Menopause and related conditions

Disease Description (Causes and Symptoms)

• Definition and causes: A condition in which ovulation and menstruation cease due to ovarian aging and decreased follicle formation and secretion of estrogen and progesterone (menopause), along with a series of physical and psychological symptoms caused by hormonal changes before and after menopause (climacteric). The average age at menopause is around 50, but there are considerable individual differences.
• Summary of pathophysiology: Decreased estrogen → changes in central thermoregulation (hypothalamus) causing hot flashes, sweating, and sleep disturbances; increased bone resorption in the skeletal system leading to decreased bone density (increased risk of osteoporosis); atrophy of the vulvar and vaginal mucosa causing vaginal dryness and dyspareunia; increased cardiovascular risk due to changes in blood lipids.
• Main symptoms: Hot flashes (temporary heat sensation/sweating), sleep disturbances, anxiety·depression·memory decline, tachycardia·palpitations, decreased skin elasticity, sweating, vaginal dryness·sexual atrophy (dyspareunia·susceptibility to infection), increased risk of osteoporosis and fractures, and decreased libido.

Treatment Methods

• General principles: Treatment is determined by considering the severity of symptoms and the individual's health risks (such as breast cancer, cardiovascular disease, and thrombosis). Use of the minimum effective dose for the shortest possible duration is recommended.
• Hormone therapy (HRT; menopausal hormone therapy)
  • Effects: Improves hot flashes, sleep disturbances, and vaginal atrophy, and maintains bone density while reducing fracture risk. Local (vaginal) estrogen is also effective for vaginal symptoms.
  • Methods: When the uterus is present, a progestin is combined with estrogen to prevent endometrial cancer. When the uterus is absent, estrogen alone may be used. Oral, transdermal (patch), and vaginal formulations are available.
  • Contraindications: Active breast cancer·endometrial cancer (including suspected cases), recent thromboembolism (history of DVT/PE), recent myocardial infarction·stroke, uncontrolled severe liver disease, unexplained abnormal uterine bleeding, etc.
  • Adverse effects/risks: Increased risk of thrombosis·stroke (especially with oral formulations and in high-risk individuals), possible increased risk of breast cancer with long-term use (varies depending on the formulation and duration), gastrointestinal symptoms, weight changes, etc.
• Nonhormonal medications (when hormones are contraindicated or not desired)
  • Selective serotonin reuptake inhibitors (SSRIs)·serotonin-norepinephrine reuptake inhibitors (SNRIs): Used for hot flashes·mood symptoms (e.g., fluoxetine, paroxetine, venlafaxine, etc.; approval and dosage vary by country and medication).
  • Clonidine, gabapentin: Used to improve hot flashes in some patients.
  • Local estrogen (vaginal cream·ring·gel): Effective for symptoms of vaginal atrophy, with little systemic absorption.
• Prevention·treatment of osteoporosis
  • Lifestyle measures: Intake of calcium (from food and supplements if necessary)·vitamin D, regular weight-bearing·strength exercises, smoking cessation·moderation of alcohol, and fall prevention.
  • Medications: Bisphosphonates (e.g., alendronate), selective estrogen receptor modulators (SERMs; raloxifene), denosumab, etc. (determined according to individual risk and bone density results).
• Lifestyle management (recommended for all patients)
  • Regular aerobic·strength exercise, weight management, smoking cessation, a low-salt·low-saturated-fat diet, adequate calcium·vitamin D intake, improved sleep hygiene, and stress management.
• Monitoring and vaccinations/tests
  • Monitoring underlying diseases and medication safety: Blood pressure, weight, and breast screening (mammography) are recommended; additional evaluation if endometrial abnormalities are present; fracture risk assessment with DEXA (bone density) testing.

Pre-Outpatient Visit Checkpoints (Including Example Questions)

• Items/materials to prepare or bring
  • A list of all medications·supplements currently being taken (including dosages).
  • Medical history: Breast cancer·ovarian cancer·endometrial cancer·thromboembolism (personal·family history), cardiovascular disease, liver disease, etc.
  • Surgical history: Hysterectomy (whether the uterus·ovaries are present), oophorectomy, etc.
  • Recent test results: Bring mammography (most recent year), DEXA bone density test, and blood test results (lipids, liver function, etc.) if available.
  • Symptom records: Timing·frequency·severity of hot flashes·sleep disturbances·vaginal dryness, etc. (symptom diary).
  • Lifestyle information: Smoking·alcohol use·amount of exercise·eating habits.
• Information to show the doctor during the outpatient visit
  • The date of the last menstrual period or the time of complete menopause (cessation of menstruation).
  • When symptoms began and the degree to which they affect daily life·sleep (mild to severe).
• Example questions (statements the patient can use when speaking with the doctor)
  • "I have recorded how many times a day and how many times at night I experience hot flashes over the past 6 months. At this level, do I need treatment?"
  • "There is a family history of breast cancer. Is it safe for me to receive hormone therapy?"

Examples of General Questions to Ask the Doctor

• What are the common side effects and serious side effects of this medication (the recommended treatment)?
• If I start hormone therapy, how long is it usually continued? What happens when it is stopped?
• How high is my risk of osteoporosis, and how often should I have a DEXA test?
• What tests should I have regularly while receiving hormone therapy (mammography, blood tests, etc.)?
• What lifestyle changes should I prioritize (exercise·diet·smoking cessation, etc.)?

Examples of Disease-Specific Questions

• If the uterus is present: "If estrogen-only therapy is used while the uterus is present, does the risk of endometrial cancer increase? How long should progestin be used in combination?"
• When concerned about osteoporosis: "Based on my current bone density (T-score), do I need medication for osteoporosis? What are the recommended amounts of calcium·vitamin D, and should I take supplements?"

(If needed, we can provide a list of items to prepare before the outpatient visit and a sample symptom diary.)