Management of Menopausal Symptoms
NEW Management of Menopausal Symptoms (compiled from the EDL and NICE 2015)
Medicine treatment for severe menopausal symptoms
Management of menopausal symptoms (compiled from the EDL and NICE 2015)
Diagnosis
Otherwise healthy women aged over 45 years with menopausal symptoms:
- perimenopause based on vasomotor symptoms and irregular periods
- menopause in women who have not had a period for at least 12 months and are not using hormonal contraception
- menopause based on symptoms in women without a uterus.
No laboratory tests needed to confirm diagnosis in these cases.
Do a FSH test (estrogen level not necessary) to diagnose or exclude menopause in:
- women aged 40 to 45 years with menopausal symptoms, including a change in menstrual cycle.
- women aged under 40 years in whom menopause is suspected (premature ovarian failure).
General Measures
Counselling:
- Stop smoking.
- Maintain a balanced diet.
- Regular exercise
Do general examination as well as breast and gynaecological examination (including cervical cytology if indicated) to exclude any pathology or contraindications for HT.
Medicine Treatment for Severe Menopausal Symptoms
Hormone therapy (HT)
- This is not indicated in all postmenopausal women. Women with significant menopausal symptoms and those with osteoporosis risk factors will benefit most.
- The benefits of HT need to be weighed against the potential harm (e.g. breast cancer, venous thrombo-embolism)
- Long-term use of hormone therapy has safety issues and stopping treatment will result in return of menopausal symptoms. Gradually reducing HRT may limit recurrence of symptoms in the short term but not in the long term.
- Therapy in symptomatic postmenopausal women should be based on consideration of all risk factors for cardiovascular disease, age, and time from menopause
Contraindications to HT:
- Current, past or suspected breast cancer
- Known or suspected oestrogen-dependent malignant tumours
- Undiagnosed genital bleeding
- Untreated endometrial hyperplasia
- Previous or current venous thrombo-embolism
- Known arterial chronic heart disease (refer for specialist opinion)
- Active liver disease
- Porphyria
- Thrombophilia
A. Intact uterus (no hysterectomy)
HT can be offered as sequentially opposed or continuous combined preparations. Continuous combined preparations have the advantage of less breakthrough bleeding, but should only be commenced once the woman has been stable on sequentially opposed therapy for a year. Treatment should be planned for 5 years only and reviewed annually.
Sequentially Opposed Therapy
- Conjugated equine estrogens (e.g. Premarin), oral, 0.3–0.625 mg daily for 21 days
- Add medroxyprogesterone acetate, oral, 5–10 mg daily from day 11–21
- Followed by no therapy from day 22–28
OR
- Estradiol valerate, oral, 1–2 mg daily for 11 days
- Add medroxyprogesterone acetate, oral, 10 mg daily from day 11–21
- Followed by no therapy from day 22–28
Equivalent doses to medroxyprogesterone acetate:
- Norethisterone acetate, oral, 1 mg daily from day 11–21
- Cyproterone acetate, oral, 1 mg daily from day 11–21
Continuous Combined Therapy e.g.:
- Conjugated equine estrogens, oral, 0.3–0.625 mg plus medroxyprogesterone acetate, oral, 2.5–5mg daily.
OR
- Estradiol valerate, oral, 0.5–1 mg plus norethisterone acetate, oral, 0.5–1 mg daily.
Note:
- Start at the lowest possible dose to alleviate symptoms.
- The need to continue HT should be reviewed annually.
- Abnormal vaginal bleeding requires specialist consultation/referral.
- Any unexpected vaginal bleeding is an indication for excluding endometrial carcinoma. The use of transvaginal ultrasound to measure endometrial thickness plus the taking of an endometrial biopsy are recommended.
B. Uterus absent (post hysterectomy)
HT is given as estrogen only:
- Estradiol valerate, oral, 1–2 mg daily.
OR
- Conjugated equine estrogens, oral, 0.3 mg daily or 0.625 mg on alternative days up to a maximum of 1.25 mg daily.
REFERRAL to Tygerberg gynaecology (tel 021 938 4437):
- Premature menopause < 40 years of age
- Severe osteoporosis
- Management difficulties, e.g. where a contra-indication to oestrogen replacement therapy exists
- Post-menopausal bleeding
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Tygerberg Hospital, Department of Obstetrics and Gynaecology; Management of menopausal symptoms (compiled from the EDL and NICE 2015); Version: May 2013; Last checked for updates by EMGuidance: Oct 2023