Menopause and Perimenopausal Health
What the exam tests
Menopause items test three separate skills: recognizing that diagnosis is clinical, individualizing symptom management, and knowing that hormone therapy is not a prevention strategy.
Core concepts
- Diagnosis is clinical: 12 months of amenorrhea in a woman over 45. FSH is not needed and can mislead, particularly during perimenopause or while on hormonal contraception.
- Perimenopause brings irregular bleeding; bleeding that is heavy, prolonged, or occurs after menopause needs evaluation.
- Vasomotor symptoms: hormone therapy is the most effective treatment. Use estrogen plus a progestin in women with a uterus; estrogen alone after hysterectomy.
- Timing matters: starting under age 60 or within 10 years of menopause carries a more favorable risk profile. Hormone therapy is not indicated for primary prevention of cardiovascular disease or dementia.
- Contraindications include breast cancer, VTE, stroke, coronary disease, undiagnosed bleeding, and active liver disease.
- Genitourinary syndrome of menopause: low-dose vaginal estrogen is effective with minimal systemic absorption.
- Nonhormonal options: SSRIs or SNRIs, gabapentin, and neurokinin antagonists.
- Bone health: DXA at 65 or earlier with risk factors; calcium, vitamin D, and weight-bearing exercise.
Traps
- Estrogen alone in a woman with a uterus, risking endometrial hyperplasia or cancer.
- Ordering FSH to confirm menopause in a woman taking combined oral contraceptives.
- Assuming unscheduled bleeding on hormone therapy is benign without evaluation.
Worked example
A 52-year-old with a uterus has bothersome hot flashes and no contraindications. Offer estrogen plus a progestin at the lowest effective dose with annual review. If her only symptom were vaginal dryness, low-dose vaginal estrogen alone would be first-line.