Management of the menopause

Published on 09/03/2015 by admin

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Last modified 09/03/2015

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Chapter 13 Management of the menopause

Michael Flynn

Assessment

History

• past medical/surgical history
• family history
• oestrogen deficiency symptoms
• cigarette smoking (which changes the metabolism of oestrogen and reduces responsiveness to it)

Examination

• general, weight, blood pressure
• breast examination, pelvic examination

Investigations

• cervical cytology
• mammography and, if required, breast ultrasound
• bone density assessments
• vaginal ultrasound
• full blood examination, coagulation studies, lipid profile fasting glucose
• thyroid-stimulating hormone (TSH)

Management

The management of the menopausal woman is aimed at a full treatment regimen to optimise quality of life. The concept of risk and benefit should be fully explained. This includes management of:

• osteoporosis: prevention and treatment
• cardiovascular risk factors
• incontinence advice and treatment
• nutrition and exercise
• psychosexual dysfunction
• symptom relief of oestrogen deficiency symptoms

Oestrogen is the best short-term treatment for most symptomatic women with vasomotor symptoms. Contraindications to oestrogen therapy include history of breast cancer, coronary artery disease, thromboembolic event and stroke, or those at high risk of these complications. In women who have not had a hysterectomy, combined oestrogen and progesterone therapy is indicated.

The aim is to commence at lowest dose therapy for cessation of vasomotor symptoms. Topical vaginal oestrogen is effective in genitourinary symptoms. Testosterone therapy may be of help in some women with significant loss of libido or fatigue.

Trials

The Women’s Health Initiative (WHI)

This has been a long-term research program to address the most common causes of death, disability and quality of life in postmenopausal women. There have been many publications using these data.

Nurses Health Study

This study commenced in 1976 and expanded in 1989 with information from nurse participants in the United Kingdom. The primary focus is cancer prevention.

Million Women Study

Coordinated in Oxford, UK, women were recruited between 1996 and 2001 to investigate women’s health specifically in those over age 50. It particularly looks at hormone replacement therapy (HRT) and its effects on the breast and other aspects of health.

Within a clinical field where advice is changing as data emerge, the International Menopause Society provides consensus advice on the trials.

Cardiovascular disease and HRT

• HRT does not increase the risk in healthy women aged 50–59 and may even decrease the risk.
• It is unclear if there is an increase in stroke risk in healthy women aged 50–59, as no difference in WHI; however, increased risk was reported in the Nurses Health Study.
• The risk of venous thromboembolism is increased with HRT (less so with transdermal therapy); however, prevalence is low.

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