Chapter 11 – Menopause
CONTENTS
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Menopause: An introduction
- Normal physiological and endocrine changes at perimenopause and post menopause
- Menopausal symptoms
- The menopause consultation
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Menopausal Hormone Therapy (MHT)
- Systemic menopausal hormone therapy
- Women with an intact uterus
- After hysterectomy (with ovaries retained)
- Systemic MHT preparations and delivery systems
- Tibolone
- Selective estrogen receptor modulators
- Contraindications to systemic MHT including Tibolone and SERMs (consider referral to menopause specialist):
- Side effects and adverse events of systemic MHT
- Topical vaginal estrogen and genitourinary symptoms of menopause (vulvovaginal atrophy)
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Non-hormonal pharmacological treatments for menopausal vasomotor symptoms
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Alternative and herbal treatments
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Treating menopausal symptoms after breast cancer
- Premature ovarian insufficiency
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Other issues to consider
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- Low bone mass/ osteoporosis
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Cardiovascular disease
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Resources
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References
Find the information you need
Cardiovascular disease
Australasian Menopause Society. Menopause Basics. [Internet]. Australasian Menopause Society; 2019. Available from: https://www.menopause.org.au/hp/management/menopause-basics.
CloseHarlow 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.
CloseJean Hailes. About Menopause. [Internet]. Jean Hailes; 2017 [updated 2019 February 4]. Available from: https://jeanhailes.org.au/health-a-z/menopause/about-menopause.
CloseSperoff L. The perimenopause: definitions, demography and physiology. Obstet Gynecol Clin North Am. 2002;29(3):397-410.
CloseAvis N, Crawford SL, Greendale G, et al. Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Intern Med. 2015;175(4):531-9.
CloseGartoulla 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.
CloseFaddy 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.
CloseRichardson 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.
CloseBurger 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.
CloseSantoro N, Buster JE. Hormonal changes of the menopausal transition Sex Reprod Menopause Supplement 2009;May 2009:33-40.
CloseDavis S, Lambrinoudaki I, Lumsden M, Mishra GD, Rees M, Santoro N, et al. Menopause. Natural Reviews Disease Primers. 2015; 1(15004).
CloseDepmann M, Broer SL, van der Schouw YT, et al. Can we predict age at natural menopause using ovarian reserve tests or mother’s age at menopause?. Menopause 2016;23(2):224-32.
CloseArcher D, Sturdee DW, Baber R, et al. Menopausal hot flushes and night sweats: where are we now?. Climacteric. 2011;14(5):515-28.
CloseAustralian absolute cardiovascular disease risk calculator [Internet]. National Vascular Disease Prevention Alliance. 2012. Available from: http://www.cvdcheck.org.au/.
CloseDepartment of Health. BreastScreen Australia Program. [Internet]. Australian Government. Available from: http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/breast-screening-1.
CloseDepartment of Health. National Bowel Cancer Screening Program [Internet]. Australian Government; 2019]. Available from: http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/clinical-guidelines.
CloseNational Health and Medical Research Council (NHMRC). Australian guidelines to reduce health risks for drinking alcohol.[Internet].Canberra, ACT: NHMRC; 2009. Available from: https://www.nhmrc.gov.au/about-us/publications/australian-guidelines-reduce-health-risks-drinking-alcohol
CloseCancer Australia. Risk Factors. [Internet]. Australian Government. Available from: https://breastcancerriskfactors.gov.au/risk-factors/lifestyle-factors.
CloseThe Faculty of Sexual & Reproductive Healthcare of the Royal College of Obstetricians & Gynaecologists (FSRH). FSRH Clinical Guideline: Progestogen-only Injectable Contraception December 2014 (Amended April 2019). [Internet]. FSRH; 2014. Available from: https://www.fsrh.org/standards-and-guidance/fsrh-guidelines-and-statements/method-specific/progestogen-only-injectables/.
CloseAustralasian Menopause Society. NonHormonal Treatments for Menopausal Symptoms. [Internet]. Australasian Menopause Society; 2018. Available from: https://www.menopause.org.au/hp/information-sheets/600-nonhormonal-treatments-for-menopausal-symptoms.
