Menopause
Recommended Reading
ARTICLE: Menopause
ARTICLE: Managing Menopausal Symptoms: Common Questions and Answers
Board Questions
A sexually active 45-year-old female who has been using oral contraceptives for years without experiencing any problems asks how much longer she should continue contraception. She is happy with her current low-dose estrogen combined oral contraceptive and would like to continue this if possible. She asks if the health risks are high enough to warrant a change to another option. She does not smoke and is in excellent health. Which one of the following would be most appropriate for this patient?
A) Continue her current oral contraceptive
B) Discontinue contraception
C) Obtain FSH and LH levels today and discontinue contraception only if the results confirm infertility
D) Replace the oral contraceptive with a barrier method
ANSWER: A
The defined age at which a woman loses natural fertility is not known. The median age for menopause in the United States is approximately 51 years of age, but it can normally occur anytime between 40 and 60 years of age. The American College of Obstetricians and Gynecologists and the North American Menopause Society both currently recommend that women continue contraceptive use until menopause or age 50–55 years. For women on hormonal contraception no current laboratory test can confirm the menopausal state. Natural pregnancy is uncommon for women over 44 years of age, but the risks associated with pregnancy beyond that age may exceed the risks associated with use of combined oral contraceptives (COCs) in women who do not have certain chronic conditions. For this group, increased risks for developing breast cancer in women over 40 years of age and stroke for women over 45 years of age who continue to use COCs has been shown to be nonsignificant in recent studies (level of evidence 2). It is not clear that the increased risk for myocardial infarction or thromboembolism associated with the use of COCs is any higher above baseline for women over the age of 45 years than for younger women.
A 51-year-old female presents with concerns about a change in her cognition. She says she has difficulty retrieving words, loses her train of thought, and goes into a room and forgets why she came there. She also has had more frequent hot flashes and sleep disturbances. She still menstruates but has noticed a change from her previous pattern. A physical examination is unremarkable, and recent laboratory tests were all normal, including vitamin B12 and thyroid studies. Cognitive testing is normal.
Which one of the following would be the most appropriate next step?
A) Reassurance only
B) CT of the head
C) MRI of the brain
D) Hormone therapy
E) Referral to a neurologist
ANSWER: A
Women experience subjective cognitive difficulties during their menopausal transition. This may include retrieving numbers or words, losing one’s train of thought, forgetting appointments, and forgetting the purpose of behavior such as entering a room. Clinical studies of these women showed intact cognitive test performance. The treatment consists of patient education and reassurance, since studies have shown that 62% of women report subjective cognitive problems during their menopausal transition. Imaging and referral to a neurologist are not indicated, and there are no trials that support the use of hormone therapy.
A 65-year-old female sees you to establish primary care. Her past medical history is significant only for hypertension, which is well managed on hydrochlorothiazide, and menopausal symptoms managed with oral estrogen/progestogen for the past 10 years. She has no current health concerns and her vital signs are normal. She requests a refill of her hormone medication. Which one of the following would be most appropriate at this time?
A) Refill her hormone medication, but with a tapering schedule to end the therapy
B) Recommend switching from oral hormone therapy to vaginal estrogen and oral progestogen
C) Discuss the possible risks of continued hormone therapy before deciding whether she should continue
D) Order a bone density test and use the results to determine whether to continue hormone therapy
E) Recommend discontinuation of hormone therapy as soon as possible, as she has already been on the treatment for more than 5 years
ANSWER: C
This patient has been on menopausal hormone therapy for an extended period of time. A discussion about cessation is warranted, as it is common practice to use hormones for the shortest duration possible. The American College of Obstetricians and Gynecologists does not recommend discontinuation based on age or duration of treatment alone, however, recommending instead that the patient history and symptoms be taken into account. Tapering hormones versus abrupt discontinuation of hormones is not well studied, and patients can do well with either plan. Vaginal estrogen should be used with similar cautions as oral estrogen and is primarily indicated for genitourinary symptoms of menopause, so switching from oral estrogen to vaginal estrogen would not be indicated in this case. Menopausal hormone therapy does decrease the risk for hip fractures, but the American Academy of Family Physicians, like the U.S. Preventive Services Task Force, does not recommend using hormone therapy for prevention of chronic conditions, so the patient’s bone density should not be a consideration.
