Menopause
Definition and Symptoms of Menopause
Menopause is defined as the final menstrual period, with symptoms affecting approximately 75% of individuals presumed female at birth.
- Menopause occurs at a median age of 51 years, with a normal range of 45 to 55 years.
- Perimenopause is a transitional stage lasting 4 to 8 years before menopause, characterized by irregular menstrual cycles.
- Symptoms include vasomotor symptoms (hot flushes, night sweats), urogenital symptoms (vaginal dryness, urinary issues), psychological symptoms (anxiety, depression), and musculoskeletal symptoms.
- Symptoms can start during perimenopause and last an average of 7 to 10 years, with 28% experiencing moderate to severe symptoms.
Diagnosis of Menopause
Menopause diagnosis is primarily clinical, based on menstrual patterns, symptoms, and age.
- Diagnosis typically does not require hormone concentration assessments for individuals over 45 years.
- Hormone tests (FSH and estradiol) may be necessary for those with ambiguous menstrual histories or younger individuals with amenorrhea.
- Serum FSH and estradiol should not be measured if estrogen-containing therapies have been used in the past 4 weeks.
Overview of Systemic MHT
Systemic MHT is indicated for treating menopausal symptoms and preventing osteoporosis.
- It includes estrogen-only MHT, combined MHT, and other forms like tibolone.
- Individualized assessment of benefits and harms is essential before starting therapy.
Contraindications, Benefits, and Harms of Systemic MHT
Contraindications must be assessed before initiating systemic MHT.
- Contraindications include age over 60, previous thromboembolism, and estrogen-dependent cancers.
- Benefits of MHT include reduced fracture risk and improved vasomotor symptoms, while risks include increased breast cancer and thromboembolism rates.
Estrogen-Only Systemic MHT
Estrogen-only systemic MHT is used for individuals who have had a total hysterectomy.
- It is available in various formulations, including oral and transdermal.
- Individualized assessment of expected benefits and harms is necessary before starting therapy.
What is sequential therapy?
Oestrogen is taken daily, and a progestogen is added for 10–14 days per month. This causes a predictable monthly withdrawal bleed. It’s typically used in perimenopausal women or within ~12 months of the last period who still have a uterus.
1. Oral Sequential Combination Tablets (Pre-packed Cyclical Regimens)
These contain estradiol daily with cyclical progestogen built into the monthly pack:
-
Femoston
Estradiol + dydrogesterone in a sequential pack (e.g., 1/10, 2/10 formulations). -
Novofem
Estradiol daily with norethisterone added in the second half of the cycle. -
Trisequens
A three-phase sequential regimen (varying estradiol doses plus cyclical norethisterone).
These are convenient because dosing is pre-arranged in calendar packs.
2. Oestrogen + Separate Oral Progesterone (Custom Sequential Regimen)
Doctors may prescribe:
Daily Oestrogen:
-
Estrofem (oral estradiol)
- Estradiol gel or patch (e.g., Estradot)
Plus Cyclical Progesterone (10–14 days/month):
-
Utrogestan
(Micronised progesterone; often preferred for a more “natural” profile)
This approach allows flexible dose adjustment and is commonly used in specialist practice.
3. Transdermal Sequential Regimens
South Africa does not commonly stock many pre-combined sequential patches, so sequential therapy is often created by:
- Continuous estradiol patch or gel
- Adding oral progesterone (e.g., Utrogestan) cyclically
This is frequently chosen for women who:
- Have migraine
- Have increased clot risk
- Prefer to avoid oral oestrogen
4. Tibolone (Not Sequential, but Sometimes Used Instead)
-
Tibolone
Although not a sequential therapy, tibolone is sometimes prescribed in early post-menopause as an alternative to cyclical regimens. It does not usually cause monthly bleeding.
