History

Fact Explanation
Irregular menstruation and amenorrhea All healthy women transition from a reproductive, or premenopausal, period, marked by regular ovulation and cyclic menstrual bleeding, to a postmenopausal period, marked by amenorrhea. The onset of the menopausal transition is marked by changes in the menstrual cycle and in the duration or amount of menstrual flow.Subsequently, cycles are missed, but the pattern is often erratic early in the menopausal transition. Menopause is defined retrospectively after 12 months of amenorrhea.The menopausal transition usually begins in the mid-to-late 40s and lasts about 4 years, with menopause occurring at a median age of 51 years. Cigarette smokers undergo menopause about 2 years earlier than nonsmokers. During the early menopausal transition, estrogen levels are generally normal or even slightly elevated.The level of follicle-stimulating hormone begins to increase but is generally in the normal range. As the menopause transition progresses, hormone levels are variable, but estrogen levels fall markedly and levels of follicle-stimulating hormone increase. After menopause, ovulation does not occur. The ovaries do not produce estradiol or progesterone but continue to produce testosterone. A small amount of estrogen is produced by the metabolism of adrenal steroids to estradiol.[1].
Hot flushes Women in the menopausal transition commonly report a variety of symptoms, including vasomotor symptoms (VMS) such as hot flushes and night sweats. A hot flush is a sudden feeling of warmth that is generally most intense over the face, neck, and chest. The duration is variable but averages about 4 minutes. The prevalence of hot flushes is maximal in the late menopausal transition, occurring in about 65% of women. Cigarette smoking increases the likelihood of flushing other factors including surgical menopause, physical activity, body-mass index, alcohol consumption, and socioeconomic status have been inconsistently associated with hot flushes. In most women, hot flushes are transient. The condition improves within a few months in about 30 to 50% of women and resolves in 85 to 90% of women within 4 to 5 years.However, for unclear reasons, about 10 to 15% of women continue to have hot flushes many years after menopause. Hot flushes resemble heat-dissipation responses and may represent abnormal thermoregulation by the anterior hypothalamus. The precise role of estrogen in the pathogenesis of this symptom is not clear. Endogenous estrogen levels do not differ substantially between postmenopausal women who have hot flushes and those who do not have them.Flushes do not occur in women with gonadal dysgenesis unless estrogen therapy is used and then discontinued,which suggests that estrogen withdrawal is important.[1].
Night sweating Another vasomotor symptom. Hot flushes is often accompanied by sweating that can be profuse and followed by a chill.[1]. VMS are theorized to result from dysfunction in the woman’s “tightly controlled temperature circuitry,” leading to exaggerated activation of heat dissipation responses such as peripheral vasodilation and sweating. The thermoregulatory circuitry includes the brain, internal body cavity, and the peripheral vasculature. It is thought that this circuitry functions under the influence of consistent concentrations of the neurotransmitters serotonin and norepinephrine. Changes in gonadal hormones, notably estrogen, have been associated with fluctuations in serotonin and norepinephrine.[2].
Vaginal dryness Vaginal symptoms including dryness are reported by about 30% of women during the early postmenopausal period and up to 47% of women during the later postmenopausal period. Unlike hot flushes, vaginal symptoms generally persist or worsen with aging. As compared with premenopausal women, postmenopausal women with vaginal symptoms generally have decreased vaginal blood flow and secretions, hyalinization of collagen, fragmentation of elastin, and proliferation of vaginal connective tissue.[1].
