Describe menopause and hormone replacement therapy — its aetiology, clinical features and management.

Definition

Menopause is the permanent cessation of menstruation due to loss of ovarian follicular activity, diagnosed retrospectively after 12 months of amenorrhoea. It occurs at an average age of about 50 years.

Features (of Oestrogen Deficiency)

• Vasomotor — hot flushes and night sweats.
• Urogenital atrophy — vaginal dryness, dyspareunia and urinary symptoms.
• Long-term — osteoporosis (fracture risk) and an increased cardiovascular risk; mood and sleep disturbance.

Hormone Replacement Therapy (HRT)

• Composition — oestrogen for symptom relief, combined with a progestogen in women with a uterus (to protect the endometrium from unopposed-oestrogen hyperplasia/cancer); oestrogen alone after hysterectomy.
• Indications — troublesome vasomotor/urogenital symptoms and premature menopause; benefits include symptom relief and bone protection.
• Risks — venous thromboembolism, a small increase in breast cancer (combined HRT) and endometrial cancer (unopposed oestrogen).
• Contraindications — oestrogen-dependent cancer, undiagnosed bleeding, active thromboembolism and severe liver disease.

Diagnosis and Non-hormonal Measures

The diagnosis is clinical (12 months' amenorrhoea at the appropriate age), with a raised FSH where confirmation is needed. Non-hormonal options for those who cannot take HRT include lifestyle measures, SSRIs/SNRIs or clonidine for flushes, vaginal moisturisers/local oestrogen for atrophy, and calcium/vitamin-D with bisphosphonates for bone protection.

A Note on WHY the Timing of HRT Determines its Safety

A useful and much-misunderstood point is why hormone replacement therapy swung from being prescribed to almost everyone, to being feared and abandoned, and now to being used selectively — and why the key variable is timing. The alarm followed the Women's Health Initiative trial, which reported increased breast cancer, stroke and thromboembolism. But that trial studied predominantly older women, many of them a decade or more past the menopause. Subsequent analysis produced the 'timing hypothesis' (the window of opportunity): HRT started close to the menopause — in a woman under 60, within 10 years of her last period — relieves symptoms with a favourable risk-benefit balance and may even be cardioprotective, whereas HRT begun many years later, in arteries that have already developed atherosclerotic plaque, may destabilise them and cause harm. This is why current practice is to give HRT for the relief of significant symptoms (vasomotor flushes, urogenital atrophy), at the lowest effective dose, for the shortest necessary time, in appropriately-selected women started early. Two further rules: a woman with a uterus must always be given a progestogen with the oestrogen (unopposed oestrogen causes endometrial carcinoma), and purely local vaginal symptoms need only local oestrogen.

Add progestogen if the uterus is present, to protect the endometrium.

• Menopause = permanent cessation of menstruation for 12 months (mean ~47–51 years) due to ovarian follicular exhaustion — confirmed by a high FSH.
• Symptoms: vasomotor (hot flushes, night sweats), urogenital atrophy (dryness, dyspareunia, urinary symptoms), mood and sleep disturbance; long-term — osteoporosis and cardiovascular risk.
• HRT is given mainly for significant symptoms — the 'window of opportunity': start within 10 years of the menopause / under 60, at the lowest effective dose.
• A woman with A uterus must receive a progestogen with the oestrogen — unopposed oestrogen causes endometrial hyperplasia and carcinoma.
• Risks: breast cancer (with long use), VTE and stroke; contraindications include breast/endometrial cancer, undiagnosed bleeding, active VTE and liver disease. Local vaginal oestrogen suffices for urogenital symptoms alone.