Menopause/Perimenopause Station

Presenting Complaint - Irregular Menstrual Bleeding

History of Presenting Complaint:

• Menstrual History:
  • Her last menstrual period was 2 months ago
  • Her periods have always been regular until the last 6 months
  • Menses usually last 5 days but now last from anywhere between 2-10 days
  • Cycle length varies from 25 days to 33 days
  • She reports having heavier periods than usual. She sometimes passes large blood clots and has to change her pads every 2 hours
  • She denies having any dysmenorrhoea, intermenstrual bleeding, or post-coital bleeding
  • She had her first period when she was 13 years old
  • She reports having dyspareunia for the past 3-4 months
  • She denies having any vulval skin changes and itching or abnormal vaginal discharge
• Obstetrics History:
  • G3 P2
  • She has been pregnant 3 times
  • She has given vaginal birth to 2 children at full-term. No associated complications.
  • She has had 1 miscarriage but no terminations in the past
• Sexual History:
  • She is sexually active and has 1 partner only (her husband)
  • She reports having low libido
  • She uses the Mirena coil for contraception, which was inserted 5 years ago.
• She reports occasionally experiencing hot flushes and night sweats
• She denies the following symptoms:
  • Mood changes
  • Changes to weight
  • Tremors
  • Palpitations
  • Abdominal pain
  • No urinary symptoms or changes to bowel habits
  • Systemic symptoms e.g. fatigue, changes to appetite

Previous Medical History

• Otherwise healthy with no significant past medical history

• No recent illnesses or surgery

Drug History

• Nil regular

Allergies

• NKDA

Family History

• No menstrual or gynaecological problems in the family

Social History

• She works as a secondary school teacher

• Lives with her husband

• Does not drink alcohol. Has never smoked or taken recreational drugs.

ICE

• Ideas: “What has caused my periods to become heavier all of a sudden?”

• Concerns: “I’m worried it might be a sign of cancer”

• Expectations: “I want to get to the bottom of what’s caused my periods to become irregular and heavier.”

Most Likely Differentials:

• Perimenopause (due to 6-month history of heavy and irregular periods, her age, and associated menopausal symptoms of dyspareunia, low libido, hot flushes, and night sweats)
• Endometrial Cancer (due to most common symptom being abnormal vaginal bleeding)
• Uterine Fibroids (can present with heavy menstrual bleeding)
• Adenomyosis (can present with heavy menstrual bleeding)

Management

• BMI (BMI >30 kg/m² is linked to an increased risk of venous thromboembolism (VTE). Option for transdermal HRT over oral HRT can be beneficial, as transdermal HRT is associated with a lower risk of VTE compared to oral HRT).
• Blood Pressure (untreated high blood pressure is a contraindication to taking HRT)

1. What are gravida and parity?

• Gravida (G) refers to the number of times a woman has been pregnant, regardless of the outcome.
• Parity (P) refers to the number of pregnancies that have reached viable gestational age (typically 24+ weeks), regardless of whether the baby was born alive or stillborn.

2. Examples - What is G1P0? What is G5P2?

• G1P0 – A woman who is currently pregnant for the first time and has not delivered yet or a woman who was previously pregnant and had a miscarriage or abortion.
• G5P2 – A woman who has been pregnant five times but only had two pregnancies reach 24 weeks (this could mean miscarriages or terminations in the other three pregnancies).

3. What is menopause?

Definition

Menopause is a natural biological process that marks the end of a woman’s reproductive years. It is defined as occurring 12 months after a woman’s last menstrual period and typically happens between ages 45 and 55, with the average age being 51. It is caused by the loss of ovarian follicular function and decline in oestrogen levels.

Stages of Menopause

• Perimenopause: The transitional period leading up to menopause, which is characterised by a decline in ovarian activity, fluctuating hormone levels, and irregular menstrual cycles. Perimenopause typically begins in a woman’s 40s and symptoms can start anywhere from a few months to several years before menopause.
• Menopause: The point in time when a woman has not had a menstrual period for 12 months.
• Post-menopause: The years following menopause, during which symptoms may continue but often decrease in intensity.

Clinical Presentation

Symptoms of menopause include:

• Vasomotor:
  • Hot Flushes: Sudden feelings of warmth, often accompanied by sweating and flushing.
  • Night Sweats: Hot flashes that occur at night, causing sweating and sleep disturbances.
• Cognitive e.g. mood swings, low mood, anxiety, irritability, difficulty concentrating
• Sleep Problems: Insomnia or disrupted sleep.
• Urogenital:
  • Vaginal dryness
  • Dyspareunia
  • Low libido
• Weight Gain: Changes in metabolism can lead to weight gain, particularly around the abdomen.
• Others: Palpitations, Tremors (internal trembling, vibrations, shaking, or buzzing sensations).