Dyspareunia Dyspareunia, or pain during sexual intercourse, is among the problems most frequently reported by postmenopausal women. Postmenopausal dyspareunia occurring concurrently with vaginal atrophy is strongly associated with a lack of estrogen in the genital tract. However, a significant percentage of postmenopausal women experience dyspareunic pain that is not caused by hypoestrogenism.Dyspareunic pain often results in distress, decreased sexual functioning and enjoyment, relationship difficulties and reduced quality of life.For postmenopausal women, dyspareunia may also accentuate personal issues related to aging, body image and health.Two somewhat vague anatomical locations of dyspareunic pain, ‘superficial (external genital) and ‘deep’ (ie, internal genital or pelvic), have been assessed in postmenopausal women. Superficial provoked pain on contact, particularly in the vulvar area, is the most common form of premenopausal dyspareunia, affecting an estimated 12% of women. Although there is a paucity of information about deep dyspareunia in the general population of postmenopausal women, it has been found to be less prevalent than superficial dyspareunia in clinical samples. Postmenopausal women are more commonly affected by pelvic floor hypotonus .This may cause deep dyspareunia due to lack of pelvic stability. Furthermore, lack of estrogen can also lead to vaginal narrowing and shortening, thereby increasing the likelihood of painful intercourse [3].
Vulvar pruritus As a result of aging tissue and decreasing levels of endogenously produced estrogens during menopause, in particular estradiol (E2), atrophic changes may be observed in the external genital region, introitus and vagina.The resulting symptoms may include itching and vulvar pruritus.[3].
Vaginal discomfort Another vaginal symptom resulted in menopause.The responsiveness of many of these physiologic changes to estrogen therapy suggests that estrogen deficiency may contribute to the pathogenesis. However, vaginal symptoms have been associated with lower serum levels of androgens but not of estrogens. [1].
Decreased arousal and lack of lubrication Decreased physiological arousal and lack of lubrication during intercourse are frequently reported sexual difficulties in menopause and are commonly attributed to decreasing estrogen levels. Certainly, lack of lubrication increases friction during intercourse and can lead to pain.[3].
Weight gain Weight gain also commonly seen in menopause.[1].Overweight could be increased by perimeno­pausal metabolic change and not simply by over-­eating and/or under-exercising.However, there are clearly changes in metabolic rate that occur in midlife women based on the 1.5 BMI unit gain in the 45-54 decade in population based data. Perimenopausal women with a past history of gestational diabetes, those with a Type 2 diabetes mellitus family history and those who are most generally symptomatic seem to be at increased risk for weight gain.[5].
Musculoskeletal pain Musculoskeletal pain and other somatic symptoms are also a common symptoms of menopause.[7].
Urgency and frequency Urologic symptoms including urgency, frequency, dysuria, and incontinence can seen in menopause women but are not clearly correlated with the menopausal transition.[1].
Urinary incontinance Urinary incontinence also associated with menopause. In young women, the prevalence of incontinence is usually low, but prevalence peaks around menopause, with a steady rise there-after into later life. Although the prevalence of stress and mixed (stress and urge) incontinence is higher than urge incontinence, the latter is more likely to require treatment.[4].
Sleep disturbance Specifically, in women who experience VMS, 62% of them also experience sexual disturbances, 74% suffer from sleep disturbances. that the presence of VMS is associated with all aspects of sleep disturbances including poor continuity and quality and early morning awakening.[2].This sleep disturbance typically occurs in three different patterns: increased trouble falling asleep, early morning wakening or, as is most common, abrupt waking after a few hours of deep sleep.[5].
Headache Headache is also a symptom in menopause.[1]. But commonly seen in perimenopausal stage.Migraine headaches may occur for the first time in perimenopause. However, typically a woman will have experienced them at puberty or when first using oral contraceptives. What is unique about perimenopausal migraines is that they seem more refractory to management with acute therapies, and often occur at midcycle and peri-menstrually, thus twice a month. This can be debilitating if each migraine episode lasts for 3-5 days.[5].
Fatigue Fatigue is also a common presentation seen in menopause.[1].
