Vision for menopause care in the UK

How our Vision is being implemented?

We are working closely with our membership to implement the BMS Vision for menopause care in the UK and provide better menopause and post reproductive health care. This includes education and training for HCPs and for women through our patient arm, Women’s Health Concern (WHC), whose mission as a charity is: To provide an independent service to advise, reassure and educate women. We operate in partnership with the RCOG, FSRH, RCGP, RCN, other specialist organisations and health charities. In addition, we provide a wide range of easily accessible resources principally through our two websites (www.thebms.org.uk and www.womens-health-concern.org). Media campaigns and social media, including Twitter, are further important components of our outreach.

Clinical background

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, lack of concentration, vaginal dryness, vulval irritation, discomfort during sex, loss of interest in sex and increased urinary frequency or urgency. This is not an exhaustive list.

With an average female life expectancy in the UK of 83.6 years, many women are living in this post menopausal phase for half to one-third of their life. A combination or any one of these symptoms can have a significant impact on their health and wellbeing, on their personal and social relationships and on their work and careers. The menopause is not something that only affects older women. Those in mid-life can be adversely affected, often when they are juggling demanding jobs, school age children and elderly parents. Despite all this, many women are unaware of the impact of symptoms and implications for later health. They may not realise or choose to ignore that diet and lifestyle changes can help improve their symptoms, quality of life and long-term health. Regrettably, many may have been misinformed about the benefits and risks of treatment options.

The launch of the 2015 NICE guideline ² was a monumental moment in menopause care provision. Leading experts thoroughly examined all the existing evidence, so ensuring 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. Definitive information and advice was presented which enables women to better understand the consequences of the menopause and make informed choices about their treatment.

Following on from this NICE guideline, the BMS published the practical guide Management of the Menopause. ³ This handbook is the key reference for all HCPs wishing to learn about best practice in menopause and post reproductive health.

We know that many women choose to go through the menopause without asking for advice or requesting treatment. Others prefer to seek help to manage their symptoms either by using hormone replacement therapy (HRT) or alternative treatment options such as cognitive behavioural therapy (CBT), relaxation techniques or herbal medicines such as black cohosh, isoflavones (plant estrogens) or St John’s wort.

HRT continues to divide opinion. The evidence underpinning the benefits and risks has been accumulating for many years, and the NICE guideline has focused specifically on the risks of breast cancer, heart disease, stroke and bone health in women aged between 50 and 59. For younger women with premature ovarian insufficiency (POI) or surgical menopause, NICE guidance highlights the need to recommend estrogen replacement until at least the average age of menopause, unless contraindicated. Women with POI require counselling and support regarding their fertility chances and management options depending on their wishes.

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 improve bone health and reduce the risk of osteoporosis and fractures in later life. Increasingly, evidence suggests that HRT started early reduces the risk of cardiovascular disease. However, the benefits, risks and side effects will stack up differently for each woman. Whether or not to take HRT is essentially an individual choice, but one that should be offered or recommended, unless clinically inappropriate.

The slightly increased risk of breast cancer associated with HRT has been widely documented and continues to be 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 50–59 will suffer from breast cancer over a period of 7.5 years. The literature review from the NICE 2015 guideline on the diagnosis and management of the menopause concluded that 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. These data do not apply to women with POI taking HRT. Estrogen-only treatment, which is given to women who have had a hysterectomy, appears to be associated with lesser risk in the same time frame. This risk is related to the treatment duration and reduces after stopping HRT, although this may take several years, 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. Some 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 a small component of post reproductive health. The management of the 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. HCPs must ensure that women receive clear, evidence-based information to help them make informed decisions about their health. Note: The BMS and WHC 2020 recommendations on HRT in menopausal women is published in the December 2020 edition of the society’s journal Post Reproductive Health and is available online.

It is especially important to remember that lifestyle factors such as obesity, smoking and alcohol play a large 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, refrain from smoking and control alcohol intake. This advice is particularly relevant for menopausal women, as lifestyle factors – particularly being overweight – impact on the severity and length of menopausal symptoms and on later health and wellbeing.

Women deserve high quality information on which to base their choices. Managing the menopause is an area of medicine that is truly individual, and our Vision will help to empower HCPs and women to work together on deciding the best treatment options.

