Menopause
Menopause is the permanent cessation of menstruation due to loss of ovarian follicular activity, usually occurring between 45-55 years of age.
This updated UKMLA guide to menopause is based on NICE NG23 and NICE CKS, which covers definitions, symptoms, complications, diagnosis, and management.
Definitions
Menopause refers to the biological stage where menstruation stops permanently due to loss of ovarian follicular activity.
Some other closely related terms:
| Term | Definition |
|---|---|
| Early menopause | Menopause that happens between 40-45 y/o |
| Peri-menopause | The period before menopause, where there are irregular cycles of ovulation and menstruation |
| Post-menopause | The period after menstruation has not occurred for 12 consecutive months |
| Premature ovarian insufficiency (premature ovarian failure) | Transient or permanent loss of ovarian function before 40 y/o |
Expected Timing
Menopause usually happens between 45-55 y/o, mean age of menopause is 51 y/o
Early menopause is defined as menopause happening between 40-45 y/o
Causes and Risk Factors
Most common cause: physiological age-related menopause
- Women are born with a fixed number of oocytes, which reduces with each menstrual cycle
- Menopause is characterised by the depletion of the oocyte store and the cessation of menstruation
Iatrogenic causes of menopause:
- Bilateral oophorectomy
- Gonadotoxic medications (e.g. GnRH agonist)
- Pelvic radiotherapy
- Chemotherapy
Risk factors for early menopause:
- Early menarche
- Nulliparity / low parity
- Smoking
- Underweight
Clinical Features
Menopausal symptoms typically last for 7–9 years. ~20% of women experience symptoms for up to 15 years.
| Changes in menstrual cycle | During peri-menopause
When menopause occurs: complete amenorrhoea (if the person is not using HRTHormone replacement therapy or hormonal contraception) |
| Vasomotor symptoms |
Caffeine, spicy food and alcohol may trigger vasomotor symptoms |
| Urogenital symptoms (genitourinary syndrome of menopause) | Urogenital symptoms arise from vulvovaginal atrophy (caused by declining oestrogen levels):
|
| Cognitive impairment and mood disorders |
Mood disorders can also result in sleep disturbances |
| Sexual dysfunction | Loss of sexual desire and libido can result from:
|
| Other features |
|
Complications
Post-menopausal women are at increased risk of:
- Osteoporosis and associated fragility fractures
- Cardiovascular diseases
- Cerebrovascular disease (stroke and TIATransient ischaemic attack)
Investigation and Diagnosis
Menopause can be diagnosed clinically (with no blood tests) if a patient is:
- ≥45 y/o, AND
- Has ≥12 months of amenorrhoea
If a <45 y/o woman presents with menopause symptoms → measure serum FSH level (take 2 samples, 4-6 weeks apart):
- Persistently elevated FSH indicates reduced ovarian function
- The exact diagnosis depends on the age of the patient:
- 40-44 y/o → early menopause
- <40 y/o → premature ovarian insufficiency
Consider performing a pregnancy test to exclude pregnancy as a cause of amenorrhoea.
Do not measure FSH levels to identify menopause in those who are taking COCPCombined oral contraceptive pill or high-dose progestogen or tamoxifen.
Do NOT use the following tests to identify menopause in people aged 45 or over:
- Anti-Müllerian hormone
- Inhibin A and B
- Oestradiol
- Antral follicle count
- Ovarian volume
Management
Tailor management to the patient’s presenting symptoms and priorities; do not offer all treatments routinely.
| Menopause symptom | Recommended management |
|---|---|
| Vasomotor symptoms (hot flushes / night sweats) |
|
| Urogenital symptoms (genitourinary syndrome of menopause) |
Vaginal oestrogen should be avoided in those with a personal history of breast cancer → offer non-hormonal vaginal moisturisers / lubricants as 1st line. |
| Depressive symptoms | Consider:
|
| Sleep disturbances | Consider menopause-specific CBTCognitive behavioural therapy |
| Low sexual desire / libido | Consider testosterone supplementation if HRT alone is not effective |
References
NICE guideline Menopause: identification and management
NICE CKS Menopause
Related Articles
Hormone Replacement Therapy (HRT)