The experience of the menopause can vary dramatically between women. Some need information and reassurance and others require medical intervention.

The menopause is characterised by a reduction in oestrogen production due to primary ovarian failure. There is an increase in LH/FSH levels due to negative feedback. It occurs gradually with the climacteric or ‘peri-menopausal’ phase. The average age of the menopause in the UK is approximately 51–52 years.

Menopause in a woman <45 years is defined as premature (see premature menopause box). Treatment with HRT is usually recommended until the age of 50.

Diagnosis

The menopause is defined as >12 months of amenorrhoea. It can be difficult to establish when the menopause has occurred, especially if HRT is taken in the peri-menopausal phase.

History

Ask the patient about the following:

• Severity of symptoms. The impact is probably multi-factorial and may be influenced by culture and psycho-social factors.
  
• Menstrual changes. Periods usually become less regular as there are an increased number of anovulatory cycles.
  Post-coital, intermenstrual, post-menopausal or heavy and/or painful bleeding may indicate other pathologies.
  
• Flushes/sweats: experienced by up to 85%. The severity can vary dramatically; they are often associated with palpitations.
  
• Psychological: a complex and controversial area. Symptoms including anxiety and depression, irritability, insomnia, loss of libido and memory loss have been said to be attributable to the menopause. However, these may be multi-factorial and also caused by changes going on in the individual’s life at that time. Some symptoms such as hot flushes may have direct impact on sleep.
  
• Urogynacological: urinary and sexual symptoms are common:
  
  
  
  • As the vagina, urethra and bladder trigone are oestrogen dependent they gradually atrophy
    
  • Vaginal dryness and atrophy are common and may lead to superficial dyspareunia and vaginal bleeding
    
  • A reduction in bladder elasticity and pelvic floor support can produce symptoms of stress incontinence.

Investigations

Investigations are usually unnecessary except if the diagnosis is in doubt or premature menopause is suspected.

A serum FSH (>30 IU/L) is usually diagnostic in women not taking hormonal contraception (if in doubt repeat in 6 weeks).

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