BMS and WHC Factsheets, BMS Bulletins and News Alerts and BMS TV: The Menopause Explained all provide detailed up-to-date information and are peer-reviewed.

We endorse the RCOG statement: ⁴

From 51+ years: Historically this stage of a woman’s life course has received little attention and many women find themselves without support from health care services until they present with an acute episode or medical problem. Managing the transition through the menopause including treatment of symptoms where appropriate, provides for the opportunities to promote healthy lifestyles and decrease the likelihood of the early onset of chronic disease such as osteoporosis, cardiovascular disease, frailty and dementia.

How menopause care is provided?

The principal aim of menopause care is to provide women with information, assessment, advice and treatment which improve 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 in a coordinated manner so increasing awareness of everyone to the consequences of the menopause and ensuring that women are given consistent advice.

The NICE guideline ² provides the clarity encompassing the care for most menopausal women who may self-manage or can be managed in primary care. However, some women with complex needs will require input from an HCP with a special interest in menopause or from a recognised BMS Menopause Specialist.

Menopause clinics

We will continue to develop the excellent resources prominently shown on our websites, including: Locations of NHS and private BMS specialist menopause clinics and services: Click. Search. Contact. Find your nearest BMS-recognised Menopause Specialist: www.thebms.org.uk/find-a-menopause-specialist.

The RCN document ‘Nurse Specialist in Menopause’ describes the role of the nurse in menopause care from registration to specialist practice level. ⁵

NICE quality standard for menopause. ⁶

This quality standard covers diagnosing and managing menopause, including women who have POI (menopause before the age of 40, which can occur naturally or as a result of medical or surgical treatment). It describes high quality care in priority areas for improvement.

NICE quality statements

Statement 1: Women over 45 presenting with menopausal symptoms are diagnosed with perimenopause or menopause based on their symptoms alone, without confirmatory laboratory tests.

Statement 2: Women under 40 years presenting with menopausal symptoms have their levels of follicle-stimulating hormone measured.

Statement 3. Women with POI are offered HRT or a combined hormonal contraceptive.

Statement 4. Women having treatment for menopausal symptoms have a review three months after starting each treatment and then at least annually.

Statement 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.

The BMS Vision for menopause care in the UK builds on the core principles developed by NICE and the RCN. It provides an overview for HCPs across primary and secondary care and is designed to help facilitate the achievement of NICE quality standards. It recognises and takes into account the management and organisational systems currently in place or being considered, subject to financial constraints.

A key recommendation in our submission to the Secretary of State ¹ was: ‘Primary Care Teams invite women on their register, around the time of their 50th birthday, to attend a health and lifestyle consultation to discuss a personal health plan for the menopause and beyond’. This remains an important aspiration although we acknowledge that currently, the NHS is unlikely to prioritise the allocation of resources to implement it. Options such as providing information along with national screening notification should be considered.

Primary/community menopause care

Women may recognise that the troubles they are having are menopause-related. With provision of accurate and 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 (GP). ⁷ 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 mid-life, the system should be alerted to consider a menopause link, particularly since to have made an appointment is in itself 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 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 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 and its 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 the menopause transition is affecting her. The HCP can go on to further assessment in the context of her general health and previous 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 POI 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.

Foundation (Level one) education will allow practices to discuss and cascade to their team the strategy they wish to follow: i.e. if women identify their problem as menopause-related whether they should be directed at that stage to an HCP who is both interested and has appropriate expertise (Level two). With increasing collaboration and inevitable specialisation, such interested HCPs should emerge. These HCPs will strengthen their primary care practice and in effect become a new, internal resource. This would require a prioritisation exercise within practices and by individual HCPs. Where a menopause-specific service is available within primary care, consideration must, of course, be given to time allocation. While time pressures prevail, experience has shown that allocation of extended time for menopause-specific appointments leads to a reduced number of subsequent appointments. ⁸

Specialist level care

If the patient is perceived as having a complex medical background, has POI or there are multiple factors that affect decision-making, then the patient should be referred to an HCP with appropriate menopause expertise to assess her options. Menopause specialists (Level three) have a higher level of responsibility and clinical experience. They accept referrals of the more complex patients and support colleagues to manage patients with higher risk factors. The aspiration is that practices should have access to at least one known specialist for clinical and professional support and that local networks will emerge.

