The menopause consultation

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Chapter 11
The menopause consultation

Chapter 11 – Menopause

Topic

Menopause: An introduction
Normal physiological and endocrine changes at perimenopause and post menopause
Menopausal symptoms
The menopause consultation
Menopausal Hormone Therapy (MHT)
Non-hormonal pharmacological treatments for menopausal vasomotor symptoms
Alternative and herbal treatments
Treating menopausal symptoms after breast cancer
Premature ovarian insufficiency
- Causes
- Management
Other issues to consider
Low bone mass/ osteoporosis
- Factors associated with an increased risk of osteoporosis
- Management
Cardiovascular disease
Resources
References

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History

Patients will often present to discuss bodily changes that are occurring at this time. It is also important for clinicians to proactively ask about menopause and symptoms a woman may be experiencing when seeing a woman in the relevant age group.

Consultations should be patient centred and take account of both the patient and clinician agenda. Discuss the patient’s symptoms and concerns and enquire about other common symptoms of menopause, as well as taking a general medical history. It is important to validate the woman’s experience. Determine the level of distress these symptoms are causing. Explain the physiological and hormonal changes that are happening. Talking through issues and normalising what is happening may be all that is required for an individual woman. For others, more active treatment or management may be requested.

It can be very useful to provide information sheets or websites to your patient. Excellent resources can be found on the websites below:

Australasian Menopause Society (AMS) Jean Hailes Foundation

A menopause symptom score sheet can be useful in identifying symptoms potentially related to menopause, and monitoring change over time and in response to therapy. This can be accessed on the AMS website: www.menopause.org.au/images/stories/education/docs/AMS_Diagnosing_Menopause_Symptom_Score.pdf

Important areas, other than the obvious management ... Buy now

Examination

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Lifestyle advice

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Contraceptive advice in the perimenopause

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Management of menopausal symptoms

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Non-pharmacological treatment options

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Australasian Menopause Society. Menopause Basics. [Internet]. Australasian Menopause Society; 2019. Available from: https://www.menopause.org.au/hp/management/menopause-basics.

Harlow S, Gass M, Hall JE, Lobo R, Maki P, Rebar RW, Sherman S, Sluss PM, de Villiers TJ STRAW+10, diagram, ‘Executive Summary of the Stages of Reproductive Aging Workshop +10: Addressing the Unfinished Agenda of Staging Reproductive Aging. The North American Menopause Society. 2012;19(4):387-95.

Jean Hailes. About Menopause. [Internet]. Jean Hailes; 2017 [updated 2019 February 4]. Available from: https://jeanhailes.org.au/health-a-z/menopause/about-menopause.

Speroff L. The perimenopause: definitions, demography and physiology. Obstet Gynecol Clin North Am. 2002;29(3):397-410.

Avis N, Crawford SL, Greendale G, et al. Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Intern Med. 2015;175(4):531-9.

Gartoulla P, Worsley R, Bell RJ, Davis SR. Moderate to severe vasomotor and sexual symptoms remain problematic for women aged 60 to 65 years. Menopause. 2015;22(7):694-701.

Faddy M, Gosden RG, Gougeon A, et al. Accelerated disappearance of ovarian follicles in mid life: implications for forecasting menopause. Hum Reprod 1992;7(10):1342-6.

Richardson S, Senikas V, Nelson JF. Follicular depletion during the menopausal transition: evidence for accelerated loss and ultimate exhaustion. J Clin Endocrinol Metab. 1987;65:1231-7.

Burger H, Hale GE, Dennerstein L, Robertson DM. Cycle and hormone changes during perimenopause: the key role of ovarian function. Menopause 2008;15(4):603-12.

10.

Santoro N, Buster JE. Hormonal changes of the menopausal transition Sex Reprod Menopause Supplement 2009;May 2009:33-40.

11.

Davis S, Lambrinoudaki I, Lumsden M, Mishra GD, Rees M, Santoro N, et al. Menopause. Natural Reviews Disease Primers. 2015; 1(15004).

12.

Depmann M, Broer SL, van der Schouw YT, et al. Can we predict age at natural menopause using ovarian reserve tests or mother’s age at menopause?. Menopause 2016;23(2):224-32.

13.

Archer D, Sturdee DW, Baber R, et al. Menopausal hot flushes and night sweats: where are we now?. Climacteric. 2011;14(5):515-28.

14.

Australian absolute cardiovascular disease risk calculator [Internet]. National Vascular Disease Prevention Alliance. 2012. Available from: http://www.cvdcheck.org.au/.

15.

Department of Health. BreastScreen Australia Program. [Internet]. Australian Government. Available from: http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/breast-screening-1.

16.

