Management of the menopause: integrated health-care pathway for the menopausal woman

Management of the menopausal woman has become controversial since publication of the results of the Women's Health Initiative and the Million Women Study from 2002 onwards. This health-care pathway summarizes the role of hormone replacement therapy and non-estrogen-based treatments as well as alternative and complementary therapies. It is based on the fifth edition of Management of the Menopause and was updated on 5 April 2011.     

Cultural issues and the menopause

Culture is a rather amorphous concept yet has a huge impact on our attitudes to diet, lifestyle, religion, sexuality and, via its influence on society, attitudes to education and health care. The midlife is a time of emotional and hormonal upheaval for any woman so defining the effects on culture on her response is challenging. Much depends on the value she places on her fertility and sexuality together with her own goals and aspirations, yet these are also influenced by culture. Very few traditional cultures survive in isolation for comparison. Shifting populations mean counter influences and transitional societies can be ambivalent. Emigrants and refugees transplanted into a different environment may struggle with the concept of acculturation. In time, all cultures evolve regardless. Finally, there may be biological and hormonal differences between races. This article seeks to place these different forces into context.     

Metabolic syndrome and the menopause

The metabolic syndrome consists of a combination of risk factors that include abdominal obesity, atherogenic dyslipidaemia, hypertension and insulin resistance. It increases the risk of cardiovascular disease and type 2 diabetes. The increased risk of cardiovascular disease is higher in women than in men. The first manifestation of metabolic syndrome may occur in pregnancy presenting as gestational diabetes or preeclampsia. Both conditions are associated with increased insulin resistance. Also metabolic syndrome is more common in polycystic ovarian syndrome. It has been suggested that there is a metabolic syndrome resulting from the menopause due to estrogen deficiency, as many of the risk factors are more prevalent in postmenopausal women. Also estrogen replacement improves insulin sensitivity and reduces the risk of diabetes. The key elements in managing the metabolic syndrome are weight reduction, increasing physical activity and diet modification. If blood pressure, lipid and glycaemic control are not achieved through these interventions then pharmacological therapy will be required.     

Homocysteine, menopause and cardiovascular disease

A high plasma concentration of total homocysteine (tHcy) and a deficiency of vitamins related to its metabolism, such as vitamin B12 and folate, have been associated with cardiovascular disease. Postmenopausal women have higher concentrations than age-matched premenopausal women, and plasma concentrations of homocysteine in postmenopausal women taking hormone replacement therapy are significantly lower than they are in those who do not take estrogen supplements. Because of the possible mixed effects of HRT on cardiovascular events, surrogate end-points must be evaluated with caution. While measuring homocysteine levels is relatively simple, evidence from well designed trials is awaited before population screening can be advocated. Also, the benefits of reducing homocysteine levels with folic acid and vitamin B6 and B12 supplements are highly debated.     

Mental health around and after the menopause

The menopause is a time in a woman's life when it is recognized that biological and social changes can impact upon mental wellbeing. Several studies have investigated the relationship between menopause and psychological symptoms, especially depression, with mixed results. In part, this is due to a considerable overlap between depressive symptoms and those due to declining estrogen levels, causing challenges in assessment. However it appears that vulnerable women are at a higher risk of succumbing to depression during menopausal transition. Antidepressants remain the mainstay of treating depressive symptoms, with little conclusive evidence for hormone replacement therapy. Memory problems during menopause are a common complaint, but there is no demonstrated link to subsequent dementia. This paper also reviews considerations of diagnosis and treatment of postmenopausal depression.     

