Abstract
Key points
Menopause is a major life event affecting all women, in a variety of ways, both short and long term. All women should have access to accurate information, available in a variety of forms. All healthcare professionals (HCPs) should have basic understanding of menopause and know where to signpost women for advice and support. Each primary care team should have an HCP or HCPs who have a special interest and knowledge in menopause. Each HCP with special interest in menopause should have access to at least one menopause specialist for advice, support, onward referral and leadership of multidisciplinary education.
Why do we need a vision?
Cuts to NHS budgets are creating a climate of uncertainty surrounding menopause service provision, yet the effects of menopause on quality of life and later health in an ageing population are becoming increasingly apparent.
The British Menopause Society (BMS) vision sets out the fundamental principles that should underpin menopause care provision for all to ensure that, even at this turbulent time, providers and commissioners are held to account and service users can access high-quality menopause care as standard.
Developed with and by the BMS Medical Advisory Council, the vision is designed to demonstrate that good menopause care is key to healthy lives in the middle and later years. This care encompasses education, lifestyle advice and evidence-based information regarding interventions to optimise post-reproductive health.
What is our vision?
Our vision focuses on three key areas:
The patient experience – ensuring that women have access to a wide range of types of information and can see a suitably trained HCP to discuss their experience of menopause and the options available to them. A well-educated workforce – making sure that they are ‘vision-ready’ with the optimum skill mix to cater for a wide population demand. Integrated care – establishing clear referral pathways between services so that care can be integrated around the needs of the individual, not disjointed by institutional or professional silos.
The BMS vision is not restricted to one care setting – it applies across the health sector where menopause care is an element. General practice in particular is acknowledged to have a pivotal role promoting high-quality menopause care to all and specialist referral if needed.
How are we going to implement our vision?
We look forward to working in partnership with all our members to successfully implement the vision and provide better menopause and post-reproductive health care for all. This will include education both for women and HCPs, media campaigns and provision of easily accessible resources.
Introduction
The menopause affects all women and refers to the biological stage when periods stop and the ovaries lose their reproductive function. Usually, this occurs between the ages of 45 and 55, but in some cases, women may become menopausal in their 30s, or even younger.
Every woman experiences the menopause differently. Symptoms can last from a few months to several years and up to 80% of women experience physical and/or emotional symptoms during this time. These can include: hot flushes and sweats, tiredness and sleep disturbance, joint and muscle ache, heart palpitations, mood swings, anxiety and depression, forgetfulness or lack of concentration, vaginal dryness, vulval irritation and discomfort, discomfort during sex, loss of interest in having sex and increased urinary frequency or urgency.
With average female life expectancy in the UK at 83.2 years, many women are living in this post-menopausal phase for half to one-third of their life, and these symptoms can have a significant impact on their health and wellbeing as well as their work and relationships. The menopause is not something that just affects ‘older women’ but those in ‘mid-life’ – often when they are juggling demanding jobs, school-age children and elderly parents. Despite this, many women are unaware of the impact of symptoms and later health problems and that diet and lifestyle changes can help improve their symptoms. Sadly, many are also often confused about the benefits and risks of treatment options.
The launch of the NICE guideline on the diagnosis and management of the menopause was a monumental menopausal moment! 1 Leading experts in the field examined all the existing evidence and we have been presented with information and advice which will not only enable women to better understand the consequences of the menopause and make informed choices about their treatment, but also ensure that HCPs can provide women with evidence-based information about the benefits and risks of different treatment options in order to come to decisions on an individual basis.
We know that many women choose to go through the menopause without seeking treatment. Others prefer to help to manage their symptoms either by using hormone replacement therapy (HRT) or an alternative treatment option such as cognitive behavioural therapy, relaxation techniques or herbal medicines such as black cohosh, isoflavones (plant estrogens) or St John’s wort.
HRT has been controversial for many years and has frequently divided opinion. The evidence underpinning the benefits and risks has been accumulating for many years and this guideline has focussed specifically on the risks of breast cancer, heart disease, stroke and bone health in women aged between 50 and 59. For young women with premature ovarian insufficiency or surgical menopause, NICE guidance highlights the need to recommend estrogen replacement until at least the average age of menopause, unless contraindicated. Women with premature ovarian insufficiency also require counselling and support regarding their fertility chances and management options in that respect depending on their fertility desires.
The NICE guidance is unequivocal in recognising that HRT is an effective treatment for menopausal symptoms, particularly with the management of hot flushes. In addition, HRT can also improve bone health and reduce the risk of osteoporosis and fractures in later life, and increasingly, evidence suggests that HRT started early reduces risk of cardiovascular disease. However, the benefits and risks will stack up differently for each woman, and whether or not to take HRT should be an individual choice, but one that should be offered.