Department of Health. National Bowel Cancer Screening Program [Internet]. Australian Government; 2019]. Available from: http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/clinical-guidelines.

17.

National Health and Medical Research Council (NHMRC). Australian guidelines to reduce health risks for drinking alcohol.[Internet].Canberra, ACT: NHMRC; 2009. Available from: https://www.nhmrc.gov.au/about-us/publications/australian-guidelines-reduce-health-risks-drinking-alcohol

18.

Cancer Australia. Risk Factors. [Internet]. Australian Government. Available from: https://breastcancerriskfactors.gov.au/risk-factors/lifestyle-factors.

19.

The Faculty of Sexual & Reproductive Healthcare of the Royal College of Obstetricians & Gynaecologists (FSRH). FSRH Clinical Guideline: Progestogen-only Injectable Contraception December 2014 (Amended April 2019). [Internet]. FSRH; 2014. Available from: https://www.fsrh.org/standards-and-guidance/fsrh-guidelines-and-statements/method-specific/progestogen-only-injectables/.

20.

Australasian Menopause Society. NonHormonal Treatments for Menopausal Symptoms. [Internet]. Australasian Menopause Society; 2018. Available from: https://www.menopause.org.au/hp/information-sheets/600-nonhormonal-treatments-for-menopausal-symptoms.

21.

Nonhormonal management of menopause-associated vasomotor symptoms: 2015 position statement of The North American Menopause Society. Menopause. 2015 Nov;22(11):1155-72.

22.

Ayers B, Smith M, Hellier J, Mann E, Hunter MS. Effectiveness of group and self-help cognitive behaviour therapy in reducing problematic menopausal hot flushes and night sweats (MENOS 2): a randomized controlled trial. Menopause. 2012 July;19(7):749-59.

23.

Mann E, Smith MJ, Hellier J, Balabanovic JA, Hamed H, Grunfeld EA, Hunter MS. Cognitive behavioural treatment for women who have menopausal symptoms after breast cancer treatment (MENOS 1): a randomised controlled trial. Lancet Oncol. 2012 Mar;13(3):309-18.

24.

Green S, Haber E, McCabe RE, Soares CN. Cognitive-behavioural group treatment for menopausal symptoms: a pilot study. Arch Womens Ment health. 2013;16(4):325-32.

25.

Elkins G, Fisher WI, Johnson AK, Carpenter JS, Keith TZ. Clinical hypnosis in the treatment of postmenopausal hot flashes: a randomized controlled trial. Menopause. 2013 Mar;20(3):291-8.

26.

Australasian Menopause Society. Bioidentical hormone therapy. [Internet]. Australasian Menopause Society; 2018. Available from: https://www.menopause.org.au/health-info/fact-sheets/bioidentical-hormone-therapy.

27.

Australasian Menopause Society. Lifestyle and behavioural modifications for menopausal symptoms. [Internet]. Australasian Menopause Society; 2019. Available from: https://www.menopause.org.au/hp/information-sheets/1087-lifestyle-and-behavioural-modifications-for-menopausal-symptoms.

28.

The Royal Women’s Hospital. Managing Menopause. [Internet]. Victoria: The Royal Women’s Hospital. Available from: https://www.thewomens.org.au/health-information/menopause-information/managing-menopause.

29.

Hickey M, Szabo RA, Hunter MS. Non-hormonal treatments for menopausal symptoms. BMJ. 2017 Nov;23(359).

30.

de Villiers T, Hall JE, Pinkerton JV, Cerdas Pérez S, Rees M, Yang C, Pierroz DD Revised Global Consensus Statement on Menopausal Hormone Therapy Climacteric. 2016;19(4):313-5.

31.

Vinogradova Y. Use of hormone replacement therapy and risk of venous thromboembolism: nested case-control studies using the QResearch and CPRD databases. BMJ. 2019;364:k4810.

32.

Asi N, Mohammed K, Haydour Q, Gionfriddo MR, Morey Vargas OL, Prokop LJ et al,. Progesterone vs. synthetic progestins and the risk of breast cancer: a systematic review and meta-analysis. Syst Rev. 2016;5(121-129).

33.

Cuadros J, Fernandez-Alonso AM, Chedraui P, Cuadros AM, Sabatel RM, Perez-Lopez R. Metabolic and hormonal parameters in postmenopausal women 10 years after transdermal oestradiol treatment, alone or in combination to micronized oral progesterone. Gynae Endocrinol. 2011;27(3):156-62.

34.

Genazzani A, Pluchino N, Bernardi F, Centofanti, Luisi M. Beneficial effect of tibolone on mood, cognition, well-being, and sexuality in menopausal women. Neuropsychiatr Dis Treat. 2006;2(3):299-307.