Depression Menopause associated changes in mood may result from a wide range of variables, including elevated sensitivity to environmental events secondary to decreased hormonal levels, changes in socioeconomic and/or marital status, culture, lifestyle factors, level of education, and history of depressive symptoms. Depression scores were found to be highest in women who were in the menopause transition stage (who had not reached their final menstrual period) or who had experienced surgical menopause.[6].
Anxiety The physiologic changes associated with menopause often result in increased anxiety and stress. These feelings may arise from sleep deprivation, mood swings, and unpredictable hot flushes.VMS cause a significant negative impact on quality of life in younger and older women, contributing to physical as well as psychosocial impairment .Becoming flushed and sweating profusely in a social or work related situation may cause extreme anxiety for many women and lead to social isolation.[6].
Cognitive disturbance Memory impairment is directly related to hot flushes in women who have undergone oophorectomy, but natural menopause itself does not necessarily result in significant cognitive dysfunction.During a hot flush, blood flow decreases in the hippocampus, possibly impairing memory and cognition. It has been suggested that such reductions in blood flow may contribute to the decreased mental clarity and short-term verbal memory problems experienced by many perimenopausal and postmenopausal women .[6].
Abnormal uterine bleeding Postmenopausal women presenting with vaginal bleeding must be evaluated. The most common cause of postmenopausal bleeding is vaginal atrophy (59%).It is important, however, to rule out endometrial carcinoma (10%) and cervical carcinoma (2%).[8].
Osteoporotic fractures There is a sharp increase in risk for both cardio vascular disease (CVD) and osteoporosis that occurs with menopause.This dramatic rise in chronic disease risk likely in part reflects the abrupt hormonal alterations, especially the decline in estrogen levels that occur during this period, along with the associated constellation of atherogenic, neuroendocrine, and metabolic changes linked to the insulin resistance syndrome.[7].Osteoporosis is a major health problem, particularly in the elderly postmenopausal women because of the fractures that arise as a consequence of the decreasing bone mineral density (BMD) with age. Common sites of fragility fracture are at the hip, spine, and wrist. The incidence of these and other fragility fractures rises markedly with age. The most serious fracture in terms of morbidity, mortality, and health-care costs is hip fracture. So that some recommend that postmenopausal women with a prior fragility fracture may be considered for interventions without the necessity for a BMD test (other than to monitor treatment).[9].
References
  1. GRADY DEBORAH. Management of Menopausal Symptoms. N Engl J Med [online] 2006 November, 355(22):2338-2347 [viewed 23 August 2014] Available from: doi:10.1056/NEJMcp054015
  2. UMLAND EM, FALCONIERI L. Treatment options for vasomotor symptoms in menopause: focus on desvenlafaxine Int J Womens Health [online] :305-319 [viewed 23 August 2014] Available from: doi:10.2147/IJWH.S24614
  3. KAO A, BINIK YM, KAPUSCINSKI A, KHALIFé S. Dyspareunia in postmenopausal women: A critical review Pain Res Manag [online] 2008, 13(3):243-254 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2671314
  4. NITTI VW. The Prevalence of Urinary Incontinence Rev Urol [online] 2001, 3(Suppl 1):S2-S6 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1476070
  5. PRIOR JC. Progesterone for Symptomatic Perimenopause Treatment - Progesterone politics, physiology and potential for perimenopause Facts Views Vis Obgyn [online] 2011, 3(2):109-120 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3987489
  6. UTIAN WH. Psychosocial and socioeconomic burden of vasomotor symptoms in menopause: A comprehensive review Health Qual Life Outcomes [online] :47 [viewed 24 August 2014] Available from: doi:10.1186/1477-7525-3-47
  7. INNES KE, SELFE TK, VISHNU A. Mind-body Therapies for Menopausal Symptoms: A Systematic Review Maturitas [online] 2010 Jun, 66(2):135-149 [viewed 24 August 2014] Available from: doi:10.1016/j.maturitas.2010.01.016
  8. TELNER DE, JAKUBOVICZ D. Approach to diagnosis and management of abnormal uterine bleeding Can Fam Physician [online] 2007 Jan, 53(1):58-64 [viewed 25 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1952557
  9. KANIS J. Commentary on guidelines on postmenopausal osteoporosis - Indian Menopause Society J Midlife Health [online] 2013, 4(2):129-131 [viewed 25 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3785152