Summary of 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 with general health advice being given. Local pathways will have been developed with routes to specialist level menopause services for further advice or referral.

Level three – Menopause specialist

The menopause specialist will have additional knowledge and skills; assessing and treating women with complex needs such as multiple treatment failures, POI, 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 traditional (or NICE) guidance.

Referrals to a menopause specialist may include patients diagnosed with POI or where there are multiple factors that affect decision-making.

It would remain the responsibility of the specialist to practise 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 they 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 and Psychiatry.

Women with POI may, 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.

BMS Principles and Practice of Menopause Care

The launch of the BMS Principles and Practice of Menopause Care (PPMC) programme ⁹ on World Menopause Day, 18 October 2020, was specifically designed to encourage and support all the levels of care described above. This carefully researched programme comprises progressive theory and practical training components that lead to a qualification in menopause care.

The programme is aimed at doctors, nurses and pharmacists (clinical / independent prescribers) working in menopause care, including those engaged in community, primary and secondary care. Trainees must be registered with the GMC/NMC/GPC.

The two-day stand-alone theory course is appropriate for all HCPs who wish to understand the essential foundations of menopause care.

The BMS Certificate in the PPMC is an appropriate qualification for doctors, nurses and pharmacists (clinical / independent prescribers) who undertake menopause consultations in general practice, including NHS and private clinics, and who wish to utilise their knowledge and skills in menopause care. They will need support/advice for management of complex cases.

The BMS Advanced Certificate in the PPMC is designed for doctors, nurses and pharmacist independent prescribers wishing to provide specialist menopause care, including the management of complex cases, and who may have career ambitions to lead a service. This includes HCPs working in hospital and community menopause services, GPs with an extended role in menopause and those leading menopause services in private healthcare organisations.

BMS menopause specialist

Trainees awarded the Advanced Certificate in PPMC are eligible and encouraged to become a BMS Menopause Specialist. Details are shown at: www.thebms.org.uk.

BMS menopause trainers

The Vision recognises that there is an urgent need to register more qualified menopause trainers throughout the UK. A BMS Training the Trainers one day (two half days) interactive framework course will be introduced in 2021.

We acknowledge that with the welcome increase in professional interest in the menopause, the BMS alone is unable to fulfil the overall need for education, whether through our one-day Women’s Health meetings, WHC symposium, annual two-day scientific conference and the PPMC programme. Thus, the BMS encourages other organisations to run theoretical training courses. For the purpose of certification, we will endorse those that meet the set criteria laid out in our own curriculum.

Workplace support

Before the publication of the first edition of the Vision in July 2017, and increasingly, since then, there has been a greater focus on the need to support the 1 million+ mid-life women in employment and perhaps, in effect, facing discrimination because of menopausal concerns. Thus, this section has been added to the Vision.

In 2015, Sally Davies, the Chief Medical Officer for England, acknowledged that ‘The menopause is a natural part of life, but it can feel like a great taboo. It is inexcusable that women who are experiencing menopausal symptoms should feel unable to discuss how they are feeling at work’ and ‘I want to encourage managers to ensure working women feel as comfortable discussing menopausal symptoms as they would any other issues affecting them in the workplace’ (CMO Report 2014). ¹⁰

In December 2019, more than four years later, the RCOG published a strategy document. ⁴ Recommendation 21:

Women’s health issues should be embedded in workshop policies. The UK Government should introduce a requirement for mandatory menopause workplace policies to help keep women in work and to break the stigma associated with menopause. These policies should detail the reasonable measures that should be available for women experiencing symptoms, including flexible working patterns and workplace adjustments to make the physical office environment more comfortable. HR departments should offer training and support to line managers. All workplaces should have guidance about the menopause readily available if women request it – the signs and symptoms, self-help advice for women, and where to seek professional help. As one of the world’s largest employers, the NHS should create robust policies and set an example for all employers to follow.

Recommendation 22: Appointment times at GP services should increase to 15 minutes.

‘The RCOG supports the RCGP’s call for 15 minute appointments as standard in general practice’.

The BMS strongly supports these recommendations in relation to menopause treatment and go further, as stated earlier in the Vision, that a health check at 50 should be offered.

