Menopause resident survival guide

Menopause Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayeesha Kattubadi, M.B.B.S[2]

Synonyms and keywords: Perimenopause approach, Climacteric workup, Approach to menopause, Menopause workup, Menopause management

Overview

Menopause is a clinical state indicating the permanent cessation of ovarian function. Perimenopause refers to the period of transitioning before menopause characterised by irregular menstrual cycles. The diagnosis of menopause is made retrospectively based on the absence of menstrual cycles for 12 months. The average age of menopause is 51 years. Women can have symptoms of hot flashes, night sweats, sleep disturbance, mood changes, decreased libido, vaginal dryness, dyspareunia, etc. Women with intolerable symptoms can be treated with hormonal and non hormonal therapy. Conditions where menopause can occur early are primary ovarian insufficiency, bilateral oophorectomy, chemotherapy and radiation induced.

Causes

Common Causes

Commn causes of menopause include:

• Natural menopause
• Premature ovarian failure or Early menopause
• Surgical menopause
• Chemotherapy and radiation induced menopause

Diagnosis

Shown below is an algorithm summarizing the diagnosis of menopause.

Presence of Menopausal Symptoms + irregular/absent menstrual periods

Age

≥45 years

40-45 years

≤40 years

Uterus

Rule out other causes like pregnancy, hyperthyroidism, prolactinoma

Rule out medical and surgical causes of amenorrhea/oligomenorrhe

Absent

Present

Normal

Abnormal

Measure FSH and Estradiol two samples 4-6 weeks apart

Menopause diagnosed based on symptoms

Irregular periods+ menopausal symptoms

Amenorrhea>12 months ± menopausal symptoms

Amenorrhea > 12 months

Menopause ruled out

FSH elevated Estradiol depressed

Perimenopause

Menopause

Early menopause

Premature ovarian failure

Treatment

Shown below is an algorithm summarizing the treatment of menopause.

Menopausal symptoms

Genitourinary syndrome of menopause (vaginal dryness, itching, dyspareunia, urinary incontinence)

Vasomotor symptoms (hot flashes, night sweats)

Sleep problems

Water based lubricants Ospemifene Vaginal oestrogen

Based on patient preference

Regular exercise Sleep hygiene Avoid alcohol and caffeine

Life style modification

Medical therapy

-Avoid smoking, caffeine, alcohol -Use of fan, cool bedroom, cool shower -Relaxation exercises

Hormonal replacement therapy

Non-hormonal therapy

Post hysterectomy status

When hormonal use is contraindicated (History of breast cancer, Venous thromboembolism, Undiagnosed vaginal bleeding, etc.

Hysterectomised

Uterus in-situ

Paroxetine(SSRI) Clonidine Gabapentin

Oestrogen alone

Oestrogen+Progesterone

Do's

• In women with moderate risk of cardiovascular disease requiring treatment for vasomotor symptoms of menopause, use transdermal estradiol alone or in combination with micronised progesterone in women with uterus instead of oral oestrogen preparations.

• In women on hormone replacement therapy, use the lowest possible dose for the shortest duration(3-5 years).
• In women on hormone replacement therapy with unscheduled bleeding, evaluate for endometrial hyperplasia and endometrial cancer.
• In women with primary ovarian insufficiency and surgical menopause, hormonal replacement therapy to be given until anticipated age of menopause.
• Counsel patients regarding continued symptoms after discontinuing hormone replacement therapy.
• To maintain bone health recommended weight-bearing exercises, calcium and vitamin D supplements.

Don'ts

• Do not use measurements of anti müllerian hormone, inhibin B, estradiol, FSH, LH, testosterone in the diagnosis of menopause in women of age ≥45 years.
• Do not use FSH levels in diagnosing menopause in women <45 years of age who are on oral contraceptives.
• Do not use hormonal replacement therapy in women with high risk for cardiovascular disease, venous thromboembolism, breast cancer.
• Do not recommend use of complimentary medicine treatment options like black cohash, omega-3 fatty acids, red clover, vitamin E due to lack of sufficient data proving its efficacy.
• Do not use ospemifene for vaginal dryness in women with history of breast cancer.