Examination

Fact Explanation
Vaginal atrophy Vaginal atrophy is a manifestation of aging tissue, and the cytological and chemical transformations in the genital region that result from declining levels of estrogens, particularly E2, during menopause. It is purported to be the primary cause of postmenopausal dyspareunia.[2].Postmenopausal vaginal atrophy is generally identified when there are vaginal symptoms and findings of pallor, dryness, and decreased rugosity of the vaginal mucosa. A pelvic examination should be performed to look for these signs and to rule out other potential causes of symptoms, including trauma and infection.[1].
UTI Urinary Tract Infections (UTI) is common among menopausal women. Vaginal fluid, which is acidic before menopause, becomes more neutral, facilitating the proliferation of enteric organisms associated with urinary tract infection.[1].
Hypertension The loss of ovarian hormones around menopause has many adverse effects on CHD risk factors.Hypertension is by far the most important risk factor that affects women in the early postmenopausal years. About 30 to 50% of women develop hypertension (RR >140/90 mmHg) before the age of 60 and the onset of hypertension can cause a variety of symptoms that are often attributed to menopause.Systolic blood pressure rises more steeply in ageing women compared with men, and this may be related to the hormonal changes per se during menopause. Several other hormone-related factors have an additive effect on the increase in blood pressure during menopausal transition. The decline in the oestrogen/androgen ratio dilutes the vasorelaxant effects of oestrogens on the vessel wall and promotes the production of vasoconstrictive factors such as endothelin.[3].
References
  1. GRADY DEBORAH. Management of Menopausal Symptoms. N Engl J Med [online] 2006 November, 355(22):2338-2347 [viewed 23 August 2014] Available from: doi:10.1056/NEJMcp054015
  2. KAO A, BINIK YM, KAPUSCINSKI A, KHALIFé S. Dyspareunia in postmenopausal women: A critical review Pain Res Manag [online] 2008, 13(3):243-254 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2671314
  3. MAAS AH, FRANKE HR. Women's health in menopause with a focus on hypertension Neth Heart J [online] 2009 Feb, 17(2):68-72 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2644382

Differential Diagnoses

Fact Explanation
Hypothyroidism It is known cause to develop vasomotor symptoms like hot flushes.[1]. Hypothyroidism, the clinical syndrome resulting from a deficiency in thyroid hormone, is a common problem encountered in the clinical setting. Deficiencies in thyroid hormone can produce numerous deleterious effects on the human body. The manifestations of hypothyroidism are varied and, to a large measure, age dependent. These abnormalities may range from global developmental abnormalities to acute metabolic derangement. Hypothyroidism is usually represented in the literature as a stereotypical cluster of symptoms, most typically fatigue, cold intolerance, dry skin, hair loss, menstrual irregularities, and constipation. Commonly recognized signs may include hoarse voice, bradycardia, nonpitting edema, facial puffiness, slow speech, and delayed relaxation phase of the deep tendon reflexes. In addition, psychiatric disorders often accompany hypothyroidism. Mental status examination of a hypothyroid patient may reveal a broad spectrum of dysfunction, ranging from mild attentional impairment to significant agitated delirium or psychosis.[2].
Pheochromocytoma Another known cause that contribute for the development of vasomotor symptoms.[1]. Pheochromocytomas are catecholamine-producing tumours arising from chromaffin cells in the sympathoadrenal system.The various catecholamines give rise to sustained or paroxysmal hypertension, along with symptoms of headaches, palpitations, profuse sweating, breathlessness, anxiety, a sense of dread, chest pain, nausea, vomiting, tremors, and paraesthesia. Hyperglycaemia due to the anti-insulinaemic actions of catecholamines can produce polyuria and polydipsia. In severe cases, a patient can present with myocardial infarction, heart failure, pulmonary oedema, arrhythmias, or intracranial haemorrhage . A diagnosis is established by measuring the levels of metanephrines in the urine or blood . Localisation of the tumour is performed by computed tomography (CT) or magnetic resonance imaging (MRI).[3].
Polycystic ovarian syndrome (PCOS) Despite being heterogeneous in nature, the hallmarks of the disease are hyperandrogenism and chronic anovulation.Hyperandrogenism may present clinically as hirsutism, acne, and/or male pattern alopecia. Hirsutism can be defined as the growth of coarse hair on a woman in a male pattern (upper lip, chin, chest, upper abdomen, back etc.). This is to be distinguished from hypertrichosis that involves a more uniform, whole body distribution of fine hair. Chronic anovulation often present as oligomenorrhea, amenorrhea, dysfunctional uterine bleeding, and/or infertility.Some women may only develop menstrual problems later in life, perhaps after significant weight gain. Furthermore, primary amenorrhea is possible although not common.[4].
References
  1. GRADY DEBORAH. Management of Menopausal Symptoms. N Engl J Med [online] 2006 November, 355(22):2338-2347 [viewed 23 August 2014] Available from: doi:10.1056/NEJMcp054015
  2. HEINRICH TW, GRAHM G. Hypothyroidism Presenting as Psychosis: Myxedema Madness Revisited Prim Care Companion J Clin Psychiatry [online] 2003, 5(6):260-266 [viewed 25 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC419396
  3. SUNIL KUMAR K, SIVA KRISHNA K, SANDIP P, KIRTIKUMAR D M. Pheochromocytoma: An Uncommon Presentation of an Asymptomatic and Biochemically Silent Adrenal Incidentaloma Malays J Med Sci [online] 2012, 19(2):86-91 [viewed 25 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3431738
  4. SHEEHAN MT. Polycystic Ovarian Syndrome: Diagnosis and Management Clin Med Res [online] 2004 Feb, 2(1):13-27 [viewed 25 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1069067

