9.6 Menopause & HRT, Subfertility, Prolapse & Urinary Incontinence
Key Takeaways
Menopause can be diagnosed clinically in women over 45 with typical symptoms; FSH testing is reserved for women aged 40–45 with symptoms or under 40 with suspected premature ovarian insufficiency.
Women with a uterus who take oestrogen HRT also need a progestogen to prevent endometrial hyperplasia and cancer.
Transdermal oestrogen does not increase venous thromboembolism risk above baseline, so it is preferred for women with VTE risk factors or a BMI over 30.
Couples are investigated for subfertility after 1 year of regular unprotected intercourse, or sooner if the woman is 36 or over or a cause is known (NICE CG156).
Stress urinary incontinence is treated first with supervised pelvic floor muscle training for at least 3 months, and urge incontinence with bladder training for at least 6 weeks (NICE NG123).
Menopause & HRT, Subfertility, Prolapse & Urinary Incontinence
Menopause (NICE NG23)
The menopause is the final menstrual period, confirmed after 12 months of amenorrhoea; the average age in the UK is 51.
- Diagnosis: clinical in women over 45 with vasomotor symptoms or irregular periods; FSH is not needed. Consider FSH in women aged 40–45 with symptoms, and in women under 40 with suspected premature ovarian insufficiency. FSH is unreliable in women taking combined hormonal contraception or high-dose progestogens.
- Symptoms: hot flushes and night sweats, mood change, poor sleep, joint aches, reduced libido and genitourinary syndrome of menopause (vaginal dryness, dyspareunia, urgency, recurrent UTI). Long-term, oestrogen deficiency increases osteoporosis and cardiovascular risk.
- Premature ovarian insufficiency (POI): menopause before 40, with raised FSH on two samples 4–6 weeks apart. Offer hormone therapy (HRT or combined hormonal contraception) at least until the average age of menopause to protect bones and the heart.
Hormone Replacement Therapy (HRT)
| Situation | Regimen |
|---|---|
| No uterus (hysterectomy) | Oestrogen alone |
| Uterus, perimenopausal (period within the last 12 months) | Sequential (cyclical) combined HRT: monthly withdrawal bleed |
| Uterus, postmenopausal (12 months without periods) | Continuous combined HRT |
| Uterus, also needs contraception | Oestrogen with a 52 mg levonorgestrel IUS for endometrial protection |
| Vaginal symptoms only | Vaginal oestrogen (can be used long-term and with systemic HRT) |
Important
Endometrial Protection: Unopposed oestrogen in a woman with a uterus causes endometrial hyperplasia and cancer, so a progestogen must be added. Persistent unscheduled bleeding on HRT (beyond the first 3–6 months, or after a period of no bleeding) needs investigation.
Benefits and risks (NICE NG23): HRT is the most effective treatment for vasomotor symptoms and prevents osteoporosis.
- VTE: oral oestrogen increases the risk; transdermal oestrogen does not increase it above baseline, so it is preferred with VTE risk factors or BMI over 30.
- Breast cancer: combined HRT causes a small increase that depends on duration and falls after stopping; oestrogen-alone HRT causes little or no change.
- Stroke: small increase with oral (not transdermal) oestrogen.
- Contraindications include current or past breast cancer, undiagnosed vaginal bleeding, active VTE or arterial disease, and untreated endometrial hyperplasia.
- Alternatives: CBT for vasomotor and mood symptoms; non-hormonal drugs such as some SSRIs or SNRIs, clonidine or gabapentin (avoid fluoxetine and paroxetine with tamoxifen).
- Contraception is still needed for 2 years after the last period if it occurred under 50, and 1 year if over 50 (HRT is not contraceptive).
Subfertility (NICE CG156)
Definition: failure to conceive after 1 year of regular unprotected intercourse. Investigate earlier if the woman is 36 or over, or there is a known cause (amenorrhoea, previous pelvic surgery or PID, undescended testes, chemotherapy).
Causes: male factor (about 30%), ovulatory disorders (mainly PCOS), tubal damage (chlamydia, PID, endometriosis, surgery), uterine factors, and unexplained subfertility.
