia (avoids hepatic first-pass)

✓ Breast cancer risk: Combined HRT increases risk after 1 year; oestrogen-only safer for 7 years

✓ Cardiovascular window: Start HRT <60 years or within 10 years menopause for cardioprotective benefit

✓ POI (<40 years): Requires 2 FSH >25 IU/L; treat with HRT until age 51 to prevent osteoporosis/CVD

✓ Vaginal oestrogen safe long-term for urogenital atrophy, including in breast cancer survivors (systemic absorption negligible)

⚠️ Warning: Unscheduled bleeding on continuous combined HRT after 12 months requires urgent endometrial investigation (2-week-wait if suspicious features)