📊 Summary Table
|
Type
|
Example Brands in SA
|
Causes Monthly Bleed?
|
Best For
|
|
Oral sequential pack
|
Femoston, Novofem, Trisequens
|
Yes
|
Early menopause / perimenopause
|
|
Oestrogen + cyclical progesterone |
Estrofem + Utrogestan |
Yes
|
Flexible dosing
|
|
Transdermal + cyclical progesterone
|
Estradot/Evorel + Utrogestan
|
Yes
|
Higher clot risk / migraine
|
|
Tibolone
|
Tibolone
|
No
|
Established menopause
|
Continuous Combined Menopausal Hormone Therapy
Continuous combined MHT provides a consistent dose of progestogen to avoid monthly withdrawal bleeds.
- It is indicated for individuals who have completed menopause and is associated with lower progestogen doses than cyclical regimens.
- Combined formulations simplify dosing and improve adherence.
- Regular monitoring is essential to assess benefits and manage any adverse effects.
Other Systemic Menopausal Hormone Therapy Options
Alternative therapies include conjugated estrogens with bazedoxifene and tibolone for postmenopausal individuals.
- Conjugated estrogens+bazedoxifene improves bone mineral density but has unclear long-term risks for breast cancer.
- Tibolone has estrogenic, progestogenic, and androgenic effects and does not require concurrent progestogen.
- Tibolone may increase the risk of breast cancer recurrence and stroke in individuals over 60.
Monitoring Systemic Menopausal Hormone Therapy
Regular clinical reviews are necessary for individuals on systemic MHT to ensure efficacy and safety.
- Initial review should occur 6 to 8 weeks after starting or changing therapy, followed by assessments every 6 to 12 months.
- Monitoring includes evaluating symptom control, comorbidities, and potential adverse effects.
- Adjustments to therapy may be needed based on individual responses and health changes.
Managing Adverse Effects of Systemic MHT
Management strategies for adverse effects of MHT are crucial for patient comfort and safety.
- Unscheduled vaginal bleeding should be investigated if heavy or irregular, especially in high-risk individuals.
- Adjustments to progestogen dosage or type may be necessary if bleeding persists.
- Other adverse effects like breast tenderness and nausea can be managed by altering dosages or switching therapies.
Stopping Systemic Menopausal Hormone Therapy
Decisions regarding the cessation of MHT should be individualized based on benefits and risks.
- There is no specific duration for MHT; ongoing assessment is necessary.
- Up to 50% of individuals may experience symptom recurrence after stopping therapy.
- Tapering the dose over 3 to 6 months may help manage symptoms upon discontinuation.
Considerations for Systemic MHT in Perimenopause
Perimenopausal individuals may have unique needs for symptom management and contraception.
- Options include continuous estrogen therapy with a levonorgestrel-releasing IUD or combined hormonal contraception.
- Cyclical combined MHT is suitable for those not requiring contraception.
- Mood swings and depressive symptoms are common and should be treated appropriately.
Systemic MHT in Specific Patient Groups
Certain patient populations require tailored approaches to MHT due to increased risks.
- Individuals with a history of venous thromboembolism should use transdermal formulations.
- Starting MHT in individuals aged 60 and older is contraindicated without specialist advice.
- Those with familial breast cancer risk should undergo individual risk assessments before starting MHT.
Intravaginal Estrogen Therapy for Vulvovaginal Symptoms
Intravaginal estrogen is effective for treating vulvovaginal atrophy symptoms.
- It can be used alone or with systemic MHT and is not associated with increased cardiovascular risks.
- Treatment options include estriol cream or pessaries, with a typical regimen of daily use for 2 to 3 weeks, followed by maintenance doses.
- Nonhormonal therapies are preferred for individuals with a history of breast cancer.
Nonhormonal Drug Therapy for Vasomotor Symptoms
Nonhormonal options are available for managing vasomotor symptoms like hot flushes.
- SNRIs and SSRIs ( antidepressants) can reduce hot flushes by 40% to 64% and improve mood and sleep.
- Gabapentinoids are effective for night-time symptoms and can also help with migraine prevention.
- Clonidine is another option but is less effective than hormonal therapies.