Menopause, Perimenopause, and Hormone Therapy
Physiology and diagnosis
Menopause is 12 months of amenorrhoea after the final menstrual period; median age ~51. Perimenopause features variable cycles and vasomotor symptoms. Diagnosis is clinical; FSH is unreliable during perimenopause and unnecessary when symptoms are typical.
Hormone therapy
Systemic HT is the most effective treatment for vasomotor symptoms. Estrogen alone for women without a uterus; estrogen plus progestogen for women with a uterus to prevent endometrial hyperplasia. Use the lowest effective dose for the shortest duration consistent with treatment goals, with periodic reassessment.
Know the Women's Health Initiative context: risks are age- and time-dependent, with a favorable window near menopause onset. Transdermal estrogen may be preferred with hypertriglyceridaemia or migraine.
Traps
- Giving unopposed estrogen to a woman with a uterus.
- Using HT for primary prevention of cardiovascular disease-it is not indicated.
- Missing that vaginal estrogen is safe and effective for genitourinary syndrome and does not require a progestogen.
- Interpreting a mildly elevated FSH as diagnostic of menopause in a symptomatic 47-year-old.
Worked example
A 52-year-old with a uterus and hot flushes: start combined estrogen–progestogen at low dose, counsel on risks/benefits, and reassess annually. If she has only vaginal dryness, use local estrogen alone.