The slight increased risk of breast cancer associated with HRT has been widely documented and is still debated. To put this into perspective, breast cancer is the most common cancer in women and approximately 23 in every 1000 women in the general population aged 50 to 59 will suffer from breast cancer over a period of 7.5 years. For women taking estrogen and progesterone HRT, we may see around five extra cases of breast cancer over the same time frame. It should be noted that the number is not exact; it could be less or more since risk depends on the individual and other factors unique to each woman such as weight and family history and that these data do not apply to women with premature ovarian insufficiency taking HRT. Estrogen-only treatment, which is given to women who have had a hysterectomy, is not associated with an increase in breast cancer in the same time frame. This risk is related to the treatment duration and reduces after stopping HRT, suggesting that HRT may, in a small number of women, promote the growth of breast cancer cells which are already present rather than cause the cancer. Many women and HCPs continue to see the risks as greater than the benefits because of incorrect interpretation of data and sensationalist media reporting, leading to non-informed decision making.
It is important to remember that HRT is just a small component of post-reproductive health and the treatment of menopause depends on a clear and complete understanding of an individual woman’s circumstances as well as factors which affect the health of women in their later years. Our focus as HCPs is to ensure that women receive clear, evidence-based information to help them make informed decisions about their health.
It is also important to remember that lifestyle factors such as obesity and smoking play a huge role in a woman’s short and long-term health and we encourage all women, no matter what their age, to maintain a balanced diet, engage in regular physical activity and refrain from smoking. This advice is particularly relevant for menopausal women, as lifestyle factors – particularly being overweight – impacts on the severity and length of menopausal symptoms and on later health.
Women deserve high-quality information on their choices. Managing the menopause is an area of medicine that is truly individual and we hope that our vision will empower both HCPs and women to work together on deciding the best treatment options for them.
Who provides menopause care?
The primary aim of menopause care is to provide women with assessment, advice and treatment which improves quality of life and promotes health into the post-reproductive years.
Menopausal women are seen in primary and secondary care and by a variety of HCPs across a range of services. It is therefore essential that work continues to increase awareness of the importance and consequences of menopause to all.
The NICE guideline on Menopause: diagnosis and management: NICE guidelines (NG23) 2015, 1 provides clarity which encompasses the care of most menopausal women who may self-manage, or can be managed in primary care. However, some women with complex needs may require input from an HCP with a special interest in menopause, who may still be based within primary care, or from a menopause specialist outwith the practice.
The RCN document ‘Nurse Specialist in Menopause’ describes the role of the nurse in menopause care from registration to specialist practice level. 2
NICE quality standard for menopause covers diagnosing and managing menopause in women and describes high-quality care in priority areas for improvement. 3
Quality statements
The BMS vision for menopause care in the UK builds on the RCN work, and provides an overview of the BMS vision across primary and secondary care and across HCPs, taking into account systems that will facilitate achievability of NICE quality standards.
Primary/community menopause care
Women may recognise that the troubles they are having are menopause related. With provision of accurate, easily accessible information, many women may adequately self-manage symptoms and improve their later health (see Appendix 1).
In the UK, women who choose to access menopause advice from an HCP will mostly attend their general practitioner. 4 Some women may not make a connection that their problems are menopause related, but decide that whatever problem they have is sufficiently bothersome or worrisome to need to seek help. When women who rarely attend present in midlife, the system should be alerted to consider a menopause link, particularly since to have made an appointment is often a challenge.
The whole practice team – including the receptionists should be ‘menopause aware’ and consider their initial response to an obvious menopause-related request so that an inappropriate comment is not off putting. The practice team should discuss and decide whether women are directed to a specific HCP who has an interest in menopause or whether this is a second stage process.
This latter could cause inconvenience or put women off and use additional appointments but the former risks de-skilling the rest of the team and disrupting continuity of care. The right solution will be that which works best for the practice team and their patients.
If this is an overtly menopause presentation, the HCP should take a full history to understand
The complaint How the woman is affected by other possible estrogen deficiency effects Her bleeding pattern
This should facilitate diagnosis as recommended by NICE Quality statements 1 and 2, and an explanation of how menopause transition is affecting her. The HCP can go on to further assess in the context of her general health and history, family history, medication and lifestyle.
