Managing short-term menopausal symptoms (Section 8)

Introduction (8.1)

Troublesome symptoms are probably the commonest reason for women seeking advice on hormone replacement therapy (HRT). Around the time of the menopause, women describe both physical and psychological symptoms, sometimes before changes occur in menstrual pattern, some of which are sufficiently troublesome to lead women to seek medical help. Flushes and sweats, the most commonly reported symptoms, affect some women both day and night and can lead to profound sleep disturbance over many months. ¹ Women describe low mood, irritability and poor concentration which may be due to changing hormonal levels or to sleep disturbance. Symptoms relating to sexual function include vaginal dryness, dyspareunia and low libido. Symptoms vary between women and the duration of symptoms has been reported to be up to 10 years in around 10% of women. ²

Review question (8.2.2)

The menopause guideline development group addressed the question – ‘What is the most clinical and cost-effective treatment for the relief of individual menopause-related symptoms for women at menopause?’ ³ (8.2.2)

The group reviewed evidence regarding the use of ‘hormonal pharmaceutical treatments, non-hormonal pharmaceutical treatments, non-pharmaceutical treatments and psychological therapies’ ³ (cognitive behavioural therapy). (8.2.2)

The scope of the guideline was to include treatments for short-term symptoms which included the following:

frequency of vasomotor symptoms. (8.2.2)

The guideline describes the 51 studies which were considered in the network meta-analysis (NMA) and the 69 trials included in the pair-wise comparisons. The full results of the analysis can be found in the document Evidence summary. (8.2.3)

Key conclusions (8.2.7.6)

The guideline concluded from the evidence that transdermal estrogen replacement is an effective therapy for reducing frequency of hot flushes. The group supports the use of oral HRT in clinical practice as well as estrogen plus progestogen where indicated. (8.2.7.6)

On reviewing the evidence for non-pharmaceutical treatments, they concluded that isoflavones and black cohosh may be beneficial for vasomotor symptoms and that isoflavones and red clover may improve anxiety. Clinicians are reminded to discuss with women the lack of standardisation of products and variation in quality of available supplements. (8.2.7.6)

The guideline group reviewed the evidence for treatments for low mood associated with menopause and found that HRT and cognitive behavioural therapy (CBT) may help. (8.2.7.6)

In clinical practice, women are often seen with menopausal symptoms which have been induced by cancer treatments, e.g. Tamoxifen. The evidence reviewed for the guideline was limited and few recommendations were made for this group of women. Clinicians are referred to the NICE Guidance on Early and locally advanced breast cancer diagnosis and treatment. ⁴ St John’s wort is highlighted in the guidance as possibly helping vasomotor symptoms with some uncertainty about: appropriate doses and ‘potential serious interactions with other drugs (including tamoxifen)’. ³ (8.2.8.23)

Many menopause specialists advise women about low libido and sometimes recommend the use of testosterone therapy. Licensed testosterone products are limited in the UK, following the withdrawal of patches and greatly reduced availability of implants. The guideline group concluded that evidence supports the use of testosterone for women in surgical menopause ⁵ and recognises that this may mean prescribing off license. (8.2.8.20)

Recommendations (8.2.8)

Research recommendations (8.2.9)

The group considered the way forward with future research requirements and suggested the following questions. (8.2.9)

‘What is the safety and effectiveness of alternatives to systemic HRT as treatments for menopausal symptoms in women who have had treatment for breast cancer?’ ³ (8.2.9)

In clinical practice, it is often these women who challenge us the most and more research in these areas will be beneficial.

Other considerations – When to refer for management of short-term symptoms

Given the time and information, many women will come to a decision about treatment options with their regular primary care practitioner. For women with more complex treatment needs, a menopause specialist may be needed, who either in primary or secondary care has the clinical knowledge and experience to treat such women.

Based on clinical experience and expert opinion, the guideline development group recognise that there are times when referral may be indicated and highlight that in relation to short-term symptom management, a clinician may wish to refer to a professional with expertise in menopause. Such women may include:

Women in whom symptoms continue despite treatment or who have bothersome side effects. (9.8.34)

Women who themselves consider that they are ‘special cases’ outside of the normal menopause experience, really seem to value the extra time and discussion available with a clinician who has expertise in menopause. Such a referral may also open the door to other resources such a support groups, counselling and interdisciplinary working, not always available in primary care.

Practical prescribing considerations (8.2.8)

These recommendations, published by NICE, are aimed at treating women experiencing menopause at the average age of 51 years. The guideline offers some recommendations for women with POI and for women with or at high risk of breast cancer, although the latter are considered in a separate guideline. ⁴

Women need information to be able to make informed choices and the guideline suggests this should be provided in different ways, according to the needs of the individual. Clinicians should be aware of high quality web-based resources as well as written materials. The discussion about treatments for symptoms should include a discussion of risks and benefits of all treatment options. The guidelines encourage individualised care and indicate the need for on-going treatment review. The guidance suggests an initial three-month assessment and then annually thereafter recognising that here may be clinical indications for an earlier review (1.3.33), which might include treatment ineffectiveness, side effects or adverse events. Fully informed women are less likely to discontinue the treatment offered and need further consultations, leading to a more cost-effective therapy.

Clinical comment

It is reassuring to practitioners that these guidelines clearly acknowledge the need for women to be offered information and treatment for short-term symptoms of the menopause. Too many women have reported problems with accessing information and for many women it can be an uphill struggle to get HRT from clinicians anxious about risks and unclear on current evidence. In the past, women have described not being given sufficient information to make an informed decision about treatments options and having a poor understanding of the risks and benefits of HRT. ⁶ These guidelines clearly outline the potential benefits for short-term symptoms and will help clinicians guide the discussion on risks and benefits in a tailored way. The challenge for clinicians is to provide such information to all women and discuss tailored treatment within the confines of a busy primary care consultation and also to seek out the elusive ‘healthcare practitioner with an expertise in menopause’ to which the guidance refers, in all geographical areas of the UK.