Menopause For Primary Care

Terminology (perimenopause, menopause, postmenopause, POI, early menopause). STRAW+10 criteria for staging reproductive ageing. Epidemiology: mean age of natural menopause (51 years UK), global variation, and determinants.

Hypothalamic-pituitary-ovarian axis changes. Declining oestrogen, rising FSH, falling AMH. Role of inhibin B. Neuroendocrine mechanisms underpinning vasomotor symptoms (KNDy neuron pathway). Endocrine milieu shift from oestrogenic to androgenic dominance.

Vasomotor symptoms (VMS), sleep disturbance, mood changes, cognitive symptoms, musculoskeletal complaints, sexual dysfunction. Validated assessment tools: Greene Climacteric Scale, MRS, MENQOL. Differential diagnosis of menopausal symptoms.

Menopause as a clinical diagnosis in women aged >45. When FSH testing is indicated (ages 40–45 with symptoms; under 40 if POI suspected). FSH interpretation caveats (hormonal contraception, fluctuation). Role of AMH and oestradiol. When NOT to test.

Definition (POI <40 years; early menopause 40–44 years). Aetiology: idiopathic, autoimmune, iatrogenic, genetic (Turner syndrome, FMR1). Diagnostic criteria (FSH >25 IU/L on two occasions 4–6 weeks apart). Long-term health consequences. Multidisciplinary management.

Thyroid disease, PCOS, hypothalamic amenorrhoea, hyperprolactinaemia. Red flags: postmenopausal bleeding, unscheduled bleeding on HRT. When to refer. BMS guidance on unscheduled bleeding investigation.

Oestrogen options: oral oestradiol, transdermal patches/gel, conjugated equine oestrogens. Progestogen options: micronised progesterone, dydrogesterone, norethisterone, LNG-IUS. Sequential vs continuous combined regimens. Tibolone. Body-identical vs synthetic vs compounded preparations.

Patient selection and pre-treatment assessment. Counselling on risks (such as breast cancer, and other medical conditions- see NICE decision aid). Starting doses, dose titration, and formulation switching. Managing common side effects (breast tenderness, bloating, mood changes). Route selection based on patient risk factors (risk of breast cancer, BMI, VTE risk, migraine). Indications and administration of vaginal oestrogen for genitourinary syndrome of menopause (GSM).

Symptom relief efficacy. Bone protection. Cardiovascular ‘window of opportunity’ hypothesis. Breast cancer risk: type of progestogen, duration, oestrogen-only vs combined. VTE and stroke risk by route. WHI reanalysis. Million Women Study critique. Absolute vs relative risk communication.

Prescribing for women with a history of breast cancer, VTE, cardiovascular disease, migraine with aura, liver disease, endometriosis, fibroids. Contraindications (absolute and relative). The Davis contraindications framework. Specialist referral criteria.

No arbitrary time limits. Annual review framework. When to consider stopping: shared decision-making. Gradual dose reduction vs abrupt cessation. Monitoring blood pressure, bleeding patterns, breast screening. MHT beyond age 60: evidence and guidance.

Fezolinetant (NK3 receptor antagonist): mechanism, SKYLIGHT and DAYLIGHT trial data, NICE TA1143 appraisal. SSRIs/SNRIs (limited evidence, off-label). Clonidine. Gabapentin. Oxybutynin. Evidence hierarchy and patient selection.

Menopause-specific CBT: evidence base for VMS, sleep, and low mood. Mindfulness-based stress reduction. When to offer CBT (alongside or instead of HRT). Accessing CBT in the NHS. Self-help resources.

Mediterranean diet and cardiometabolic protection. Weight management in midlife (5–10% weight loss and insulin sensitivity). Exercise for bone, muscle, and cardiovascular health. Smoking cessation, alcohol reduction. Complementary therapies: what the evidence actually shows (isoflavones, black cohosh, St John’s Wort).

Definition and distinction from VVA. Urinary, genital, and sexual symptom domains. Vaginal pH, microbiome changes. Clinical assessment and examination findings. Under-recognition and barriers to presentation. Chronic progressive nature.

Vaginal oestrogen formulations (creams, pessaries, rings). Vaginal prasterone (DHEA). Ospemifene. Non-hormonal options: lubricants, moisturisers. Laser therapy (evidence limitations). Safety of vaginal oestrogen in breast cancer survivors. Long-term use and no need for progestogen.

Accelerated atherosclerosis post-menopause. Cardiometabolic changes by menopausal stage (premenopause, perimenopause, postmenopause). VMS as a biomarker of cardiovascular risk. Blood pressure, lipid, and insulin resistance changes. CVD risk assessment at menopause: a window of opportunity. Transdermal vs oral MHT and cardiovascular safety.

Accelerated bone loss in early postmenopause. FRAX assessment. Role of MHT in fracture prevention (WHI data). Calcium, vitamin D, and exercise. When to refer for DEXA. Transition from MHT to bone-specific agents. Sarcopenia: an emerging concern.

Indications: hypoactive sexual desire disorder (HSDD). Global consensus position. Formulations and monitoring (total testosterone target). Off-label prescribing in the UK. NICE and BMS positions. Safety data (cardiovascular, breast).

Menopause-associated symptoms in trans men and non-binary individuals who have taken gender-affirming hormone therapy. NICE 2024 recommendations. Sensitive history-taking and inclusive language.

Socioeconomic disparities in access to menopause care. Geographic variation in prescribing. Ethnicity-related differences in menopausal experience and symptom reporting. The UK Government Women’s Health Strategy. Closing the Women’s Health Gap report findings.

Estetrol (E4): a native oestrogen with selective tissue activity. NK3 receptor antagonists beyond fezolinetant. Oestrogen receptor agonists/antagonists in development. Precision menopause medicine: pharmacogenomics and individualised risk stratification. The role of AI in menopause care.

Five clinical scenarios spanning primary and secondary care: (1) 48-year-old with VMS and anxiety; (2) 38-year-old with suspected POI; (3) 55-year-old breast cancer survivor with GSM; (4) 52-year-old with metabolic syndrome considering MHT; (5) 60-year-old on long-term HRT requesting review. Worked answers with guideline references.

20 short-answer questions mapped to each chapter. Model answers with marking rubrics. Designed for CPD portfolios and appraisal evidence.