Menopause
Exam Tips
- In OSCEs, diagnose menopause clinically in women 45+ with typical symptoms; avoid routine FSH in this group.
- Always state uterine status before prescribing HRT: uterus present requires progestogen for endometrial protection.
- Name absolute/major contraindications to systemic HRT: active or recent breast cancer, unexplained vaginal bleeding, active VTE/thrombophilia, active severe liver disease, pregnancy.
- Mention route selection: transdermal estradiol is preferred when VTE risk is higher.
- For POI, examiners expect: confirm diagnosis, offer HRT unless contraindicated, continue to around age 51, and address fertility plus bone/cardiovascular protection.
- Use a visual memory aid for viva answers: hypothalamic-pituitary-ovarian feedback changes across reproductive life (see figure in your core gynaecology endocrinology chapter).
Definition
Menopause is the permanent end of menstruation caused by loss of ovarian follicular activity, diagnosed clinically after 12 consecutive months without periods when no other cause is present. In UK practice, natural menopause usually occurs between 45 and 55 years (average about 51), while early menopause occurs at 40-45 years and premature ovarian insufficiency (POI) is ovarian failure before 40.
Pathophysiology
Women are born with a finite ovarian follicle pool; progressive follicular depletion leads to falling inhibin B and estradiol, reduced negative feedback at the hypothalamic-pituitary axis, and rising FSH/LH. During perimenopause this endocrine change is fluctuating, so ovulation becomes irregular and often anovulatory before periods cease. Persistent hypoestrogenism then drives vasomotor instability (hot flushes/night sweats), urogenital atrophy (genitourinary syndrome of menopause), sleep disturbance, and long-term effects on bone, vascular, and metabolic health. In POI, the same hormonal pattern occurs earlier and may be intermittent, so occasional spontaneous ovulation can still occur.
Risk Factors
- Increasing age (typical 45-55 years)
- Smoking
- Underweight/low BMI
- Early menarche
- Nulliparity or low parity
- Family history of early menopause or POI
- Bilateral oophorectomy
- Chemotherapy or pelvic radiotherapy
- Autoimmune disease (for example autoimmune thyroid disease, Addison disease, type 1 diabetes)
- Genetic/chromosomal causes (for example X-chromosome abnormalities, galactosaemia)
Clinical Features
Symptoms
- Irregular menstrual cycles progressing to amenorrhoea
- Hot flushes and night sweats
- Sleep disturbance and fatigue
- Mood change (irritability, anxiety, low mood), cognitive complaints (poor concentration/memory)
- Vaginal dryness, burning, itching, discomfort
- Dyspareunia and reduced libido
- Urinary urgency/frequency, dysuria, recurrent lower UTI symptoms
- Headache, joint and muscle aches
Signs
- Often no specific examination signs in early transition
- Features of vulvovaginal atrophy: pale, dry, thin vaginal epithelium with reduced rugae
- Possible introital narrowing/tenderness on pelvic examination
- Associated cardiometabolic risk factors or reduced bone health may be present in later disease
Investigations
Management
Lifestyle Modifications
- Explain menopause trajectory and validate symptoms; shared decision-making
- Smoking cessation, regular weight-bearing/resistance exercise, healthy weight, Mediterranean-style diet
- Limit alcohol and excess caffeine; identify flush triggers (for example spicy foods, overheating)
- Sleep hygiene and psychological support (including CBT approaches for vasomotor symptoms, mood, and insomnia)
- Sexual health advice: lubricants/moisturisers, pelvic floor support, partner communication
- Contraception advice until menopause is confirmed (HRT is not contraception)
Pharmacological Treatment
Systemic HRT: oestrogen-only (women without a uterus)
- Estradiol oral 1 mg once daily, increase to 2 mg once daily if needed
- Estradiol transdermal patch 25-100 micrograms/24 h (commonly start 25-50 micrograms/24 h), changed twice weekly
- Estradiol gel 0.75-1.5 mg daily initially, titrate to symptom control
Use lowest effective dose with regular review. Transdermal route is preferred in higher VTE risk, migraine, obesity, smokers, and hypertension.
Systemic HRT: combined oestrogen + progestogen (women with a uterus)
- Micronised progesterone 200 mg at night for 12 days per 28-day cycle (sequential regimen) with continuous estradiol
- Micronised progesterone 100 mg at night continuously (continuous combined regimen) with continuous estradiol
- Levonorgestrel intrauterine system (52 mg LNG-IUS) with systemic estradiol for endometrial protection
Progestogen is essential to prevent endometrial hyperplasia/cancer when uterus is present. Use sequential regimens if perimenopausal; continuous combined regimens are usually preferred once postmenopausal.
Local vaginal oestrogen for GSM
- Estradiol vaginal tablet 10 micrograms daily for 2 weeks, then 10 micrograms twice weekly maintenance
- Estriol 0.01% vaginal cream 0.5 mg daily for 2-3 weeks, then 0.5 mg twice weekly
- Estradiol vaginal ring releasing about 7.5 micrograms/24 h, changed every 90 days
Can be used alone or with systemic HRT and usually continued long term because symptoms often recur when stopped. Systemic absorption is low.
Non-hormonal options for vasomotor symptoms when HRT unsuitable or declined
- Venlafaxine modified-release 37.5 mg once daily, increase to 75 mg once daily
- Escitalopram 10 mg once daily (or citalopram 10-20 mg once daily)
- Gabapentin 300 mg at night initially, titrate to 300 mg three times daily as tolerated
- Clonidine 25 micrograms twice daily, titrate cautiously (for example to 50 micrograms twice daily)
Benefits are usually smaller than HRT; select based on comorbidity and adverse-effect profile. Avoid paroxetine/fluoxetine with tamoxifen due to CYP2D6 inhibition.
Androgen therapy for hypoactive sexual desire disorder (specialist use)
- Testosterone transdermal gel, female dose about 5 mg daily (off-label in UK female menopause practice)
Consider only after optimising oestrogen and excluding psychosocial/relationship causes; monitor clinical response and androgen excess.
Complications
- Osteoporosis and fragility fracture
- Cardiovascular disease
- Cerebrovascular disease (stroke/TIA risk with ageing profile)
- Genitourinary syndrome of menopause with recurrent urinary symptoms
- Sexual dysfunction and relationship strain
- Mood disorders, sleep disturbance, reduced quality of life
- In POI: reduced fertility, increased all-cause mortality, higher risk of type 2 diabetes and cognitive decline
Prognosis
Symptom burden is highly variable: many women have vasomotor symptoms for around 7-9 years, and a substantial minority for longer than 10 years. GSM often persists or worsens without treatment. Early menopause/POI carries greater long-term cardiometabolic and bone risk, but timely HRT (usually until the average age of natural menopause) plus lifestyle risk reduction improves outcomes.
Sources & References
🏥BMJ Best Practice(2)
✅NICE Guidelines(1)
- Menopause[overview]
📖Textbook References(1)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1712)[context]