Menopause INVESTIGATIONS MANAGEMENT
> 12 months of amenorrhea • FSH/LH > 40 1. Vasomotor symptoms
• Estrogen (E2) low • Lifestyle – exercise and healthy weight, quit smoking,
Normal: 45-55 yo (mean age 51.4)
• Fasting lipid/glucose clothing layers, fans
< 40 = Primary ovarian insufficiency
• Pelvic US • Non-hormonal medical – clonidine, SSRI, gabapentin
40-45 = early menopause
• Mammogram • Hormonal (HRT) – E + P if uterus, E alone if no uterus
> 55 = late menopause
• BMD (osteoporosis) 2. Urogenital atrophy** gets worse with time
Perimenopause
• Local vaginal estrogen
• Cream Premarin 2-3x/week
• FSH > LH, both > 40 IU/L
• Tablet Vagifem 2-3x/week
• Ring Estring q3 months
SYMPTOMS (tissues with estrogen receptors)
• Vasomotor instability (hot flashes, night sweats, sleep disturbance, nausea, palpitations) 3. Preventative care
• CVS – BP, glucose, lipid, thyroid (TSH all women > 50),
• Genitals (atrophy, dryness, increased infections)
smoking cessation, exercise, moderate EtOH
• Urinary tract (increased frequency, urgency, incontinence)
• Breasts (Atrophy) • Cancer – pap smear, breast exam, mammogram, CRC
• CV (atherosclerosis, stroke, lower HDL, higher LDL, TG, TC) screen
• Osteoporosis – BMD, calcium, Vit D, exercise, fall-
• Skeleton (osteoporosis, joint + muscle pain, back pain)
proofing
• Skin (thinning, loss of elasticity)
• Psych (mood disturbance, irritability, fatigue, decreased libido, memory loss) Contraindications to HRT:
• Liver dz
PATHOPHYSIOLOGY • Undiagnosed vaginal bleeding
• Reduction in follicles = reduced binding sites for LH/FSH • Hormone-dependent cancers
• Increased production of LH/FSH as a result • Cardiovascular dz/ DVT/PE (thromboembolic dz)
• Reduced estrogen due to lack of follicles
Note: HRT increases risk of breast cancer and stroke/DVT/PE
, Menopause - CMAJ article Lega et al 2023
Contraindications to systemic menopausal hormone therapy:
Estrogen
Vasomotor symptoms: hot flashes, night sweats
• Undiagnosed AUB
>45 yo w symptoms of menopause or amenorrhea = no work up except bHCG if sexually active with no contraception • Current or hx of breast ca
• E-dependent cancers
< 45 yo = FSH, endocrine disorders, pregnancy • CAD
• VTE
<40 yo – complete work up for secondary amenorrhea including FSH and estradiol • Stroke
• Known thrombophilia
• Active liver dz (abnormal liver function tests, cirrhosis)
Atypical vasomotor symptoms = r/o malignancy – carcinoid syndrome, pheo, heme or solid malignancy
Progestin:
• Undiagnosed AUB
• Current or hx of breast ca
Investigations for secondary amenorrhea < 45 yo:
Red flags and secondary work up to consider if vasomotor symptoms:
Ddx Diagnostic test
Symptoms Ddx Secondary work up
Premature ovarian insuff/early FSH, estradiol
menopause B symptoms Malignancy
Hyperprolactinemia Serum prolactin
Worsening VMS, remote from CAD Echo, holter, stress test
Pregnancy bHCG menopause
VMS with skin flushing, diarrhea, SOB Carcnoid syndrome 24h urine collection for 5-HIAA
Hypo/hyperthyroidism TSH
PCOS Clinical diagnosis +/- total serum Episodic headache, htn, palpitations Pheochromocytoma 24h urine total metanephrines
testosterone
> 12 months of amenorrhea • FSH/LH > 40 1. Vasomotor symptoms
• Estrogen (E2) low • Lifestyle – exercise and healthy weight, quit smoking,
Normal: 45-55 yo (mean age 51.4)
• Fasting lipid/glucose clothing layers, fans
< 40 = Primary ovarian insufficiency
• Pelvic US • Non-hormonal medical – clonidine, SSRI, gabapentin
40-45 = early menopause
• Mammogram • Hormonal (HRT) – E + P if uterus, E alone if no uterus
> 55 = late menopause
• BMD (osteoporosis) 2. Urogenital atrophy** gets worse with time
Perimenopause
• Local vaginal estrogen
• Cream Premarin 2-3x/week
• FSH > LH, both > 40 IU/L
• Tablet Vagifem 2-3x/week
• Ring Estring q3 months
SYMPTOMS (tissues with estrogen receptors)
• Vasomotor instability (hot flashes, night sweats, sleep disturbance, nausea, palpitations) 3. Preventative care
• CVS – BP, glucose, lipid, thyroid (TSH all women > 50),
• Genitals (atrophy, dryness, increased infections)
smoking cessation, exercise, moderate EtOH
• Urinary tract (increased frequency, urgency, incontinence)
• Breasts (Atrophy) • Cancer – pap smear, breast exam, mammogram, CRC
• CV (atherosclerosis, stroke, lower HDL, higher LDL, TG, TC) screen
• Osteoporosis – BMD, calcium, Vit D, exercise, fall-
• Skeleton (osteoporosis, joint + muscle pain, back pain)
proofing
• Skin (thinning, loss of elasticity)
• Psych (mood disturbance, irritability, fatigue, decreased libido, memory loss) Contraindications to HRT:
• Liver dz
PATHOPHYSIOLOGY • Undiagnosed vaginal bleeding
• Reduction in follicles = reduced binding sites for LH/FSH • Hormone-dependent cancers
• Increased production of LH/FSH as a result • Cardiovascular dz/ DVT/PE (thromboembolic dz)
• Reduced estrogen due to lack of follicles
Note: HRT increases risk of breast cancer and stroke/DVT/PE
, Menopause - CMAJ article Lega et al 2023
Contraindications to systemic menopausal hormone therapy:
Estrogen
Vasomotor symptoms: hot flashes, night sweats
• Undiagnosed AUB
>45 yo w symptoms of menopause or amenorrhea = no work up except bHCG if sexually active with no contraception • Current or hx of breast ca
• E-dependent cancers
< 45 yo = FSH, endocrine disorders, pregnancy • CAD
• VTE
<40 yo – complete work up for secondary amenorrhea including FSH and estradiol • Stroke
• Known thrombophilia
• Active liver dz (abnormal liver function tests, cirrhosis)
Atypical vasomotor symptoms = r/o malignancy – carcinoid syndrome, pheo, heme or solid malignancy
Progestin:
• Undiagnosed AUB
• Current or hx of breast ca
Investigations for secondary amenorrhea < 45 yo:
Red flags and secondary work up to consider if vasomotor symptoms:
Ddx Diagnostic test
Symptoms Ddx Secondary work up
Premature ovarian insuff/early FSH, estradiol
menopause B symptoms Malignancy
Hyperprolactinemia Serum prolactin
Worsening VMS, remote from CAD Echo, holter, stress test
Pregnancy bHCG menopause
VMS with skin flushing, diarrhea, SOB Carcnoid syndrome 24h urine collection for 5-HIAA
Hypo/hyperthyroidism TSH
PCOS Clinical diagnosis +/- total serum Episodic headache, htn, palpitations Pheochromocytoma 24h urine total metanephrines
testosterone
