WHNP menopause: hormone therapy, genitourinary syndrome, and bone health management

Stages of menopause (STRAW+10 framework): Menopausal transition (perimenopause) begins with variable cycle length and rising FSH; late perimenopause: amenorrhoea ≥60 days; menopause: 12 months of amenorrhoea; early postmenopause: first 5–6 years; late postmenopause: thereafter.

Diagnosis: Typically clinical — age, symptoms (vasomotor symptoms, sleep disturbance, mood changes, vaginal dryness), irregular/absent periods. FSH >25–30 IU/L (postmenopausal range) and low oestradiol support diagnosis. In women aged 45–55 with typical symptoms: no hormone testing required for clinical diagnosis. Consider POI (premature ovarian insufficiency) if <40 years — FSH ×2 elevated, 4–6 weeks apart; refer for fertility and HRT counselling.

Vasomotor symptoms: Hot flashes, night sweats — occur in up to 80% of women. Triggered by a narrowed thermoregulatory zone in the hypothalamus. Duration: median 7–10 years; longer for women who report onset before final menstrual period. MHT is the most effective treatment; non-hormonal alternatives for women with contraindications.

Bone loss: Rapid in early postmenopause (3–5% per year in first 5–7 years) due to oestrogen deficiency — oestrogen inhibits osteoclast activity. Lifetime bone loss: ~15% cortical, ~35% trabecular (spine, hip) in women vs. ~5% cortical, ~15% trabecular in men.

DEXA screening and FRAX: Screen all women ≥65 (USPSTF B). Younger women with FRAX 10-year fracture risk ≥7.5% hip fracture or ≥20% major osteoporotic fracture equivalent. Interpret T-score in clinical context with FRAX.

Pharmacotherapy for osteoporosis:

• First-line: Bisphosphonates — alendronate (70 mg weekly PO), risedronate (35 mg weekly or 150 mg monthly PO), zoledronic acid (5 mg IV annually). Take alendronate/risedronate with plain water, remain upright 30 minutes, nothing else by mouth. Atypical femur fractures (stress fractures) and osteonecrosis of the jaw are rare complications; consider drug holiday after 3–5 years for oral bisphosphonates if stable T-score.
• Second-line: Denosumab (Prolia — 60 mg SQ every 6 months); must not be stopped abruptly without transitioning to bisphosphonate (severe rebound bone loss and vertebral fractures reported).
• Anabolic: Teriparatide (Forteo) or abaloparatide (Tymlos): for very high fracture risk. PTH analogue — stimulates bone formation. Max 2 years use. Transition to bisphosphonate after anabolic therapy.
• Romosozumab (Evenity): anti-sclerostin antibody — both anabolic and antiresorptive. Once monthly SC × 12 months. Contraindicated in history of MI or stroke (within 12 months — cardiovascular risk signal).