35.

Australasian Menopause Society. Tibolone as menopausal hormone therapy. [Internet]. Australasian Menopause Society; 2018. Available from: https://www.menopause.org.au/hp/information-sheets/1287-tibolone-as-menopausal-hormone-therapy.

36.

Jean Hailes. Menopause Management. [Internet]. Jean Hailes; 2017 [updated 2019 Nov 18]. Available from: https://www.jeanhailes.org.au/health-a-z/menopause/menopause-management

37.

David S. The effects of tibolone on mood and libido. Menopause. 2002;9(3):162-70.

38.

Cummings S, Ettinger B, Delmas PD, Kenemans P, Stathopoulos V, Verweij P, et al. The effects of tibolone in older postmenopausal women. New England Journal of Medicine 2008;359(7):697-708.

39.

Australasian Menopause Society. What is Menopausal Hormone Therapy (MHT) and is it Safe?. [Internet]. Australasian Menopause Society; 2019. Available from: https://www.menopause.org.au/health-info/fact-sheets/what-is-menopausal-hormone-therapy-mht-and-is-it-safe.

40.

Australasian Menopause Society. SERMs – their role in menopause management. [Internet]. Australasian Menopause Society; 2017. Available from: https://www.menopause.org.au/images/stories/infosheets/docs/AMS_SERMs_their_role_in_Menopause_Management.pdf.

41.

Collaborative Group on Epidemiological Studies of Ovarian Cancer. Menopausal hormone use and ovarian cancer risk: individual participant meta-analysis of 52 epidemiological studies. Lancet. 2015;385(9980):1835-42.

42.

Roberts H, Hickey M. Should hormone therapy be recommended for prevention of cardiovascular disease?. Cochrane Database of Syst Rev 2015;3(ED000097).

43.

Renoux C, Dell’Aniello S, Garbe E, Suissa S,. Transdermal and oral hormone replacement therapy and the risk of stroke: a nested case control study. BMJ. 2010;340:c2519.

44.

Scarabin PY. Progestogens and venous thromboembolism in menopausal women: an updated oral versus transdermal estrogen meta-analysis. Climacteric. 2018;21(4):341-5.

45.

Vinogradova Y, Coupland C, Hippisley-Cox J. Use of hormone replacement therapy and risk of venous thromboembolism: nested case-control studies using the QResearch and CPRD databases. BMJ. 2019;364:k4810.

46.

Pitkin J, British Menopause Society Medical Advisory Council. Consensus Statement Post Reproductive Health 2018;24(3):133-8.

47.

Simon J, Davis SR, Althof SE, Chedraui P, Clayton AH, Kingsberg SA, et al. Sexual well-being after menopause: An International Menopause Society White Paper. Climacteric. 2018;21(5):415-27.

48.

Buttini M, Maher C. The first published randomised controlled trial of laser treatment for vaginal atrophy raises serious questions. Med J Aust 2018;209(9).

49.

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) Women’s Health Committee. Vaginal ‘rejuvenation’ and cosmetic vaginal procedures. [Internet]. 2018. Available from: https://doi.org/10.1111/ajo.12999.

50.

U.S. Food and Drug Administration (FDA). FDA Warns Against Use of Energy-Based Devices to Perform Vaginal ‘Rejuvenation’ or Vaginal Cosmetic Procedures: FDA Safety Communication. FDA [Internet]. 2018. Available from: https://www.fda.gov/medical-devices/safety-communications/fda-warns-against-use-energy-based-devices-perform-vaginal-rejuvenation-or-vaginal-cosmetic.

51.

Australasian Menopause Society. Non-hormonal Treatments for Menopausal Symptoms. [Internet]. Australasian Menopause Society; 2018. Available from: https://www.menopause.org.au/hp/information-sheets/600-nonhormonal-treatments-for-menopausal-symptoms.

52.

Lynch C, Folkers ME, Hutson WR. Fulminant hepatic failure associated with the use of black cohosh: a case report. Liver Transpl. 2006;12(6): 989-992. Available from: https://doi.org/10.1002/lt.20778.

53.

Pinkerton J. What are the concerns about custom-compounded “bioidentical” hormone therapy? . Menopause 2014;21(12):1298-300.

54.

Baber R, Panay N, Fenton A the IMS Writing Group. 2016 IMS Recommendations on women’s midlife health and menopause hormone therapy. Climacteric. 2016;19(2):109-50.

55.

Milsom S, O’Sullivan S. Premature ovarian insufficiency. Menopause. 2017 (Autumn);19(1).

56.