CloseNonhormonal management of menopause-associated vasomotor symptoms: 2015 position statement of The North American Menopause Society. Menopause. 2015 Nov;22(11):1155-72.
CloseAyers B, Smith M, Hellier J, Mann E, Hunter MS. Effectiveness of group and self-help cognitive behaviour therapy in reducing problematic menopausal hot flushes and night sweats (MENOS 2): a randomized controlled trial. Menopause. 2012 July;19(7):749-59.
CloseMann E, Smith MJ, Hellier J, Balabanovic JA, Hamed H, Grunfeld EA, Hunter MS. Cognitive behavioural treatment for women who have menopausal symptoms after breast cancer treatment (MENOS 1): a randomised controlled trial. Lancet Oncol. 2012 Mar;13(3):309-18.
CloseGreen S, Haber E, McCabe RE, Soares CN. Cognitive-behavioural group treatment for menopausal symptoms: a pilot study. Arch Womens Ment health. 2013;16(4):325-32.
CloseElkins G, Fisher WI, Johnson AK, Carpenter JS, Keith TZ. Clinical hypnosis in the treatment of postmenopausal hot flashes: a randomized controlled trial. Menopause. 2013 Mar;20(3):291-8.
CloseAustralasian Menopause Society. Bioidentical hormone therapy. [Internet]. Australasian Menopause Society; 2018. Available from: https://www.menopause.org.au/health-info/fact-sheets/bioidentical-hormone-therapy.
CloseAustralasian Menopause Society. Lifestyle and behavioural modifications for menopausal symptoms. [Internet]. Australasian Menopause Society; 2019. Available from: https://www.menopause.org.au/hp/information-sheets/1087-lifestyle-and-behavioural-modifications-for-menopausal-symptoms.
CloseThe Royal Women’s Hospital. Managing Menopause. [Internet]. Victoria: The Royal Women’s Hospital. Available from: https://www.thewomens.org.au/health-information/menopause-information/managing-menopause.
CloseHickey M, Szabo RA, Hunter MS. Non-hormonal treatments for menopausal symptoms. BMJ. 2017 Nov;23(359).
Closede Villiers T, Hall JE, Pinkerton JV, Cerdas Pérez S, Rees M, Yang C, Pierroz DD Revised Global Consensus Statement on Menopausal Hormone Therapy Climacteric. 2016;19(4):313-5.
CloseVinogradova Y. Use of hormone replacement therapy and risk of venous thromboembolism: nested case-control studies using the QResearch and CPRD databases. BMJ. 2019;364:k4810.
CloseAsi N, Mohammed K, Haydour Q, Gionfriddo MR, Morey Vargas OL, Prokop LJ et al,. Progesterone vs. synthetic progestins and the risk of breast cancer: a systematic review and meta-analysis. Syst Rev. 2016;5(121-129).
CloseCuadros J, Fernandez-Alonso AM, Chedraui P, Cuadros AM, Sabatel RM, Perez-Lopez R. Metabolic and hormonal parameters in postmenopausal women 10 years after transdermal oestradiol treatment, alone or in combination to micronized oral progesterone. Gynae Endocrinol. 2011;27(3):156-62.
CloseGenazzani A, Pluchino N, Bernardi F, Centofanti, Luisi M. Beneficial effect of tibolone on mood, cognition, well-being, and sexuality in menopausal women. Neuropsychiatr Dis Treat. 2006;2(3):299-307.
CloseAustralasian Menopause Society. Tibolone as menopausal hormone therapy. [Internet]. Australasian Menopause Society; 2018. Available from: https://www.menopause.org.au/hp/information-sheets/1287-tibolone-as-menopausal-hormone-therapy.
CloseJean Hailes. Menopause Management. [Internet]. Jean Hailes; 2017 [updated 2019 Nov 18]. Available from: https://www.jeanhailes.org.au/health-a-z/menopause/menopause-management
CloseDavid S. The effects of tibolone on mood and libido. Menopause. 2002;9(3):162-70.
CloseCummings S, Ettinger B, Delmas PD, Kenemans P, Stathopoulos V, Verweij P, et al. The effects of tibolone in older postmenopausal women. New England Journal of Medicine 2008;359(7):697-708.
