Reproductive and Sexual Health Handbook

Menopause is the permanent cessation of menstruation resulting from the loss of ovarian follicular activity. The word ‘menopause’ is commonly used to describe the last menstrual period. It is a retrospective diagnosis and is said to have occurred after 12 months amenorrhoea. Menopause usually occurs between the ages of 45 and 55 in Australian women, with an average age of 51.^(1,74) This chapter often refers to “women” in describing those most commonly experiencing symptoms of menopause and seeking medical care. It is however acknowledged that trans and gender diverse people may also experience menopause and require care.

Menopause transition is the time before the final menstrual period when variability in the menstrual cycle is increased

Postmenopause is defined as starting 12 months after the last natural menstrual period.⁽³⁾ During this time, women may present with new or continuing symptoms such as hot flushes, night sweats, or genitourinary symptoms such as vaginal dryness and low libido. Symptoms may resolve within two to three years, but a significant number of women continue to have vasomotor symptoms for many years. A large observational study conducted over 17 years in the USA, the Study of Women’s Health Across the Nation

The primary event in the menopause transition is the ageing of the ovaries and attrition of ovarian follicles. The critical change appears to be in the number of ovarian follicles. Rapid loss of follicles occurs when the total number of follicles reaches approximately 25,000. This usually occurs when women are around the age of 37–38 years.⁽⁷⁾ The size of the ovarian reserve is the major determinant of both the transition from regular menses to the perimenopause, as well as to the menopause itself.⁽⁸⁾ The menopausal transition occurs when the ovarian primordial follicle numbers decrease to around 100.⁽⁹⁾

The reduced quality and capability of ageing follicles is reflected in an increase in the serum follicle-stimulating hormone (FSH) from the pituitary, and reduced follicular secretion of B inhibin, which is produced by the granulosa cells of the ovary, and is implicated in the pituitary’s negative feedback influence over FSH secretion. Once menstruation has ceased, ovarian follicle attrition is complete, and there are few remaining follicles. The cardinal change after menopause is the hormonal profile, which is primarily responsible for the physiological changes in the postmenopausal woman.

Due primarily to the lack of circulating estrogen, menopause may result in symptomatology which varies significantly from woman to woman. Some patients do not experience symptoms at all, while others experience symptoms which range from mild to severe. There are also longer-term changes that occur in the anatomy and physiology of the female body. Research suggests that symptoms last much longer than previously thought, which has implications for the duration of treatment.^{(5, 6)} Symptoms may be physical or psychological.

Patients will often present to discuss bodily changes that are occurring at this time. It is also important for clinicians to proactively ask about menopause and symptoms a woman may be experiencing when seeing a woman in the relevant age group.

Consultations should be patient centred and take account of both the patient and clinician agenda. Discuss the patient’s symptoms and concerns and enquire about other common symptoms of menopause, as well as taking a general medical history. It is important to validate the woman’s experience. Determine the level of distress these symptoms are causing. Explain the physiological and hormonal changes that are happening. Talking through issues and normalising what is happening may be all that is required for an individual woman. For others, more active treatment or management may be requested.

It can be very useful to provide information sheets or websites to your patient. Excellent resources can be found on the websites below:

Australasian Menopause Society (AMS) Jean Hailes Foundation

A menopause symptom score sheet can be useful in identifying symptoms potentially related to menopause, and monitoring change over time and in response to therapy. This can be accessed on the AMS website: www.menopause.org.au/images/stories/education/docs/AMS_Diagnosing_Menopause_Symptom_Score.pdf

Important areas, other than the obvious management

Systemic estrogen therapy is the most effective way of treating the vasomotor symptoms of menopause. Patients with an intact uterus should additionally always use a progestogen to protect the endometrium from hyperplasia and endometrial cancer.

Estrogen may also be administered topically to the genital tissues for genitourinary symptoms of menopause (vulvovaginal atrophy).