Webber L, Davies M, Anderson R, et al. ESHRE guideline: Management of women with premature ovarian insufficiency. Hum Reprod 2016;31(5):926-37.

57.

Crofton P, Evans N, Bath LE, Warner P, Whitehead TJ, Critchley HO, et al. Physiological versus standard sex steroid replacement in young women with premature ovarian failure: effects on bone mass acquisition and turnover. Clin Endocrinol (Oxf). 2010;73:707-14.

58.

Jean Hailes. Mental health and emotions. [Internet]. Jean Hailes; 2017 [updated 2019 Feb 04]. Available from: https://jeanhailes.org.au/health-a-z/menopause/mental-health-emotions.

59.

Osteoporosis Australia. Bone density testing in general practice. [Internet]. Osteoporosis Australia; 2017. Available from: https://healthybonesaustralia.org.au/sites/default/files/files/GP%20Bone%20Density%202017.pdf.

60.

The Royal Australian College of General Practitioners (RACGP), Osteoporosis Australia. Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age [internet]. 2^nd East Melbourne, Victoria: RACGP; 2017. Available from: https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/osteoporosis.

61.

Collins P, Webb CM, de Viller TJ, Stevenson JC, Panay N, Baber RJ. Cardiovascular risk assessment in women – an update. Climacteric. 2016;19(4):329-36.

62.

Manson J, Chlebowski RT, Stefanick MC, et al. Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women’s Health Initiative randomized trials. JAMA. 2013;310(13):1353-68.

63.

Vessey MP. Progestogen only oral contaception. Findings in a large prospective study with special reference to effectiveness. Br J Fam Plann 1985;10:117–21.

64.

The Faculty of Sexual & Reproductive Healthcare of the Royal College of Obstetricians & Gynaecologists (FSRH). FSRH Clinical Guideline: Contraception for Women Aged over 40 Years (August 2017, amended September 2019). [Internet]. FSRH; 2017. Available from: https://www.fsrh.org/standards-and-guidance/documents/fsrh-guidance-contraception-for-women-aged-over-40-years-2017/

65.

Davis SR, Bell RJ, Robinson PJ, Handelsman DJ, Gilbert T, Phung T, et al. Testosterone and Estrone increase from the age of 70 years: findings from the Sex Hormones in Older Women Study. J Clin Endocrinol Metab. 2019; 104(12):6291-300

66.

Szoeke C, Lehert P, Henderson VW, Dennerstein L, Desmond P, Campbell S. Predictive Factors for Verbal Memory Performance Over Decades of Aging: Data from the Womems Healthy Aging Project. Am J Geriatr Psychiatry. 2016; 24(10):857-67.

67.

Li FG ,Maheux-Lacroix S,Deans R, Nesbitt-Hawes E, Budden A, Nguyen K. Effect on Symptom Severity in Women with Postmenopausal Vaginal Symptoms: A randomised Clinical Trial. JAMA. 2021;326(14):1381-1389.

68.

International Society for the Study of Womens Sexual Health Clinical Practice Guideline for the Use of Systemic Testosterone for Hypoactive Sexual Desire Disorder in Women. J Sex Med. 2021;18:849-867.

69.

Executive AM, Constitution BA. Tibolone as menopausal hormone therapy. Australasian Menopause Society. 2018; 1:1-4. Availble from: https://www.menopause.org.au/hp/information-sheets/tibolone-as-menopausal-hormone-therapy

70.

Executive AM, Constitution BA. Menopause before 40 and spontaneous premature ovarian insufficciency. Australasian Menopause Society. 2020; 1:1-2. Available from: https://www.menopause.org.au/health-info/fact-sheets/menopause-before-40-and-spontaneous-poi

71.

Therapeutic Guidelines. 2021. [Internet]. Available from: https://tgldcdp.tg.org.au/viewTopic?topicfile=osteoporosis-minimal-trauma-fracture&guidelineName=Bone%20and%20Metabolism#toc_d1e1068https://tgldcdp.tg.org.au/guideLine?guidelinePage=Bone+and+Metabolism&frompage=etgcomplete

72.

Executive AM, Constitution BA. Migraine headaches, menopause and MHT/HRT. 2019; 1:1-3. Available from: https://www.menopause.org.au/hp/information-sheets/migraine-headaches-menopause-and-mht-hrt

73.

Therapeutic Guidelines. 2021. [Internet]. Available from: https://tgldcdp.tg.org.au/index#toc_d1e254

74.

The Royal Australian and New Zealand College of Obstericians and Gynaecologists. Menopause. 2016;1:1-4. Available from: https://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Patient%20information/Menopause-pamphlet.pdf?ext=.pdf

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Reproductive and Sexual Health Handbook

Chapter 11 – Menopause

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