Abstract
Keeping you up-to-date with the latest primary care guidance and publications from the National Institute for Health and Care Excellence (NICE).
Date of publication: November 2015
In the UK, the average age of menopause is 51 and approximately 80% of women will experience some perimenopausal symptoms. However, evidence suggests that services available for menopausal women in the UK are variable. The RCGP curriculum states that women-specific health matters, including contraception, pregnancy, menopause and disorders of reproductive organs, accounts for 25% of general practitioner consultations. The curriculum goes on to say ‘as a GP you should know how the social and biological features of the perimenopause and menopause period interact and affect health, social wellbeing and relationships’.
The NICE guideline Menopause: Diagnosis and management (NG23), covers the diagnosis and management of menopause, including women who have premature ovarian insufficiency. The guideline aims to improve the consistency of support and information provided to women in menopause.
Action points
NG23 makes recommendations in six areas.
1. Individualised care
The guideline advises that in all stages of diagnosis, investigation and management of menopause, the health care practitioner should adopt an individualised approach. The guideline recommends following the advice provided in the NICE guideline on Patient experience in adult NHS services (CG138).
2. Diagnosis of perimenopause and menopause
The guideline recommends diagnosing menopause in otherwise healthy women over the age of 45 if they have not had a period for at least 12 months and are not using hormonal contraception, or if they do not have a uterus and have menopausal symptoms. The guideline recommends considering the use of follicle stimulating hormone (FSH) blood test only in women aged 40 to 45 with menopausal symptoms or in women under 40 in whom menopause is suspected. This FSH test should only be undertaken if the patient is not taking a combined contraceptive pill or high dose progestogens. The guideline reminds healthcare practitioners that it can be difficult to diagnose menopause in women who are taking hormonal treatments.
3. Information and advice
The guideline advises that information should be given to menopausal women on the stages of menopause, common symptoms (such as vasomotor symptoms, musculoskeletal symptoms, effects on mood, urogenital symptoms and sexual difficulties) and diagnosis. Lifestyle changes and interventions that could help general wellbeing, benefits and risks of treatments for menopausal symptoms (including hormonal, non-hormonal and non-pharmacological treatments), as well as contraception and the long-term health implications of menopause should be discussed. The guideline recommends offering information about menopause and fertility and specialist referral to women who are likely to go through menopause as a result of medical or surgical treatment.
4. Managing short-term menopausal symptoms
The guideline advises that hormone replacement therapy (HRT) is the first-line treatment for many symptoms, except in women for whom HRT is contraindicated (e.g. women with a history or high risk of a hormone-sensitive cancer). Antidepressants are no longer recommended in women without a clinical diagnosis of depression. Other points of note are as follows.
Vasomotor symptoms: There is some evidence that isoflavones and Black Cohosh can reduce vasomotor symptoms, but their safety is uncertain. Beware of interactions with other medications and variation among brands.
Low mood: Defined as ‘Mild depressive symptoms that impair quality of life but are usually intermittent and often associated with hormonal fluctuations’. Cognitive behavioural therapy (CBT) or HRT may be offered to treat symptoms of low mood that arise because of the menopause. CBT may be offered for anxiety that arises because of the menopause.
Low libido: Testosterone supplementation may be considered if low libido persists despite HRT, though the guideline notes that this is not a licensed indication.
Urogenital atrophy: Topical oestrogen and/or moisturisers/lubricants can be offered and increased to women on HRT if required. Systemic side effects from topical HRT are very rare. Symptoms often come back when therapy is stopped. There is no need to offer routine monitoring of endometrial thickness during treatment. Women should be advised to report unscheduled vaginal bleeding.
General: Explain to women who wish to try other complementary therapies that the quality, purity and overall efficacy of products may vary between brands and sources.
Efficacy of each treatment should be assessed at 3 months and annually thereafter unless symptoms worsen. Gradually reducing HRT may limit recurrence of symptoms in the short term, but makes no difference to symptoms in the longer term.
5. Long-term benefits and risks of HRT
Oral HRT is associated with a greater risk of venous thromboembolism, but transdermal preparations are not. Consider referral of high-risk women to a haematologist before commencing oral HRT. HRT does not increase the risk of cardiovascular disease when started in women under the age of 60 years. The presence of cardiovascular risk factors is not a contraindication to HRT, providing these are optimally managed. Oral HRT (but not transdermal) may be associated with a slightly higher risk of stroke (<1% increased risk over 7.5 years of use; the baseline for women <60 years is already very low). Combined HRT (but probably not oestrogen-only HRT) may be associated with an increased risk of breast cancer, which is related to the treatment duration and reduces after stopping HRT. Use of HRT maintains bone density and muscle mass and reduces osteoporotic fractures. Risk of fracture increases after stopping HRT, but protection may continue in women who take HRT for longer periods.
6. Diagnosing and managing premature ovarian insufficiency
Premature ovarian insufficiency (POI) can be diagnosed in women under 40 based on menopausal symptoms (including oligo-/amenorrhoea) and two FSH samples taken 4–6 weeks apart. Remember that this investigation is not reliable in women taking hormonal contraceptives. Treatments to offer (unless contraindicated, for example in women with hormone-sensitive cancer) are combined HRT or the combined oral contraceptive pill (COCP) until at least the age of natural menopause. HRT may have a beneficial effect on blood pressure compared with COCP, but both offer bone protection. The guideline suggests referral of women with POI to a specialist if there is doubt about the diagnosis.
Best practice idea
The guideline advises HRT is first line for treating many symptoms of menopause, but the British National Formulary (BNF) and the Monthly Index of Medical Specialties (MIMS) reveal a vast array of options. Are there any local formulary recommendations on prescribing HRT? Could these be clarified with the local specialists?
Audit idea
After starting HRT, what proportion of women were reviewed 3 months later? Do all women on HRT have a review at least annually?
How many patients had blood tests to diagnose menopause at your practice? Were the tests clinically indicated?