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Menopause - Management
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 hormone replacement therapy (HRT) or the combined oral contraceptive pill (COC):
    • 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 oral or transdermal, combined cyclical HRT (a 3-monthly regimen may be preferred).
      • For women who have had a hysterectomy offer oral or transdermal 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).
  • Decreased libido: testosterone implants and patches may be considered (especially in oophorectomized women); however, seek specialist advice before prescribing.
  • 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.

In depth

When should I consider stopping HRT?

  • Women with premature menopause usually take hormone replacement therapy up to the age of the natural menopause (50 years); at that time, treatment is usually reassessed.

What follow-up is required?

Review 3 months after starting hormone replacement therapy (HRT) and once each year thereafter.

  • At 3-months:
    • Check blood pressure, body weight, and assess the effectiveness of treatment; adjust HRT to achieve symptom control.
    • Enquire about any adverse effects and manage appropriately.
  • Once each year:
    • Check blood pressure, effectiveness of treatment and adjust to achieve symptom control.
    • Enquire about adverse effects and manage appropriately.
    • Interrupt treatment with intravaginal oestrogen to re-assess the need for continued use.
    • Discuss the risks and benefits of HRT. Explain that some of the risks (e.g. ovarian cancer) associated with oestrogen-only HRT increase with longer duration of HRT. The risk decreases after stopping HRT.
    • Perform a breast examination if indicated by personal or family history.
    • Encourage breast awareness and participation in the national breast screening programme as appropriate for their age.
    • Pelvic examination is required only if clinically indicated (e.g. if there is unscheduled bleeding, especially if heavy, prolonged, or recurrent).

In depth

When should I refer a women with premature menopause who has started HRT?

  • For women taking cyclical hormone replacement therapy (HRT) refer if:
    • There is a change in pattern of withdrawal bleeds or breakthrough bleeding.
  • For women taking continuous combined HRT or long cycle regimens refer if:
    • Breakthrough bleeding persists for more than 4–6 months after starting therapy.
    • A bleed occurs after amenorrhoea.
  • Refer if there is multiple treatment failure e.g. three or more regimens have been tried.
  • Refer to a team specializing in the management of gynaecological cancer (depending on local arrangements) any persistent or unexplained bleeding after cessation of hormone therapy for 6 weeks.

In depth

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