Diagnosis

The diagnosis of menopause is clinical, based on the absence of menstrual periods for 12 months.

Management

Menopause is a unique experience for every woman, and the approach to managing symptoms can vary widely. Tailoring a management plan that best suits an individual’s needs is therefore essential. Management options include:

• Lifestyle Modifications:
  • Balanced Diet: Maintaining a healthy diet can help alleviate symptoms and improve cardiovascular health.
  • Calcium and Vitamin D: Important for bone health. Regular bone density screening is also recommended to assess the risk of osteoporosis.
  • Regular Exercise: The government recommends aiming for at least 150 minutes of moderate aerobic exercise or 75 minutes of vigorous exercise per week, plus strength training twice a week to help maintain bone density.
  • Good Sleep Hygiene: Maintaining a regular sleep schedule, creating a comfortable sleep environment, and avoiding caffeine and electronic screens before bedtime can help improve sleep quality.
  • Relaxation Techniques: Yoga, meditation, and mindfulness practices can help to reduce stress and anxiety.
• Non-Hormonal Therapies
  • Antidepressants and/or CBT to help manage mood symptoms
  • Clonidine (alpha-2 adrenergic agonist that treats vasomotor symptoms e.g. hot flushes and night sweats)
• Hormonal Replacement Therapy (HRT)
  • Used to alleviate menopausal symptoms, improve the quality of life and reduce the risk of osteoporosis and cardiovascular disease.
  • Vaginal oestrogen (local HRT): Local treatment for specific symptoms, such as dyspareunia caused by vaginal dryness.
  • 2 main types:
    • Oestrogen-only Therapy: For women who have had a hysterectomy
    • Combined Oestrogen and Progesterone Therapy: For women who still have a uterus, to reduce the risk of endometrial cancer.
  • Alternative Therapies
    • Herbal Remedies (e.g. evening primrose oil, black cohosh, angelia, ginseng, red clover St John’s Wort) can help alleviate menopausal symptoms
    • Acupuncture: may provide relief for some women.

4. What is the difference between menopause and perimenopause?

• Definition: Menopause is the point in time 12 months after a woman’s last menstrual period. It is caused by the loss of ovarian follicular function and decline in oestrogen levels. In contrast, perimenopause means “around menopause” and refers to the transitional period leading up to menopause. It is characterised by a decline in ovarian activity and fluctuating hormone levels. This means your periods do not stop but may become more irregular due to ovulation becoming more unpredictable; for instance, in some months, you may ovulate, occasionally even releasing two eggs in cycle, while in other months, no egg may be released at all. Perimenopause ends and menopause starts when you have not had a period for 12 months.
• Timing: Menopause typically occurs between the ages of 45 and 55, with the average age being 51. In contrast, perimenopause typically begins in a woman’s 40s and can last until menopause.
• Duration: Perimenopause can last anywhere from a few months to several years.
• Hormonal Changes: During menopause, the ovaries stop producing oestrogen and ovulation no longer occurs, whereas during perimenopause, the levels of oestrogen and progesterone produced by the ovaries fluctuate irregularly.
• Symptoms: Many symptoms of menopause are similar to those of perimenopause, including hot flushes, night sweats, sleep problems, mood swings and vaginal dryness. However, a key difference between the menopause and perimenopause is the status of menstrual periods. During menopause, a woman has not had her periods for the last 12 months, whereas during menopause, a woman’s periods may become more irregular, lighter, or heavier.

5. Can HRT be used for contraception?

HRT contains very low levels of hormones and therefore does not work as a contraceptive. Perimenopausal may require both HRT for symptom management and contraception to prevent unintended pregnancy. In women under the age of 50, contraception is required until 2 years after their last menstrual period, or for 1 year in women over the age of 50.

• Mirena coil – licensed for endometrial protection (for up to 5 years) and can be used as a contraception when combined with oestrogen-only HRT.
• The progesterone-only implant, progesterone-only injectable, and progesterone-only pill can be used as a contraception alongside HRT. However, it cannot be used for endometrial protection alongside oestrogen-only HRT.
• The combined oral contraceptive pill (COCP) should NOT be used in combination with HRT. The COCP can be used in eligible women <50 years old as an alternative to HRT for symptomatic relief. However, at the age of 50, women should be advised to switch to an alternative form of contraception.