Investigations - for Diagnosis

Fact Explanation
Hormonal assessment Menopausal transition (MT) is associated with changes in bleeding pattern and hormone profiles. Current data show an increase in FSH and decreases in AMH, inhibin B and estradiol over MT. AMH appears to be the first marker to change, followed by FSH and inhibin B. Estradiol declines in late MT. There are no validated hormone cutpoints that predict the length of MT or final menstrual period (FMP). There are very preliminary data on AMH as a predictor of menopause. Until further evidence identifies clinically useful hormone levels for predicting MT or FMP, diagnosis of MT and FMP should be based on clinical signs and symptoms only.[1].
References
  1. SU HI, FREEMAN EW. Hormone changes associated with the menopausal transition Minerva Ginecol [online] 2009 Dec, 61(6):483-489 [viewed 25 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3823936

Investigations - Fitness for Management

Fact Explanation
Fasting venous plasma glucose/ Fasting Blood Sugar (FBS) Since the metabolic syndrome risk is increased with menopause, it is better to go for a FBS test. Metabolic syndrome includes the presence of at least 3 of the following characteristics, abdominal obesity, increased triglycerides, reduced levels of high–density lipoprotein (HDL) cholesterol, high blood pressure, and increased fasting glucose.[1].
Lipid profile Also can performed due to increase risk of metabolic syndrome in postmenopausal age.increased triglycerides, reduced levels of high–density lipoprotein (HDL) cholesterol can be obtain.[1].
Blood pressure measurement Hypertension is by far the most important risk factor that affects women in the early postmenopausal years. high blood pressure can be obtain.[2].
References
  1. ZIAEI S, MOHSENI H. Correlation between Hormonal Statuses and Metabolic Syndrome in Postmenopausal Women J Family Reprod Health [online] 2013 Jun, 7(2):63-66 [viewed 25 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4064771
  2. MAAS AH, FRANKE HR. Women's health in menopause with a focus on hypertension Neth Heart J [online] 2009 Feb, 17(2):68-72 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2644382

Investigations - Screening/Staging

Fact Explanation
Cervical screening Cervical screening is one of the best defenses against the development of cervical cancer, which is the sixth commonest cause of cancer deaths in the UK.It is vitally important for medical practitioners to repeatedly emphasize the importance of attendance for cervical smear tests, especially in post-menopausal women. As many of them may never have been screened.[1].
Screening mammogram Despite the effectiveness of mammography as a method to detect breast cancer in women ages 50 and older, many women do not obtain screening mammograms.Since Brest cancer risk is increase with age it is better to go for a screening mammogram at post menopausal age.[2].
References
  1. SOLEYMANI MAJD H, WATERMEYER S, EL HAMAMY E, ISMAIL L. A postmenopausal women presenting with atypical symptoms and cervical cancer: a case report Cases J [online] :401 [viewed 25 August 2014] Available from: doi:10.1186/1757-1626-1-401
  2. BUSH RA, LANGER RD. The effects of insurance coverage and ethnicity on mammography utilization in a postmenopausal population. West J Med [online] 1998 Apr, 168(4):236-240 [viewed 25 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1304946