Non-hormonal medications may be useful if the use of a hormone preparation is contraindicated or not wanted. These include:

Clonidine 25 mcg to 50 mcg bd. Improvements in symptoms would be expected within 4 weeks. Selective Serotonin Reuptake Inhibitors (SSRIs) and Selective Serotonin and Noradrenaline Reuptake Inhibitors (SNRIs): SSRIs, e.g. escitalopram 10-20 mg daily and paroxetine 7.5 mg daily SNRIs, e.g. venlafaxine (75 mg SR per day) and desvenlafaxine (100 mg – 150 mg per day) Note that paroxetine reduces the efficacy of tamoxifen and should not be used in women taking this drug. Unlike the use of these medications for depression, relief of symptoms will be rapid and would be apparent within a month.⁽⁵¹⁾ They may also be useful in patients who present with features of anxiety and depression as well as vasomotor symptoms. Gabapentin 100 mg tds up to 300 mg tds. There may be a reduction in hot flushes within days.

Potential side effects should be discussed. Note that with the exception of clonidine, these non-hormone medications are not TGA approved for use for vasomotor symptoms and are not listed on the PBS for this indication.⁽⁵¹⁾

Herbal preparations

Many women use natural therapies to manage hot flushes and will often have tried these before they see a clinician to discuss their symptoms. Natural therapies include black cohosh, red clover and soy products, wild yam cream, flaxseed and ginseng. Black cohosh has been linked to rare cases of abnormal liver function, hepatitis and liver failure.⁽⁵²⁾ There is no consistent high-level evidence for the efficacy of these products, and their safety profile is unclear, so unless evidence for safety becomes available, their use cannot be recommended.

It is important to ask patients if they are using herbal preparations since there may be herb-drug interactions.

Bioidenticals

Bioidenticals are mixtures of hormones prepared by compounding pharmacists and supplied as lozenges, troches and creams. There is inadequate scientific evidence to show that these are effective or safe, and there is a lack of regulatory control of their manufacture. There is particular concern about the risk of endometrial hyperplasia due to inadequate endometrial protection. There is no advantage of using bioidenticals over conventional hormone therapy, and their use cannot be recommended.⁽⁵³⁾

The Australian Menopause Society factsheet on Bioidentical Hormone Therapy can be useful to share with patients as it gives a clear explanation for why they

Menopausal symptoms are common in women who are being treated for breast cancer. This may be because of chemotherapy causing ovarian failure, anti-oestrogen endocrine therapy, or because breast cancer is often diagnosed in the perimenopausal woman.

Treatment of these women is controversial, and the use of MHT has not been shown to be safe. Referral to a specialist clinic may be appropriate, or consideration of treatment with non-hormonal treatments such as SSRIs or clonidine.

Premature ovarian insufficiency (POI) (previously called premature menopause) is defined as the spontaneous onset of menopause before the age of 40 years. POI should be suspected in young women who present with menstrual irregularities, hot flushes, night sweats and vaginal dryness. It may be associated with a family history of early or premature menopause and is also associated with autoimmune conditions and chromosomal conditions such as Fragile X or Turner’s syndrome. It can follow cancer treatments, including chemotherapy and radiotherapy, to the pelvis.

Idiopathic POI occurs in about 1 per cent of women less than 40 years in most communities.⁽⁵⁴⁾

Diagnosis is made when there has been more than four months of amenorrhoea, alternate  causes are excluded and finding of FSH raised to the menopausal range on two occasions four to six weeks apart. ⁽⁷⁰⁾

 

 

