Induced menopause: Why we need to make the most of NICE quality standards

This summer in my menopause clinic I saw a patient who had been referred to me by her GP who had difficult to manage menopausal symptoms following a radical laparoscopic hysterectomy and bilateral oophorectomy for cervical carcinoma, Stage 1A1, at the age of 35 years, approximately two years ago before moving into my region. She had a few months after her surgery without any hormone replacement during which time she felt she suffered significantly with a multitude of menopausal symptoms. After discussion with her oncology team, her GP prescribed oral estrogen-only hormone therapy at a dose of 1 mg estradiol daily with a resulting significant improvement in her quality of life.

Her presenting symptoms to me were a gradual drift away from control of her vasomotor symptoms with poor sleep and a complete lack of libido. As a generally fit, active working woman in a stable relationship and with a young family, she was hopeful that seeing a menopause specialist would improve the situation she found herself in. At my first consultation with her, I felt the simplest way of improving things was to increase the estrogen dose to 2 mg daily. I offered her patch therapy but she preferred oral therapy as part of her daily routine. Examination was normal with a well-estrogenised vagina, and as she had no dyspareunia or need for lubrication during sex, we both felt that vaginal estrogen therapy was not required at the moment.

She was relatively poorly educated about menopause and its consequences in a young woman but did understand that her treatment had placed her into a premature menopause. I explained to her that the loss of a large proportion of her circulating testosterone as a result of her oophorectomy could be contributing to her problems with libido. Neither of us felt that she had any other major contributing factors to her loss of libido, such as relationship, physical or psychological features. When I explained to her that whilst testosterone replacement is often effective in someone such as her, it is important to ensure that women are receiving adequate levels of estrogen prior to adding in testosterone. She was therefore happy to try her increased dose of estrogen for a few months prior to a telephone follow-up appointment. That is how we have currently left it.

I am sure that most of the readership of this journal have seen many such patients over the years and have assiduously got on with the here and now of sorting the problems of the woman in front of them. What struck me in particular with this patient was that she asked me in a very direct way:

Why wasn’t I told just how rotten menopause would make me feel? I felt so unprepared as I initially put many of my feelings down to the major surgery that I had and they just did not settle. Once I started the HRT a cloud of suffering lifted and I started to feel normal again.

This emotive comment demands an answer that needs to be handled sensitively, recognising the need for radical surgery that is driven by a need to meet national cancer targets with the main focus on speeding the patient towards rapid and effective treatment of their cancer. Most patients are supported by a multidisciplinary team that provides an excellent level of holistic support and preparation for their treatment, but evidence from my clinic suggests that there are opportunities to improve the situation further.

This is where NICE Quality standards come in to help us. According to NICE: Quality standards set out the priority areas for quality improvement in health and social care.

They cover areas where there is variation in care. Each standard gives you:

a set of statements to help you improve quality

information on how to measure progress ¹

These standards are usually developed alongside NICE guidance and published after a NICE guideline has been published. They contain standards that can be used by commissioners, care providers and regulators to audit areas where care can be improved and to devise strategies in a local health economy to improve the quality of the delivery of care in specific areas. The use of a quality standard in this way is not mandatory but can be used as an effective tool to leverage change and perhaps divert resource to a specific area of healthcare.

Following the publication of the NICE guideline on the diagnosis and management of the menopause, ² a set of quality standards ³ were published that cover five areas of the management of the menopause that the quality standards advisory committee felt were areas of greatest priority. Of relevance to this case is quality standard number 5: ‘Women who are likely to go through menopause as a result of medical or surgical treatment are given information about menopause and fertility before they have their treatment’.

This quality standard then goes on to describe the ways in which its application can be audited, including local healthcare structure, audit process and expected outcome measures. How the audit findings should be considered by different elements of the system is a key point with the standard giving guidance to commissioners, healthcare professionals, service providers and women. It also gives brief guidance, whilst pointing to the NICE guideline, into the medical or surgical processes likely to result in induced menopause and the expectation of information that should be provided to women.

I feel strongly that this is an area where we as gynaecologists or primary care providers with a specialist interest in menopause are uniquely positioned to ensure that women who are likely to have an induced menopause as a result of their treatment of either malignant or benign gynaecological pathology are fully educated as to the potential impact of this premature and usually sudden menopause on their immediate quality of life and potential longer term issues. Not only are we well positioned, we should consider ourselves responsible for ensuring women in this unenviable position get the best possible information and advice.

To improve things locally, I suggest that you perform an audit of women on both the benign and malignant treatment pathways, initially addressing women under the age of 50. Getting data from a surgical database within a UK hospital is a relatively straightforward process, using the treatment codes for bilateral oophorectomy as an identifier. Clinical notes from these patients can then be interrogated for retrospective evidence of information provision. An alternative and more optimal audit design would be to involve women in the process by contacting them and asking for their permission to send them a questionnaire about their experiences with the system and the information they have been given. It is often more difficult to identify those women in whom gonadotrophin releasing hormone (GnRH) analogues have been prescribed, but through interrogation of electronic records with keyword search, it is now often possible to identify such women who again will need to be asked their permission to be sent a questionnaire for such an evaluation of the care they received.

Once this audit has been completed, it should be presented at a multiprofessional meeting, discussed and improvements suggested which should then, through local commissioning and care systems, be designed to improve care delivery to be in line with the quality standard. It is highly likely that such a pathway will involve both primary and secondary care and so consideration should be given to their very different needs during any period of redesign.

When I have had discussions with care providers around the country about this, they frequently ask about where the resource for improving care should come from. The reality is that the resource is there within the system and it is within your power to provide this high-quality evidence that some of it should be diverted towards these women so that they can be not only prepared for an iatrogenic temporary or permanent menopause but in many cases can avoid symptoms entirely with high -quality pre-treatment advice and planning.

What do our women need? What they need is better planning and better information. NICE quality standards provide us with the methodology to identify the extent of the problem and the tools we can use to identify deficiencies in the current care environment. Most importantly, though because this comes from NICE, the use of quality standards gives us the muscle to be able to demand the healthcare system for the resource to improve care.