Alternative and complementary therapies for the menopause

Despite a re-evaluation of risks in recent years, hormone replacement therapy is still surrounded by controversy. Almost 30% of women in a recent survey sought a natural approach to combat climacteric symptoms. Nevertheless, a large proportion of patients felt that they wanted a good safety profile and strong evidence base for treatment. This article seeks to review the evidence supporting non-hormonal approaches to treatment. There is only conflicting evidence at best to support alpha-2 agonists, e.g. clonidine and limited evidence for dihydroepiandrosterone and natural progesterones. There is limited randomized controlled trial data for gabapentin, selective norepinephrine re-uptake inhibitors (SNRIs) and selective serotonin re-uptake inhibitors (SSRIs), many of these studies being related to breast cancer patients. Of the herbal medicinal products, the largest evidence base rests with phytoestrogens. A Cochrane Database review looking at all types of phytoestrogens, e.g. red clover extracts, dietary soya and soya extracts concluded that there was no evidence to support improvement in climacteric symptoms and the meta-analysis of a 178 studies on soy products was inconsistent. Nevertheless, other studies disagree. Mammographic density is not affected by soy or phytoestrogen products and recent in vitro work shows only a weakly proliferative effect of soy isoflavone on breast cancer cells and evidence that soy isoflavone blocks the proliferative effect of estradiol on these cells. There are no studies looking at clinical outcome measures for cardiovascular disease but a number of studies looking at biochemical markers including arterial wall stiffness and apolipo protein B. Recent studies have also looked at the effects of red clover isoflavone on mood and depression, using specific depression rating scales. Finally, it is important to note that herbal medicinal products should not be used without caution. Some may produce quite marked side-effects in high doses and others can interact with pre-existing medication. A strategy for which patients are suitable for herbal medicinal products is reviewed.     

Estrogen treatment affects brain functioning after menopause

Sex hormones have powerful neuromodulatory effects on functional brain organization and cognitive functioning. This paper reviews findings from studies investigating the influence of sex hormones in postmenopausal women with and without hormone therapy (HT). Functional brain organization was investigated using different behavioural tasks in postmenopausal women using either estrogen therapy or combined estrogen plus gestagen therapy and age- and IQ-matched postmenopausal women not taking HT. The results revealed HT-related modulations in specific aspects of functional brain organization including functional cerebral asymmetries and interhemispheric interaction. In contrast to younger women during the menstrual cycle, however, it seems that HT, and especially estrogen therapy, after menopause affects intrahemispheric processing rather than interhemispheric interaction. This might be explained by a faster and more pronounced age-related decline in intrahemispheric relative to interhemispheric functioning, which might be associated with higher sensitivity to HT. Taken together, the findings suggest that the female brain retains its plasticity even after reproductive age and remains susceptible to the effects of sex hormones throughout the lifetime, which might help to discover new clinical approaches in the hormonal treatment of neurological and psychiatric disorders.     

Qualitative inquiry into women's menopause experiences in southeastern Iran

Menopause is defined as amenorrhea for one year. Signs and symptoms are categorized as physical and psychological changes, including depression, hot flushes and ageing. Woman's responses to menopause are governed by lifestyle factors. The purpose of this study was to determine how Iranian women experience menopause and hormone therapy. A qualitative inquiry was conducted through semistructured, in-depth interviews to explore study questions in 11 menopausal women. Participants had positive and negative menopause experiences. Negative menopause experiences are due to severity of symptoms. Menopause can be facilitated by increasing women's knowledge about this phase and ways to cope with it.     

Dehydroepiandrosterone (DHEA) and the menopause: an update

Since we last reviewed this topic in 2001, considerably more information about dehydroepiandrosterone (DHEA) has accrued, but this has not necessarily left us any wiser about the use of this steroid in postmenopausal women. There is no further evidence that DHEA supplementation is likely to be useful in the prevention of cardiovascular disease or cognitive impairment, or in the promotion of wellbeing. Evidence has, however, accumulated for beneficial effects of DHEA on osteoporosis, both in postmenopausal women and in patients receiving long-term glucocorticoid therapy. What is also emerging is a link between low DHEA levels and cardiovascular risk, and between high DHEA levels and breast cancer risk. In fact, the benefits and adverse effects of DHEA administration in postmenopausal women increasingly resemble those of conventional hormone replacement therapy. Overall, we conclude that DHEA is not currently to be recommended for therapeutic use in the majority of postmenopausal women. However, DHEA supplementation may be of benefit in two specific groups of women: those with the lowest circulating levels of DHEA; and those for whom osteoporosis is a particular problem.     

