Menopause / perimenopause
Ovarian oestrogen decline (>12 months amenorrhoea)
Overview
Permanent cessation of menstruation from loss of ovarian follicular activity — diagnosed clinically (≥12 months amenorrhoea, average age 51). Perimenopause is the symptomatic transition. Premature ovarian insufficiency = before age 40.
Recognise
- Vasomotor: hot flushes, night sweats
- Menstrual change then cessation; mood/sleep change, poor concentration
- Urogenital atrophy (see GSM); reduced libido
- Long term: osteoporosis, cardiovascular risk
Red flags
- Postmenopausal bleeding (PMB) → urgent exclusion of endometrial cancer
Differentials & how to tell them apart
Investigations
Clinical diagnosis over 45 — NO blood tests needed. Under 45 / atypical: FSH (raised). POI (<40): FSH on two occasions.
Management
HRT: oestrogen + progestogen (if uterus present) for symptoms
- 1HRT for vasomotor symptoms: oestrogen, PLUS a progestogen if she has a uterus.Gate: A woman WITH a uterus must have progestogen with oestrogen → unopposed oestrogen causes endometrial hyperplasia/cancer
- 2Transdermal route if VTE risk, migraine, or liver concerns (avoids first-pass). Vaginal oestrogen for genitourinary symptoms.
- 3Non-hormonal: SSRI/SNRI or CBT for vasomotor symptoms if HRT contraindicated.
Key points
HRT is NOT contraception. Combined oral HRT slightly raises breast cancer and (oral) VTE risk; transdermal oestrogen does not raise VTE risk. POI needs HRT until ~51 for bone/cardiovascular protection.
Monitor & prognosis
Symptom control, BP, breast awareness, bleeding pattern.
Symptoms ease over years; bone/cardiovascular risk persists.
Source: NICE NG23; CKS Menopause