Decrease in libido 

This issue is complex and multifactorial. Factors that lead to a decrease in libido may include relationship to partner, expectations of sexual activity, competing work and family agendas, general health, and the presence of other menopausal symptoms such as vulvovaginal atrophy causing dyspareunia. A discussion about sexual health should be a routine part of the menopause consultation. A biopsychosocial approach to management should be taken.⁽³²⁾ Management options: local vaginal therapy, in particular vaginal estrogen, helps reduce discomfort during intercourse tibolone may help to improve libido in some women although data is limited if on MHT changing to transdermal estradiol rather than oral estradiol may be helpful due to a lower effect on testosterone levels than oral preparations a transdermal 1% iopsychosoc preparation ( Androfeme®) was approved by the TGA in November 2020 for the treatment of hypoactive sexual desire dysfunction in post menopausal women. It may be useful after exclusion of other causes for low libido using a iopsychosocial model. Blood levels of testosterone should be obtained as a baseline and then levels should be monitored to ensure that testosterone levels do not exceed a normal premenopausal range. A practice guideline for the use of systemic testosterone for women with HSDD was

 

 

 

 

Osteoporosis is a condition where bone strength is compromised due to poor bone density and an alteration in bone quality, which results in an increased risk of fragility fractures. An osteoporotic fracture is one that occurs with minimal trauma.

Cardiovascular disease is the main cause of morbidity and mortality in women in westernised countries and risk increases with age, particularly after the menopause.⁽⁶¹⁾ It is important to assess for and recognise risk factors in menopausal patients and to treat them aggressively.

Significant risk factors include hypertension, cigarette smoking, dyslipidaemia, diabetes mellitus, high BMI, and the metabolic syndrome. Each patient needs to be assessed individually, but in general, MHT does not increase CHD risk in healthy women between 50 and 59.⁽³⁶⁾ It is unclear at present whether MHT in healthy women 50-59 may slightly increase the risk of ischaemic stroke although no increase in stroke was seen in this age group in the Women’s Health Initiative study.⁽⁶²⁾

Australasian Menopause Society (AMS)

Jean Hailes Foundation resources:

Jean Hailes Professionals tool Jean Hailes Menopause Management tool

Osteoporosis Australia

The Royal Australian College of General Practitioner

Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age

Jane FM, David SR. A Practitioner’s Toolkit for Managing the Menopause. Climacteric. 2014;17(5): 564-579. Available from: https://www.tandfonline.com/doi/pdf/10.3109/13697137.2014.929651?needAccess=true

Australasian Menopause Society. Menopause Basics. [Internet]. Australasian Menopause Society; 2019. Available from: https://www.menopause.org.au/hp/management/menopause-basics. Harlow S, Gass M, Hall JE, Lobo R, Maki P, Rebar RW, Sherman S, Sluss PM, de Villiers TJ STRAW+10, diagram, ‘Executive Summary of the Stages of Reproductive Aging Workshop +10: Addressing the Unfinished Agenda of Staging Reproductive Aging. The North American Menopause Society. 2012;19(4):387-95. Jean Hailes. About Menopause. [Internet]. Jean Hailes; 2017 [updated 2019 February 4]. Available from: https://jeanhailes.org.au/health-a-z/menopause/about-menopause. Speroff L. The perimenopause: definitions, demography and physiology. Obstet Gynecol Clin North Am. 2002;29(3):397-410. Avis N, Crawford SL, Greendale G, et al. Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Intern Med. 2015;175(4):531-9. Gartoulla P, Worsley R, Bell RJ, Davis SR. Moderate to severe vasomotor and sexual symptoms remain problematic for women aged 60 to 65 years. Menopause. 2015;22(7):694-701. Faddy M, Gosden RG, Gougeon A, et al. Accelerated disappearance of ovarian follicles in mid life: implications for forecasting menopause. Hum Reprod 1992;7(10):1342-6. Richardson S, Senikas V, Nelson JF. Follicular depletion during the menopausal transition: evidence for accelerated loss and ultimate exhaustion. J Clin Endocrinol Metab. 1987;65:1231-7. Burger H, Hale GE, Dennerstein L, Robertson DM. Cycle and hormone changes during perimenopause: the key role of ovarian function. Menopause 2008;15(4):603-12. Santoro N, Buster JE. Hormonal