CloseAustralasian Menopause Society. What is Menopausal Hormone Therapy (MHT) and is it Safe?. [Internet]. Australasian Menopause Society; 2019. Available from: https://www.menopause.org.au/health-info/fact-sheets/what-is-menopausal-hormone-therapy-mht-and-is-it-safe.
CloseAustralasian Menopause Society. SERMs – their role in menopause management. [Internet]. Australasian Menopause Society; 2017. Available from: https://www.menopause.org.au/images/stories/infosheets/docs/AMS_SERMs_their_role_in_Menopause_Management.pdf.
CloseCollaborative Group on Epidemiological Studies of Ovarian Cancer. Menopausal hormone use and ovarian cancer risk: individual participant meta-analysis of 52 epidemiological studies. Lancet. 2015;385(9980):1835-42.
CloseRoberts H, Hickey M. Should hormone therapy be recommended for prevention of cardiovascular disease?. Cochrane Database of Syst Rev 2015;3(ED000097).
CloseRenoux C, Dell’Aniello S, Garbe E, Suissa S,. Transdermal and oral hormone replacement therapy and the risk of stroke: a nested case control study. BMJ. 2010;340:c2519.
CloseScarabin PY. Progestogens and venous thromboembolism in menopausal women: an updated oral versus transdermal estrogen meta-analysis. Climacteric. 2018;21(4):341-5.
CloseVinogradova Y, Coupland C, Hippisley-Cox J. Use of hormone replacement therapy and risk of venous thromboembolism: nested case-control studies using the QResearch and CPRD databases. BMJ. 2019;364:k4810.
ClosePitkin J, British Menopause Society Medical Advisory Council. Consensus Statement Post Reproductive Health 2018;24(3):133-8.
CloseSimon J, Davis SR, Althof SE, Chedraui P, Clayton AH, Kingsberg SA, et al. Sexual well-being after menopause: An International Menopause Society White Paper. Climacteric. 2018;21(5):415-27.
CloseButtini M, Maher C. The first published randomised controlled trial of laser treatment for vaginal atrophy raises serious questions. Med J Aust 2018;209(9).
CloseThe Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) Women’s Health Committee. Vaginal ‘rejuvenation’ and cosmetic vaginal procedures. [Internet]. 2018. Available from: https://doi.org/10.1111/ajo.12999.
CloseU.S. Food and Drug Administration (FDA). FDA Warns Against Use of Energy-Based Devices to Perform Vaginal ‘Rejuvenation’ or Vaginal Cosmetic Procedures: FDA Safety Communication. FDA [Internet]. 2018. Available from: https://www.fda.gov/medical-devices/safety-communications/fda-warns-against-use-energy-based-devices-perform-vaginal-rejuvenation-or-vaginal-cosmetic.
CloseAustralasian Menopause Society. Non-hormonal Treatments for Menopausal Symptoms. [Internet]. Australasian Menopause Society; 2018. Available from: https://www.menopause.org.au/hp/information-sheets/600-nonhormonal-treatments-for-menopausal-symptoms.
CloseLynch C, Folkers ME, Hutson WR. Fulminant hepatic failure associated with the use of black cohosh: a case report. Liver Transpl. 2006;12(6): 989-992. Available from: https://doi.org/10.1002/lt.20778.
ClosePinkerton J. What are the concerns about custom-compounded “bioidentical” hormone therapy? . Menopause 2014;21(12):1298-300.
CloseBaber R, Panay N, Fenton A the IMS Writing Group. 2016 IMS Recommendations on women’s midlife health and menopause hormone therapy. Climacteric. 2016;19(2):109-50.
CloseMilsom S, O’Sullivan S. Premature ovarian insufficiency. Menopause. 2017 (Autumn);19(1).
CloseWebber L, Davies M, Anderson R, et al. ESHRE guideline: Management of women with premature ovarian insufficiency. Hum Reprod 2016;31(5):926-37.
CloseCrofton P, Evans N, Bath LE, Warner P, Whitehead TJ, Critchley HO, et al. Physiological versus standard sex steroid replacement in young women with premature ovarian failure: effects on bone mass acquisition and turnover. Clin Endocrinol (Oxf). 2010;73:707-14.
