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MENOPAUSE & HORMONE THERAPY
Spontaneous/Natural menopause is the final menstrual period confirmed after 12 consecutive months of amenorrhea with no pathological cause.
Induced menopause is the permanent cessation of menstruation after bilateral oophorectomy (ie surgical menopause) or iatrogenic ablation of ovarian function (eg pelvic radiation therapy, chemotherapy).
Perimenopause/Menopause transition/Climacteric is the duration when menstrual cycle & endocrine changes occur a few years before and 12 months after the final menstrual period resulting from natural menopause.
Premature menopause is menopause before 40 years of age whether natural or induced while early menopause is spontaneous or induced menopause that occurs before the average age of natural menopause at 51 years or under 45 years of age.

Physical Examination

  • Complete thorough physical exam
    • Papanicolaou smear
    • Breast exam

Laboratory Tests

  • Baseline mammogram if indicated
  • Bone density if risk factors for osteoporosis are present
    • Use World Health Organization (WHO) Fracture Risk Assessment Tool (FRAX) for estimating probability of a hip fracture and a major osteoporotic fracture in 10 years (other major bones include clinical spine, forearm, shoulder, or hip fracture)
  • Lipid profile [low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides (TG) and total cholesterol]
  • Liver function tests (LFTs)
  • Urinalysis
  • Thyroid stimulating hormone (TSH)
  • If atypical clinical features are present: Follicle stimulating hormone (FSH)/luteinizing hormone (LH)/Estradiol to confirm menopause
    • FSH test may be used to diagnose menopause in women aged <40 years old in whom premature menopause is suspected or aged 40-45 years with symptoms of menopause 
  • In healthy women >45 years old presenting with menopausal symptoms, the following may be diagnosed in the absence of lab tests:
    • Perimenopause from irregular periods and vasomotor symptoms
    • Menopause in those without a period for at least 12 months and are not using hormonal contraception
    • Menopause from symptoms in women with no uterus

Evaluation

Rating Scales

  • Each symptom is graded according to its severity (eg Menopause Rating Scale, Greene Climacteric Scale) and how it affects the patient’s well-being (Menopause-Specific Quality of Life)
  • Reliable and valid tools for assessment of menopausal symptoms

Contraindications to Menopausal Hormone Therapy (MHT)

  • Breast cancer
  • Endometrial cancer
  • Untreated endometrial hyperplasia
  • Venous thrombosis
  • Active or recent arterial thromboembolic disease [eg angina, myocardial infarction (MI)]
  • Acute liver disease
  • Unexplained genital bleeding or pregnancy
  • Hypertriglyceridemia (if estrogen is to be used, select transdermal route)
  • Untreated hypertension
  • Known hypersensitivity to the active substance of menopausal hormone therapy (MHT) or to any of the excipients
  • Porphyria cutanea tarda
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