Premature menopause and self-concept disjunctions. A case for crisis management

1. Surgically or chemically induced premature menopause is a life transition characterized by a situational crisis superimposed on a developmental crisis. 2. After surgically or chemically induced premature menopause, women's self-concept shifts and evolves through an interactive or relational process. 3. Nurses can use crisis management to increase women's understanding of the physiological and psychological dimensions of premature menopause, facilitate their links with community support systems, and strengthen their existing social networks. 4. Effective crisis intervention approaches include structuring, verbalizing, clarifying, normalizing, and supporting.     

Women's perceptions of the effects of menopause and hormone replacement therapy on skin

Although women frequently associate skin issues with menopause and hormone replacement therapy (HRT), little work has been done to investigate a possible relationship. A questionnaire was given to women attending a specialist menopause clinic; 87 women responded. Skin problems generally were common, with over 64% of respondents reporting past problems. Around half felt that the menopause had resulted in skin changes; dry skin was the predominant complaint at this stage. However, use of HRT in the short term did not result in any conclusive trends in skin condition in the majority of users.     

Insulin resistance and management of the menopause: a clinical hypothesis in practice

Insulin resistance (IR) is associated with a number of metabolic abnormalities including glucose intolerance, dyslipidemia and central obesity (the metabolic syndrome), which predispose to cardiovascular disease, diabetes mellitus and some cancers. The incidence of many of these conditions increases after the menopause, a time when IR also increases. Medical intervention to help alleviate menopausal symptoms, frequently vasomotor in origin, usually involves hormone replacement therapy (HRT), but some women may only experience partial symptom relief. We have hypothesized that this may be due to concurrent IR. Our approach is therefore to manage menopausal symptoms in conjunction with the treatment of any concurrent IR, achieved through a combination of hormone replacement, dietary intervention and, if necessary, an insulin sensitizer. We suggest that this approach may not only improve symptom relief but may also reduce the risk of developing more serious health complaints in the future.     

Unpredictable endocrinology of the menopause transition: clinical, diagnostic and management implications

The approach to menopause can be divided into the early (E) and late (L) menopausal transitions (MT) on the basis of menstrual irregularity (EMT) and subsequent observation of at least one episode of 60 or more days amenorrhoea (LMT). In total, 40-60% of cycles in the LMT are anovulatory, often with low oestradiol (E2) and high follicle-stimulating hormone concentrations. The ovulatory cycles have variable endocrine characteristics, none of which is specific to EMT or LMT. Hormonal measurements of FSH and E2 are thus of little diagnostic value because of their unpredictable variability. Symptoms during the transitions may result from high or low E2 and can often be satisfactorily managed with low-dose oral contraceptives, which suppress pituitary-ovarian function.     

Increased prevalence of premature ejaculation in men with metabolic syndrome

This prospective study aimed to investigate the relationship between metabolic syndrome (Met S) and premature ejaculation (PE) among men. The study included 300 consecutive male patients (53.6 y?±?8.7) who attended the urology clinic (December 2013–September 2014), mostly complaining of renal/ureteric calculi. A diagnostic approach was undertaken to include demographics, clinical features and laboratory investigations of the study subjects. Both erectile function and PE were evaluated using the International Index of Erectile Function (abridged form, IIEF-5) and Premature Ejaculation Diagnostic Tool (PEDT) questionnaires, respectively. Results identified 182 (60.7%) men had Met S. Prevalence of PE was significantly higher in the subjects with Met S than the controls (35.2% vs 7.6%, p?< 0.001). Patients with Met S and PE had significantly higher PEDT scores (15.4 vs 6.7), smaller waist circumference (108.3?cm vs 111.5?cm) and higher fasting blood sugar (187?mg% vs 161?mg%) than those with no PE (p?p?=?0.047 and <0.001, respectively) with PE in Met S. In conclusion, PE has a high prevalence in Met S. Patients with Met S should be questioned about PE. Both ED and systolic hypertension may be associated with PE. Prevention of Met S should be considered, and this may be of help to decrease the prevalence of PE.