Menopause is the permanent cessation of menstruation, diagnosed retrospectively after 12 months of amenorrhoea. It usually occurs between ages 45–55. The underlying cause is ovarian follicle depletion → reduced oestrogen & progesterone → systemic consequences.

Perimenopause: Transition phase with irregular cycles and vasomotor symptoms.
Menopause: The final menstrual period (diagnosed retrospectively).
Post-menopause: Time after menopause, characterised by persistent hypo-oestrogenism.

🧬 Pathophysiology

Loss of ovarian follicles → ↓ oestrogen, progesterone.
↑ FSH and LH due to lack of negative feedback.
Oestrogen deficiency affects:
- Thermoregulation: hypothalamic instability → hot flushes/night sweats.
- Genitourinary tract: thinning of vaginal epithelium → dryness, dyspareunia, recurrent UTIs.
- Bones: accelerated resorption → osteoporosis.
- Cardiovascular system: loss of oestrogen protection → ↑ risk of IHD and stroke.

🩺 Clinical History

Menstrual history: Age of onset, cycle irregularity, last period.
Symptoms:
- Vasomotor: hot flushes, night sweats, insomnia.
- Psychological: mood swings, memory issues, irritability.
- Urogenital: vaginal dryness, dyspareunia, recurrent UTIs.
- Musculoskeletal: joint aches, low bone density.
- Breast pain (mastalgia): cyclical vs non-cyclical (important in perimenopause).
Risk factors: FHx of early menopause, osteoporosis, breast cancer.
Medication history: HRT, tamoxifen, SSRIs, antihypertensives (all can influence symptoms).
Lifestyle: Smoking, alcohol, caffeine, diet, physical activity.

👩‍⚕️ Physical Examination

General: BMI, BP, mood/affect, skin/hair changes.
Breasts: inspect & palpate for asymmetry, lumps, tenderness.
Pelvis: signs of atrophic vaginitis, prolapse.
Bones: check for kyphosis, fractures (osteoporosis).

🔬 Investigations

Mostly a clinical diagnosis (women >45 with classic features rarely need labs).
Hormones: FSH ↑, oestradiol ↓ (used in younger women with premature menopause).
Imaging: DEXA scan if risk factors for osteoporosis.
Breast imaging: Mammography/US if persistent mastalgia or lumps.

🌡️ Common Menopausal Problems

Problem	Cause	Symptoms	Management
Vasomotor symptoms (hot flushes, night sweats)	Oestrogen withdrawal → hypothalamic thermoregulation disturbance	Sudden warmth, sweating, sleep disturbance	HRT (gold standard) SSRIs/SNRIs, gabapentin, clonidine Lifestyle: keep cool, weight loss, avoid alcohol/caffeine
Genitourinary syndrome of menopause (GSM) – vaginal dryness, atrophic vaginitis	Oestrogen deficiency → thinning of urogenital epithelium	Dryness, dyspareunia, recurrent UTIs	Local oestrogen (creams, rings, pessaries) Lubricants, moisturisers Systemic HRT if wider symptoms
Osteoporosis	Loss of oestrogen → ↑ bone resorption	Fragility fractures, ↓ BMD	HRT (if started early) Bisphosphonates, denosumab Calcium + vitamin D, exercise
Mood changes & cognitive issues	Neurotransmitter effects of low oestrogen	Irritability, low mood, poor sleep, memory lapses	CBT, counselling SSRIs if persistent mood disturbance HRT may help

💊 Management Principles

Hormone Replacement Therapy (HRT):
- Oestrogen alone if hysterectomy, Oestrogen + Progestogen if uterus intact.
- Benefits: relief of vasomotor/GSM, bone protection.
- Risks: small ↑ breast cancer (esp. combined HRT), VTE, stroke (depends on route, dose, duration).
Non-HRT options: SSRIs/SNRIs, clonidine, gabapentin.
Lifestyle: Weight management, smoking cessation, exercise, diet rich in calcium/vitamin D.
Psychological support: Address anxiety, insomnia, and quality of life.

⚠️ Red Flags

Postmenopausal bleeding 🚨 → suspect endometrial cancer until proven otherwise.
Breast lump or persistent mastalgia → urgent triple assessment.
Unexplained weight loss or systemic symptoms → exclude malignancy.

📚 Teaching Commentary

💡 Exam pearls: – Menopause = 12 months amenorrhoea (don’t confuse with perimenopause). – Always discuss HRT pros & cons in exams: bone & symptom relief vs breast cancer/VTE risk. – Postmenopausal bleeding is endometrial cancer until proven otherwise. – Distinguish between cyclical mastalgia (hormonal, benign) vs postmenopausal breast pain (needs exclusion of malignancy).

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Menopause and Menopausal Problems