Initial investigations:
- Semen analysis (repeat after about 3 months if abnormal).
- Mid-luteal progesterone (day 21 of a 28-day cycle, or 7 days before the expected period) to confirm ovulation.
- Chlamydia screening before uterine instrumentation.
- Tubal patency: hysterosalpingography (or hysterosalpingo-contrast-ultrasonography) if there are no comorbidities; laparoscopy and dye test if PID, endometriosis or previous surgery is suspected.
Management: lifestyle advice (BMI 19–30, stop smoking, limit alcohol, folic acid); ovulation induction (letrozole or clomifene, under specialist monitoring for multiple pregnancy) for anovulatory PCOS; tubal surgery; IVF (NICE: up to 3 full cycles for women under 40 who have not conceived after 2 years of regular intercourse or 12 cycles of artificial insemination; 1 cycle for women aged 40–42 meeting criteria); intracytoplasmic sperm injection for severe male factor. Ovarian hyperstimulation syndrome (abdominal distension, ascites, haemoconcentration, VTE risk) is a serious complication of stimulation.
Pelvic Organ Prolapse
Descent of the bladder (cystocele), rectum (rectocele), uterus or vaginal vault, due to weakened pelvic floor support. Risk factors: vaginal childbirth, age, menopause, obesity, chronic cough and constipation. Symptoms: dragging sensation, a lump, urinary or bowel emptying difficulty.
- Conservative: pelvic floor muscle training (at least 16 weeks), weight loss, treating constipation and cough, vaginal oestrogen.
- Vaginal pessaries (ring or shelf) for women who want to avoid surgery.
- Surgery (anterior or posterior repair, vaginal hysterectomy, sacrocolpopexy). The use of transvaginal mesh for prolapse has been restricted in the UK since 2018.
Urinary Incontinence in Women (NICE NG123)
Assessment: urine dipstick for infection, 3-day bladder diary, post-void residual if voiding problems are suspected, and pelvic examination.
| Type | Features | First-Line Management | Further Options |
|---|---|---|---|
| Stress | Leakage on coughing, sneezing or exercise; after childbirth | Supervised pelvic floor muscle training for at least 3 months; weight loss | Surgery (colposuspension, autologous fascial sling; mid-urethral tapes under restrictions); duloxetine only if surgery is declined |
| Urge (overactive bladder) | Urgency, frequency, nocturia, leakage on the way to the toilet | Bladder training for at least 6 weeks; reduce caffeine; review fluid intake | Antimuscarinic (avoid oxybutynin in frail older women because of cognitive effects) or mirabegron; botulinum toxin injection; sacral nerve stimulation |
| Mixed | Both | Treat the predominant symptom first | As above |
| Overflow | Dribbling with incomplete emptying | Look for obstruction or neurological cause; catheterisation | Specialist referral |
Red flags needing urgent referral include visible haematuria, recurrent UTIs with haematuria in women 40 or over, suspected pelvic mass, and a palpable bladder after voiding.
A 52-year-old woman with a uterus has had hot flushes and night sweats for 8 months. Her last period was 4 months ago. She has a BMI of 34 kg/m². She wants HRT. Which regimen is most appropriate?
Transdermal oestrogen with a cyclical progestogen
Oral oestrogen-only HRT taken daily
Oral continuous combined oestrogen and progestogen HRT
Vaginal oestrogen alone for local symptoms
A 29-year-old woman and her partner have been trying to conceive for 14 months. She has regular 28-day cycles. Which test confirms ovulation?
Anti-Müllerian hormone
Day 2 FSH and LH
Pelvic ultrasound on day 14
Day 21 serum progesterone
A 45-year-old woman leaks urine when she coughs, sneezes or runs. She has had three vaginal births. Urine dipstick is negative and examination shows no prolapse. What is the most appropriate first-line treatment?
Oxybutynin modified-release 5 mg daily
Duloxetine 40 mg twice daily as first-line
Supervised pelvic floor muscle training for 3 months
Referral for a mid-urethral sling or colposuspension
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