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[5 min read] Supporting patients with menopause in primary care
Menopause is defined as the permanent cessation of menstruation due to ovarian insufficiency resulting in a drop in the levels of oestrogen and progesterone, and actually menopause is only diagnosed when a woman has not had a natural menstrual period in at least 12 months. It typically occurs between the ages of 45 and 55, with the average age of menopause in Australia being around 51.
Women are most likely to present to their primary care practitioner with signs and symptoms of the perimenopause, the period during which hormone levels are decreasing, however menstruation may still occur. Common menstrual symptoms are irregularity, longer or shorter cycles, lighter or heavier bleeding. Women may also be troubled by other symptoms of the perimenopause such as hot flushes, night sweats, mood changes, a general “fogginess” as well as sexual symptoms such as vaginal dryness and changes in libido.
While these symptoms are most commonly due to fluctuating hormone levels, it’s important to continue to adequately investigate new symptoms – for example, new intermenstrual bleeding may be a sign of gynaecological malignancy, and mood changes may be due to depression.
The most effective way to treat perimenopausal symptoms is with menopausal hormone therapy (MHT), also known as hormone replacement therapy (HRT). The benefits of MHT are not only alleviation of troublesome symptoms, but oestrogen-containing MHT also provides protection against osteoporosis.
There are many forms of MHT and hundreds of different formulations available worldwide. MHT is typically “combined” – that is, it includes both an oestrogen to replace the dropping natural levels and alleviate symptoms and a progestogen to prevent oestrogen-induced endometrial thickening.
For women who have had a hysterectomy, endometrial protection is not required and they can therefore have oestrogen-only MHT, and for women with a Mirena coil in situ, this provides progestogenic endometrial protection. There are various modes of delivery of MHT – oral, transdermal patches and creams – and it’s often a case of trial and error to find the regime that best suits your patients.
For women still experiencing a menstrual period, cyclical MHT is recommended, which is taken on a month-to-month basis, allowing for a regular monthly bleed. For women with perimenopausal symptoms who have not had a menstrual period for over a year, a continuous form of MHT is more suitable. Not all women are suitable for MHT, for example if they have a history of hormone-sensitive cancer, cardiovascular or thrombotic disease.
Alternatives to MHT include anti-depressant medications for mood changes, and topical vaginal oestrogen if localised vulvovaginal symptoms are the main issue. Lifestyle changes such as stopping smoking, reducing caffeine and alcohol intake, increasing physical activity and adhering to a healthier diet and sleep regime can also work wonders for perimenopausal symptoms. Many women try herbal remedies such as St. John’s Wort and complimentary therapies such as acupuncture and aromatherapy.
The most important aspect of management of menopause is to provide individualised care, as menopause affects each woman differently and each patient may require a different management strategy, tailored to their personal circumstances. It’s useful to signpost patients to helpful and reputable resources such as the Australasian Menopause Society and provide ongoing support through the menopause and beyond.
Learn more about women’s health in primary care with the Professional Diploma of Women’s Health program.
- Australasian Menopause Society https://www.menopause.org.au/
- Department of Health, State Government of Victoria, Australia. Better Health Channel: Menopause. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/menopause
- Australasian Menopause Society. AMS Guide to Equivalent MHT/HRT Doses. https://www.menopause.org.au/images/stories/infosheets/docs/AMS_Guide_to_Equivalent_MHT-HRT_Doses_1020_V1.pdf
- National Institute for Health and Care Excellence (2015). Menopause: diagnosis and management. https://www.nice.org.uk/guidance/ng23/resources/menopause-diagnosis-and-management-pdf-1837330217413