Women's health toolkit: Menopause

Menopause

The menopause is the biological stage in a woman’s life when menstruation stops permanently, due to the loss of ovarian follicular activity. It is diagnosed clinically 12 months after the last menstrual period. Before that, the perimenopause is a time of irregular cycles and fluctuating hormone levels, often accompanied by vasomotor symptoms (hot flushes and night sweats), as well as other symptoms of the menopause. The average age of the menopause in the UK is 51 years – an early menopause is one that occurs at less than 45, and premature menopause or premature ovarian insufficiency (POI) is that which occurs below the age of 40. Post menopausal women are at an increased risk of osteoporosis, cardiovascular disease and genitourinary syndrome of the menopause (GSM) and those with POI are also at increased risk of all-cause mortality, depression and type 2 diabetes when compared with women who have their menopause at the usual time.

The use of hormone replacement therapy (HRT) to treat the menopause and perimenopause has fluctuated over the years, often in response to press reports of studies to do with risks such as breast cancer. Many of these studies looked at populations who are very different from women in the UK who use HRT, such as the Women’s Health Information (WHI) study, whose participants had an average age of 63 when they started HRT, using regimes that are now rarely used in the UK. We now know that the use of HRT does not increase mortality from breast cancer and that the absolute number of increased cases is small, and only seen in women using combined HRT. A woman’s risk of breast cancer is increased much more if she has obesity than if she uses HRT but has a normal BMI.

Click here to see two NUBs (‘new and useful bits’) on HRT and menopause which summarise some of the key issues to do with the menopause and the use of HRT, including some basic information about the risk of breast cancer and venous thromboembolism (VTE). In general, women who have had breast cancer in the past should not be prescribed systemic HRT without a specialist opinion, and those who are at an increased background risk of VTE should use transdermal rather than oral HRT, as transdermal preparations do not increase the risk of VTE.

More information can be found in the following resources:

• RCGP eLearning module on the menopause.

• RCGP ‘Five minutes to Change Your Practice’ screencasts on HRT and breast cancer risk, and over the counter treatment of the menopause.

• British Menopause Society consensus statements and tools for clinicians, on a variety of subjects, including the management of POI, recommendations for HRT, the benefits and risks of HRT before and after a breast cancer diagnosis, and non-hormonal treatments for menopausal women.

• Primary care women’s health forum guidance on menopause management and prescribing HRT for GPs.

• NICE CKS page on the menopause.

• NICE guidance on the menopause and on familial breast cancer – this can be helpful in deciding whether to refer to genetics if a menopause consultation uncovers a strong family history.

• Patient information from the Women’s Health Concern, Menopause Matters, Rock my menopause, the Daisy network (about POI) and the RCOG.