Management - General Measures

Fact Explanation
Healthy diet and exercise Weight gain is a common problem experienced by the menopausal women. In such cases obviously, before doing anything else, the health care provider must review actual exercise and food records and work to ensure that both of these are optimal with at least 30 minutes of moderate exercise daily.[1] However a randomized trial among overweight postmenopausal women found that moderate exercise did not improve flushing, as compared with stretching.[2].
Slow breathing (paced respiration) Some trials have found that practicing slow breathing (paced respiration), which may reduce overall sympathetic tone, reduced the frequency of flushing 35% more than did muscle relaxation.[2].
Alternative therapies Some are practicing alternative therapies to get relived from VMS such as hot flushes. But there is no convincing evidence that acupuncture, yoga, Chinese herbs, dong quai, evening primrose oil, ginseng, kava, or red clover extract improve hot flushes. One trial of vitamin E found a statistically significant effect, but the benefit was only one hot flush per day less with treatment, as compared with placebo.Evidence regarding black cohosh is mixed but primarily negative with regard to an improvement in the frequency or severity of flushing.[2].
Dietary soy and phytoestrogen Many trials have evaluated dietary soy and various phytoestrogen preparations. Although some of these studies have reported benefit, the weight of evidence, especially from good-quality trials with blinded comparisons, suggests that soy is not effective in the treatment of hot flushes. Many women prefer alternative medications in the belief that these treatments are safe, but phytoestrogens and possibly black cohosh bind estrogen receptors and could cause adverse outcomes similar to those seen with estrogen. No studies of these preparations have been of adequate size or duration to document safety.[2].
Cessation of smoking The North American Menopause Society recommends that women with mild vasomotor symptoms first consider lifestyle changes, either alone or combined with a nonprescription remedy.[1].Current active smoking is related to early menopause, and that smoking cessation prior to menopausal age seems to protect against early menopause.Early onset of menopause is a risk factor of osteoporosis and death from ischemic heart disease.However Early menopause was not significantly associated with passive smoking, or alcohol or coffee consumption.[3].
Vaginal estrogens For vaginal symptoms, vaginal estrogens (administered as creams, tablets, or an estradiol-releasing ring) are highly effective, with improvement or relief reported by 80 to 100% of treated women.Vaginal preparations are preferred over systemic estrogens for this indication, since they are similarly or more effective and generally raise serum estrogen levels very little. When they are used at the recommended dose and frequency, the addition of a progestin to protect the uterus is not necessary. However, higher doses or more frequent use of vaginal estrogens can increase systemic levels of estrogen and potentially cause estrogenic side effects.[2].
HRT The FDA and the American College of Obstetricians and Gynecologists recommend that postmenopausal hormone therapy be used at the lowest dose and for the shortest possible time for the treatment of menopausal symptoms.Multiple randomized trials have demonstrated that estrogen markedly improves the frequency and severity of hot flushes, generally reducing the frequency by 80 to 95%. All types and routes of administration of estrogen are effective. The benefit is dose-related, but even low doses of estrogen are often effective.Relief is usually substantial within 4 weeks after starting standard doses of estrogens (1 mg per day of oral estradiol or its equivalent). Lower doses may not have maximal effects for 8 to 12 weeks but are associated with lower rates of side effects, such as uterine bleeding and breast tenderness.[2].One of the main indications for prescribing HRT in postmenopausal women is the relief of vasomotor symptoms. Estrogen remains the most effective treatment in this context.Estrogen treatment has been shown to be effective in treating symptoms related to vaginal atrophy, such as vaginal dryness and superficial dyspareunia.[4]. Both estrogen alone and estrogen plus progestin increased the risk of stroke by 40%. Although the two regimens were not compared directly, estrogen with added progestin appeared to be associated with a higher risk of coronary events, pulmonary embolism, and breast cancer than was estrogen alone. However, treatment with unopposed estrogen in women with a uterus markedly increases the risk of uterine hyperplasia and cancer.Estrogen should be avoided in women who have a history of or are at high risk for cardiovascular disease, breast cancer, uterine cancer, or venous thromboembolic events and in those with active liver disease.[2].
Proper counseling The hot flushes and symptoms of vaginal atrophy are common in the menopausal transition. So they should be told that vasomotor symptoms generally improve or resolve within a few years but that vaginal symptoms may not improve spontaneously.Although it is reasonable to discuss behavioral changes (e.g., dressing in layers and lowering room temperature), such strategies are unlikely to be adequate in women with severe hot flushes.Women with moderate hot flushes, may choose to try nonhormonal therapies.Hormone therapy is the most effective treatment for severe hot flushes and is a reasonable choice in the absence of contraindications.[2].
Management of Osteoporosis HRT is effective in preserving bone density and preventing osteoporosis in both spine and hip, as well as reducing the risk of osteoporosis-related fractures.HRT is the first-line therapeutic intervention for the prevention and treatment of osteoporosis in women with premature ovarian insufficiency (POI )and menopausal women below 60 years, particularly those with menopausal symptoms.Bisphosphonates and other pharmacological agents can be used as an alternative to HRT to preserve bone density, but there can be side effects. Recent reports suggest that long-term therapy with alendronate can predispose to femoral shaft fragility fractures due to prolonged suppression of bone turnover. [4].
References
  1. PRIOR JC. Progesterone for Symptomatic Perimenopause Treatment - Progesterone politics, physiology and potential for perimenopause Facts Views Vis Obgyn [online] 2011, 3(2):109-120 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3987489
  2. GRADY DEBORAH. Management of Menopausal Symptoms. N Engl J Med [online] 2006 November, 355(22):2338-2347 [viewed 24 August 2014] Available from: doi:10.1056/NEJMcp054015
  3. MIKKELSEN TF, GRAFF-IVERSEN S, SUNDBY J, BJERTNESS E. Early menopause, association with tobacco smoking, coffee consumption and other lifestyle factors: a cross-sectional study BMC Public Health [online] :149 [viewed 24 August 2014] Available from: doi:10.1186/1471-2458-7-149
  4. PANAY N., HAMODA H., ARYA R., SAVVAS M.. The 2013 British Menopause Society & Women's Health Concern recommendations on hormone replacement therapy. Menopause International: The Integrated Journal of Postreproductive Health [online] December, 19(2):59-68 [viewed 24 August 2014] Available from: doi:10.1177/1754045313489645

