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Menopause - Management
How can I manage women with a premature menopause?
- Offer lifestyle advice.
- Refer women who are younger than 40 years of age to a gynaecologist.
- Offer systemic oestrogen replacement therapy.
- Systemic hormone replacement therapy (HRT) or the combined oral contraceptive pill (COC) may be used.
- HRT: the HRT regimens used will depend on whether or not the woman has undergone a hysterectomy, still has some ovarian activity, and still has periods.
- For women who are still having periods, offer combined, systemic (oral or transdermal), cyclical HRT:
- For women with infrequent periods or who cannot tolerate progestogens, a systemic 3-monthly regimen may be preferred.
- For women who have had a hysterectomy, offer oral or transdermal unopposed oestrogen replacement therapy.
- COC: whether or not the woman can be prescribed the COC will depend upon the woman's age and associated risk factors (e.g. smoking).
- Advise the woman that she may still become pregnant if contraception is not used.
- See the CKS topic on Contraception for a detailed discussion on the use of contraception in perimenopausal women.
- Testosterone implants and patches (licensed) may be considered for treating decreased libido (especially in oophorectomized women); however, seek specialist advice before prescribing.
Clarification / Additional information
- For the purposes of this guideline, premature menopause is menopause which occurs in women less than 45 years of age.
- After 50 years of age, therapy for osteoporosis should be reassessed.
Basis for recommendation
- These recommendations are based on published expert opinion [CSM, 2003a; Rees and Purdie, 2006a; SOGC, 2006].
- Feedback from expert reviewers recommend that women less than 40 years of age should be referred for investigation to determine the cause of premature menopause (e.g. primary ovarian failure) and to discuss fertility if appropriate. Women who have primary ovarian failure may continue to ovulate infrequently and require advice on appropriate contraception.
- Hormone replacement therapy (HRT):
- The combined oral contraceptive (COC) containing oestrogen and progestogen:
- The COC is often prescribed for younger women because it does not have the stigma of old age that HRT may have. However, trial evidence is scant on which to recommend treatment with a COC [Rees and Purdie, 2006a; SOGC, 2006]. The COC is perhaps more useful when contraception is still thought to be required (e.g. ovulation can occur for several years after premature ovarian failure in some women).
- The dose of ethinylestradiol used in standard pills is sufficient to provide control of menopausal symptoms and osteoporosis prophylaxis; however, oral contraceptives provide oestrogen for only 3 weeks in every 4 (the fourth week being pill-free). For women who are oestrogen deficient, the lack of oestrogen during this pill-free week can cause symptoms, and it may be more appropriate to provide oestrogen continuously, as with most forms of HRT.
- Testosterone:
- There is evidence that loss of libido can be improved by testosterone supplementation particularly after surgical menopause. Treatment is not always successful, other factors such as marital problems may be involved, and and testosterone may cause potentially serious adverse effects [Rees and Purdie, 2006a].
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