Questionnaire/history: Cycle irregularity (eg cycle length may shorten to 2-3 weeks or lengthen to many months and mount of menstrual blood loss may change (most commonly increases slightly)? Hot flushes? Night sweats? Cognitive impairment? - Poor concentration? - Poor memory? - Difficulties in multi-tasking? Mood disorders? - Anxiety? - Mood swings? - Irritability? - Low mood? Sleep disturbance? Urogenital symptoms? - Vulvovaginal irritation and/or dryness? - Dyspareunia? - Reduced libido? - Urinary frequency and urgency? - Recurrent lower urinary tract infections? Other? - Joint and muscle pains? - Headaches? Other causes of amenorrhoea (eg pregnancy)? Lifestyle factors? - Smoking? - Alcohol? - Exercise? - Nutrition? Need for ongoing or future contraception? Cervical screening history? Bone health and risk of osteoporosis? Treatment goals? Previous treatments? Past medical history? Family history? - Premature menopause or POI? - Venous thromboembolism? - Hormone-dependent cancer? Current medication? Drug allergies? Examination: BP? BMI? Pelvic examination if history, symptoms or family history of gynaecological disease? Investigations: Follicle stimulating hormone (FSH) if not on combined hormonal contraception or HRT and: - > 45 years with atypical symptoms - between 40-45 with menopausal symptoms, including a change in their menstrual cycle - < 40 years with suspected premature ovarian insufficiency (POI) - > 50 years using progestogen-only contraception (Single FSH > 30 IU/L: ovarian insufficiency (FSRH)) (Recommendation to check on 2 samples 4-6 weeks apart (BMS)) Diagnosis: Perimenopause: vasomotor symptoms and irregular periods Menopause: no period for at least 12 months (and is not using hormonal contraception), based on symptoms in a woman without a uterus Premature ovarian insufficiency (POI): - < 40 years (not on combined hormonal contraception) - Menopausal symptoms AND - FSH > 30 IU/L on 2 samples taken 4-6 weeks apart (LH, oestradiol, prolactin, testosterone, TSH testing may be helpful) (Anti-Muellerian hormone (AMH) not routinely) Management: Advised: - Stages of menopause - Common symptoms - Short- and long-term health implications - Support organizations (eg Daisy Network, Menopause Matters, NHS Health A to Z, Rock My Menopause, RCOG, WHC/BMS) - Lifestyle measurements: - For hot flushes and night sweats: regular exercise, weight loss (if applicable), wearing lighter clothing, sleeping in a cooler room, reducing stress, avoiding triggers (eg spicy foods, caffeine, smoking and alcohol) - For sleep disturbances: avoiding exercise late in the day and maintaining a regular bedtime - For mood and anxiety disturbances: adequate sleep, regular physical activity and relaxation exercises - For cognitive symptoms: exercise and good sleep hygiene - To seek occupational health advice if support is needed in the workplace - Measures to manage cardiovascular risk factors - Engagement with national screening programmes - Bone health - Need for contraception - HRT does not provide contraception - Potential fertility for 2 years after last menstrual period if < 50 years and for 1 year if > 50 years - In general contraception can be stopped with 55 years - Progestogen-only methods of contraception safe to use alongside cyclical HRT - Combined hormonal contraception in eligible women < 50 years can be used as an alternative to HRT for relief of menopausal symptoms and prevention of loss of bone mineral density HRT Non-hormonal HRT Reference(s): NICE CKS: Menopause Information for patient/carer(s): Daisy Network Menopause Matters NHS Health A to Z: Menopause Rock My Menopause Royal College of Obstetricians and Gynaecologists (RCOG) Women's Health Concern (patient arm of the British Menopause Society)