Management - Specific Treatments

Fact Explanation
Progestins medroxyprogesterone acetate and megestrol At high doses, the progestins medroxyprogesterone acetate and megestrol are effective for the treatment of hot flushes, but side effects are common.[1].
Tibolone Tibolone, a steroid hormone not marketed in the United States but available elsewhere, is effective for the treatment of hot flushes, but long-term risks have not been adequately investigated.[1].
SNRIs and SSRIs SNRI (Serotonin-norepinephrine reuptake inhibitors) and SSRI (Selective serotonin reuptake inhibitors) have received increased attention for the management of VMS in nondepressed menopausal women. As yet, there have been no pharmacoeconomic analyses of any agents in these classes for this indication. Results from a recent systematic review of published economic evaluations of interventions for depression indicated that SSRIs and SNRIs are more cost-effective than older antidepressant medications (eg, tricyclic antidepressants) owing to their greater efficacy and decreased side-effect profile .[2].
Gabapentin and clonidine Gabapentin has shown modest efficacy in the treatment of hot flushes, both in women with a history of breast cancer,and those without, but is also associated with side effects.The α-adrenergic agonist clonidine has been suggested as a treatment for vasomotor symptoms, but trials have suggested little or no benefit, and side effects (including dry mouth, drowsiness, and dizziness) are common.[1].
References
  1. GRADY DEBORAH. Management of Menopausal Symptoms. N Engl J Med [online] 2006 November, 355(22):2338-2347 [viewed 25 August 2014] Available from: doi:10.1056/NEJMcp054015
  2. UTIAN WULF H. . Health Qual Life Outcomes [online] 2005 December [viewed 25 August 2014] Available from: doi:10.1186/1477-7525-3-47