CloseJean Hailes. Mental health and emotions. [Internet]. Jean Hailes; 2017 [updated 2019 Feb 04]. Available from: https://jeanhailes.org.au/health-a-z/menopause/mental-health-emotions.
CloseOsteoporosis Australia. Bone density testing in general practice. [Internet]. Osteoporosis Australia; 2017. Available from: https://healthybonesaustralia.org.au/sites/default/files/files/GP%20Bone%20Density%202017.pdf.
CloseThe Royal Australian College of General Practitioners (RACGP), Osteoporosis Australia. Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age [internet]. 2nd East Melbourne, Victoria: RACGP; 2017. Available from: https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/osteoporosis.
CloseCollins P, Webb CM, de Viller TJ, Stevenson JC, Panay N, Baber RJ. Cardiovascular risk assessment in women – an update. Climacteric. 2016;19(4):329-36.
CloseManson J, Chlebowski RT, Stefanick MC, et al. Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women’s Health Initiative randomized trials. JAMA. 2013;310(13):1353-68.
CloseVessey MP. Progestogen only oral contaception. Findings in a large prospective study with special reference to effectiveness. Br J Fam Plann 1985;10:117–21.
CloseThe Faculty of Sexual & Reproductive Healthcare of the Royal College of Obstetricians & Gynaecologists (FSRH). FSRH Clinical Guideline: Contraception for Women Aged over 40 Years (August 2017, amended September 2019). [Internet]. FSRH; 2017. Available from: https://www.fsrh.org/standards-and-guidance/documents/fsrh-guidance-contraception-for-women-aged-over-40-years-2017/
CloseDavis SR, Bell RJ, Robinson PJ, Handelsman DJ, Gilbert T, Phung T, et al. Testosterone and Estrone increase from the age of 70 years: findings from the Sex Hormones in Older Women Study. J Clin Endocrinol Metab. 2019; 104(12):6291-300
CloseSzoeke C, Lehert P, Henderson VW, Dennerstein L, Desmond P, Campbell S. Predictive Factors for Verbal Memory Performance Over Decades of Aging: Data from the Womems Healthy Aging Project. Am J Geriatr Psychiatry. 2016; 24(10):857-67.
CloseLi FG ,Maheux-Lacroix S,Deans R, Nesbitt-Hawes E, Budden A, Nguyen K. Effect on Symptom Severity in Women with Postmenopausal Vaginal Symptoms: A randomised Clinical Trial. JAMA. 2021;326(14):1381-1389.
CloseInternational Society for the Study of Womens Sexual Health Clinical Practice Guideline for the Use of Systemic Testosterone for Hypoactive Sexual Desire Disorder in Women. J Sex Med. 2021;18:849-867.
CloseExecutive AM, Constitution BA. Tibolone as menopausal hormone therapy. Australasian Menopause Society. 2018; 1:1-4. Availble from: https://www.menopause.org.au/hp/information-sheets/tibolone-as-menopausal-hormone-therapy
CloseExecutive AM, Constitution BA. Menopause before 40 and spontaneous premature ovarian insufficciency. Australasian Menopause Society. 2020; 1:1-2. Available from: https://www.menopause.org.au/health-info/fact-sheets/menopause-before-40-and-spontaneous-poi
CloseTherapeutic Guidelines. 2021. [Internet]. Available from: https://tgldcdp.tg.org.au/viewTopic?topicfile=osteoporosis-minimal-trauma-fracture&guidelineName=Bone%20and%20Metabolism#toc_d1e1068https://tgldcdp.tg.org.au/guideLine?guidelinePage=Bone+and+Metabolism&frompage=etgcomplete
CloseExecutive AM, Constitution BA. Migraine headaches, menopause and MHT/HRT. 2019; 1:1-3. Available from: https://www.menopause.org.au/hp/information-sheets/migraine-headaches-menopause-and-mht-hrt
CloseTherapeutic Guidelines. 2021. [Internet]. Available from: https://tgldcdp.tg.org.au/index#toc_d1e254
CloseThe Royal Australian and New Zealand College of Obstericians and Gynaecologists. Menopause. 2016;1:1-4. Available from: https://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Patient%20information/Menopause-pamphlet.pdf?ext=.pdf
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