The BMS recognises that the menopausal transition can have a significant impact on many women. Further, symptoms may last for a number of years (seven years on average), and a third of women experience long-term symptoms. It is therefore important that support and advice is available to guide women through their menopause and help them cope with it.

NICE Guidance (NG23) highlights the need for a variety of sources of information around menopause. The British Menopause Society recognises that workplaces have an important role to play. As men and women work longer into older age, it is clear that for women, the menopause may have an impact on working capabilities. With around 25% of women experiencing moderate to severe menopause symptoms, it is unsurprising that work might be adversely affected for some.

The BMS believes that there is an urgent need to raise menopause awareness among all managers and staff. Workplace support can be achieved through the following measures:

Women should be made aware of resources available for guidance and should be encouraged to seek help for managing their menopausal symptoms.

Employers should ensure that policies are in place to support employees who are experiencing menopause-related symptoms during their menopause transition.

Employers should have defined pathways in place including on line management training resources, such as webinars about the menopause, to encourage awareness and support. Flexible working practises should be introduced wherever possible and adjustments made to improve the workplace environment as part of such pathways.

The incorporation of menopause support in workplace policies must be in accordance with legislative requirements, including adherence to the provisions of the Health and Safety at Work Act 1974, the Management of Health and Safety at Work Regulations 1999 and the Equality Act 2010.

Menopause support in the workplace requires both individual and organisational level interventions to meet the needs of working menopausal women.

The Faculty of Occupational Medicine of the Royal College of Physicians provides guidance for employers on the impact of menopause on working life.^11,12

All these references are helpful, and the BMS will continue to play a significant role by regularly revising and consolidating our range of Factsheets relating to women in the workplace. Our educational training programme will include content on current workplace issues for mid-life women. We also offer medical advice to company doctors, nurses, pharmacists and to HR teams and senior management.

Coronavirus pandemic

Covid-19 is causing major changes to the provision of primary and specialist menopause care and to the education and training of HCPs.

Women should be encouraged to seek help for managing their menopausal symptoms and should be advised that the Covid-19 pandemic should not be a reason for them to discontinue HRT or withhold starting HRT if required.

Advice should be provided to women on how they can access menopause consultations remotely to discuss their management options and the local pathways available for having HRT prescriptions issued or renewed.

In addition, HCPs and prescribers must develop pathways on the advice to be communicated to women regarding how HRT prescriptions are issued and collected, and the provision of similar information on how to request and obtain repeat HRT prescriptions.

The Covid-19 pandemic has resulted in a detrimental impact on menopause training as well as training in various other medical specialties. There is a need for modifications to the way menopause education and training is delivered and for educational meetings to be conducted virtually.

After the enforced cancellation of the BMS annual scientific conference in July 2020, the society was quick off the mark to introduce an innovative and sustainable programme of virtual educational meetings for HCPs. These include one-day women’s health meetings, the WHC symposium and two-day course for PPMC and CBT. We acknowledge and highly commend our speakers, facilitators, the chief executive and her staff for their commitment and rapidly developed expertise in managing a new and significantly increased workload.

The Vision recognises that the development of services to the BMS membership is a top priority. This will help ensure a flow of new members, crucial in terms of broadening the base of menopause education, and for the financial viability of the society. Of equal importance is our ongoing scrutiny of current and anticipated pressure points in the delivery of menopause services.

Any adaptations to the structure of menopause training are likely to be in line with that applied by other national educational bodies in the course of the coming months.

Many NHS services have already set up processes for virtual patient consultations, and this concept can also be considered to conduct HCP training remotely. This may include three-way web-based video consultations involving the trainer, the patient and the trainee. Such remote training could also allow remote assessment with the trainer observing the trainee conducting a virtual consultation in their own practice. Any such pathways should have a clear process related to patient consent and confidentiality and may require piloting when first introduced to ensure feasibility of application. It will also subsequently require validation against current conventional face-to-face methods of training.

Conclusion

The BMS Vision for menopause care in the UK is a practical and achievable aspiration that will support HCPs with the information, training, education and leadership required to help women manage the menopausal and post reproductive stages of their mid and later life. Progress will be measured annually, and this consensus statement will be further updated to reflect any required changes as appropriate.