If the presentation is not overt, the clinician should have some awareness of what may be menopause related; otherwise the opportunity to help may be lost or worse, inappropriate treatment be given. HCPs should consider asking pertinent questions at presentation for cervical screening, vaginal discharge, disturbed sleep, difficulty coping and other typical scenarios. They should be mindful that a minority of patients will present at a younger than typical age with premature ovarian insufficiency so that appropriate tests can be taken as recommended by NICE Quality statement 2.
If uncomplicated, then the patient should be managed by the HCP they have seen. The HCP needs to have awareness of the impact of menopause and of treatment options.
Baseline education will allow practice teams to discuss and cascade to their team the strategy they wish to follow: if women identify their problem as menopause related whether she should be directed at that stage to a HCP who is both interested and has some knowledge. With increasing collaboration and inevitable specialisation, such interested HCPs should emerge. They should be encouraged to take up a basic certificate in menopause as being of a similar standard to the Diploma of the Faculty of Sexual and Reproductive Health. This will strengthen practice at a primary care level, as once identified, they can cascade information within their practice and become a resource. This would require a prioritisation exercise within practices and by individual HCPs.
If a menopause-specific service is available within primary care, consideration should be given to time allocation. While time pressures prevail, experience has shown that allocation of extended time for menopause specific appointments leads to reduced number of subsequent appointments. 5
Specialist level care
If the patient is perceived as being high risk, has premature ovarian insufficiency or there are multiple factors that affect decision making, then the patient should be referred to someone with appropriate menopause expertise to assess her options in the presence of that condition.
The menopause specialist has a higher level of responsibility and holistic assessment skills. They accept referrals of the more complex patients and support colleagues to manage patients with risk factors. They should have either clinical experience supporting this role or formal competency-based accreditation if recently trained. The aspiration should be that HCPs with basic level certification will have at least one known specialist for clinical and professional support and advice and that local networks will emerge.
A BMS-recognised menopause specialist in the UK is defined as an HCP who has obtained the BMS/FSRH Advanced Menopause Certificate, or completed the RCOG/BMS ATSM in menopause care (or equivalent, e.g. the menopause and premature ovarian failure module of the subspecialty training programme in reproductive medicine) and who:
is a member of the BMS attends a National (BMS) or International Menopause Society (IMS, EMAS) conference at least once every three years provides at least 100 menopause-related consultations per year, of which at least 50 are new has the responsibility documented as part of their job plan and discussed at their annual appraisal.
‘Grandfather clause’ (available up to end 2017)
An HCP, who has been practising at Specialist level
a
for at least 10 years but does not have a certificate or completed ATSM as above, can apply to be an approved menopause specialist if he/she:
is a member of the BMS attends a National (BMS) or International Menopause Society conference at least once every three years provides at least 100 menopause-related consultations per year, of which at least 50 are new has the responsibility documented as part of their job plan and discussed at their annual appraisal.
It would remain the responsibility of the specialist to practice within their own areas of expertise and to seek further advice from other relevant specialists as required.
In addition, topic experts already have highly specialised knowledge and experience in particular areas but not necessarily the holistic skills and can be called on for advice when necessary – they should be identified in each region and for example, may include experts on Cardiology, Rheumatology, Gynaecology, Mental Health, Dermatology, Oncology, Haematology, Breast, Clinical genetics, Psychiatry and Endocrinology.
Expected levels of complexity and practice
Level one – HCPs
Every HCP should have some understanding of the impact of menopause and know where to signpost women for support and advice since women can present in a range of healthcare services.
Level two – HCP with special interest in menopause
HCPs in primary care who have special interest in menopause will see women for menopause-specific consultations. NICE guidelines will be followed and discussions will include symptoms, medication and non-prescribed therapies. Treatments will be monitored as recommended by NICE Quality standard 4, with ongoing discussions of benefits and risks and general health advice will be given. Local pathways will have been developed with route to specialist level menopause service for further advice or referral.
Level three – Menopause specialist
The menopause specialist will have additional knowledge and skills as outlined above, assessing and treating women with complex needs such as multiple treatment failures, premature ovarian insufficiency, complex medical problems, high-risk cancer genes or hormone dependant cancer. Management as recommended by NICE Quality standards 3 and 5 would be included at this level. A menopause specialist would also be responsible for provision of local education and engaging with multidisciplinary teams across specialties with development of local pathways and guidelines, including those for complex cases that fall outside of traditional (or NICE) guidance.
Women with premature ovarian insufficiency should, with consent, have their data anonymously logged onto an international POI registry such as https://poiregistry.net to facilitate research into aetiology, diagnosis and management of this condition.
Conclusion
The BMS vision is a practical and achievable aspiration that will support HCPs with the training and education required to manage mid and later life women. Its progress will be measured annually.