QuestionSBA
QuestionChoice
Women should stop taking combined hormonal contraception over the age of 50.
49851
e
She can continue to take it indefinitely
QuestionChoice
She should stop taking it now, as it is contraindicated for women over the age of 50.
49850
d
She should stop taking it in one year's time
QuestionChoice
She should not be taking combined hormonal contraception as she is over 50 years of age. Menopause is defined as not having a menstrual period for over one year, however this is difficult to ascertain when using hormonal contraception.
49849
c
She should stop taking it when she no longer has any menstrual bleeding for 1 year
QuestionChoice
The Faculty of Sexual and Reproductive Health (FSRH) UK Medical Eligibility Criteria (UKMEC) state that combined hormonal contraception is contraindicated in women over the age of 50. She should be switched to an alternative method of contraception.
49847
a
She should stop taking it now and switch to an alternative method of contraception
QuestionChoice
Contraception is no longer required after the age of 55, where natural fertility is assumed to have ceased. However, combined hormonal contraception should not be used by women over the age of 50.
49848
b
She should stop taking it after the age of 55
Concept
Chapter
# Summary
  
 
Menopause is a physiological condition leading to the permanent cessation of menstruation in women (usually aged between 45-55 years). It is caused by ovarian failure and leads to oestrogen deficiency. Key signs and symptoms include vasomotor symptoms (hot flushes and night sweats), sexual dysfunction, and psychological issues. The diagnosis is made clinically. Management strategies include hormone replacement therapy (HRT) for symptom relief and reduced risk of osteoporosis, as well as non-hormonal therapies such as lifestyle changes and cognitive behavioural therapy.
  
 
# Definition
  
 
 - **Menopause:** This term describes the permanent cessation of menstruation, characterised by at least 12 months of amenorrhoea in otherwise healthy women who are not using hormonal contraception. Menopause typically occurs between the ages of 45 and 55, with the average age in the UK being 52. The underlying reason is ovarian failure, which results in oestrogen deficiency.

 
- Perimenopause: This period begins when symptoms of menopause start and continues until 12 months after the last menstrual period.
  
 
# Epidemiology
  
 
Menopause typically occurs between the ages of 45 and 55, with the median age in the UK being 52. 
  
 
# Aetiology
  
 
Menopause is caused by ovarian failure, which leads to oestrogen deficiency. 
  
 
# Signs and Symptoms
  
 
  - Vasomotor symptoms: hot flushes, night sweats
  - Sexual dysfunction: vaginal dryness, reduced libido, problems with orgasm, dyspareunia
  - Psychological symptoms: depression, anxiety, mood swings, lethargy, reduced concentration
  
 
# Differential Diagnosis
  
 
Other medical conditions can cause similar symptoms to menopause and should therefore be considered when diagnosing:
  
  - **Hyperthyroidism:** symptoms can include hot flushes, sweating, palpitations, and changes in menstrual cycle
  - **Depression:** exhibits mood swings, lethargy, reduced concentration. 
  - **Premature ovarian insufficiency:** can cause hot flushes, night sweats, vaginal dryness, and reduced libido; however, the woman needs to aged below 40.
  
 
# Investigations
  
Menopause is diagnosed **clinically** based on absence of menses for 12 months, meaning that **no investigations are required** as long as the patient is of appropriate age (at least over 40, but usually aged over 45). 

If aged under 40, tests for premature ovarian insufficiency may be indicated, i.e. FSH level testing. 

Other indications for FSH testing include:

- Aged over 45 years with atypical symptoms
- Aged between 40–45 years with menopausal symptoms, including a change in menstrual cycle
- Over 50 years of age using progestogen-only contraception, including depot medroxyprogesterone acetate 

 
# Management

**Conservative:** 

  - Lifestyle measures: regular exercise, weight loss (if overweight), clothing alterations, stress reduction, avoiding triggers (such as spicy foods, caffeine, smoking, and alcohol), and good sleep hygiene


**Medical:**   
 

**Hormone replacement therapy (HRT):**
  
 
  - Oestrogens: these overcome oestrogen deficiency and can be given orally, transdermally, or topically.
  - Progestogens: required for endometrial protection from unopposed systemic oestrogens; can be oral, transdermal or intrauterine.
  
Oestrogen-only HRT therapy should only be given to women with a hysterectomy. Otherwise, HRT should include both oestrogen and progesterone. 
 
HRT can be given either cyclically (for perimenopausal women still having periods) or continuously (for postmenopausal women not having periods). Cyclical can include:

- Monthly: Oestrogen every day of the month + progesterone for the last 14 days 
- Every three months: Oestrogen every day for 3 months + progesterone for the last 14 days

  
Benefits of HRT include relief of vasomotor symptoms, relief of urogenital symptoms, and reduced risk of osteoporosis. Risks of oral HRT include increased risks of breast cancer, endometrial cancer (if oestrogen given alone), and venous thromboembolism.
  
Contraindications to HRT:

* Breast cancer (current, past or suspected)
* Oestrogen-dependent cancer (known or suspected)
* Vaginal bleeding of unknown cause
* Endometrial hyperplasia that remains untreated
* Pregnancy
* Thrombophilic disorder
* Venous thromboembolism, including DVTs and PEs (current or previous) - unless on anticoagulant treatment
* Arterial thromboembolic disease, including angina or MIs (active or recent)
* Liver disease with abnormal LFTs 

HRT should also be prescribed cautiously to those with:

* Diabetes mellitus
* Those with risk factors for venous thromboembolisms
* Porphyria cutanea tarda
* Endometrial hyperplasia
* Migraines
* Increased risk of breast cancer 

 
**Non-hormonal management:**
  

  - Selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs): for vasomotor and mood symptoms
  - Clonidine (an alpha-2 adrenergic receptor agonist): for vasomotor symptoms. 
  - Cognitive behavioural therapy (CBT): for vasomotor and mood symptoms
  - Vaginal moisturisers: for urogenital symptoms
  - Vaginal lubricants: for vaginal dryness and consequent dyspareunia. 


# Complications


- **Osteoporosis:** Oestrogens are important for bone maintenance; preventing osteoporosis is a key benefit of HRT.
- **Cardiovascular disease:** Women are at greater risk of cardiovascular disease from menopause, with exact mechanisms unclear. The evidence for impact of HRT on cardiovascular disease is also unclear. 
- **Dyspareunia:** Occurs as a consequence of vaginal dryness, as a result of reduced oestrogen. Can be managed with vaginal oestrogen creams or lubricants.
- **Urinary incontinence:** Caused by epithelial thinning as a result of decline in oestrogen. Managed with systemic or topical oestrogen. 
- **Side-effect of HRT**, including: VTE (not a risk if oestrogen is delivered transdermally), stroke, breast tenderness, vaginal bleeding, breast cancer. 

 
 
# NICE Guidelines 

[NICE Guidance: Menopause](https://www.nice.org.uk/guidance/ng23)

[NICE Clinical Knowledge Summary (CKS): Menopause](https://cks.nice.org.uk/topics/menopause/)


# References

[BMJ Best Practice](https://bestpractice.bmj.com/topics/en-gb/194) 

[British Menopause Society](https://thebms.org.uk/)
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Menopause
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Gynaecology
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Menopause
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Hormone replacement therapy
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Quesmed Tutorial: Gynaecology 1
10006
A 51-year-old woman attends the family planning clinic for a repeat supply of her combined oral contraceptive pill (COCP).

She has been taking this since age 37 and queries when she should stop taking it. She has completed her family and has no symptoms of menopause.

What is the correct advice to give her?
a