CPD: Key questions on menopause  

GP with an interest in women’s health Dr Laura Patterson discusses key issues in identifying and managing symptoms of menopause, including appropriate testing, choice of HRT, contraceptive advice and when to consider testosterone. Complete the full module on Pulse 365 today.

Learning objectives

This module will enhance your understanding of menopause management, including:

• When and which tests may be appropriate.
• Symptoms of menopause and recent updates to NICE recommendations on their management.
• Prescribing decisions for HRT, including when to use oestrogen-only or combined HRT, and continuous or sequential combined HRT, choice of formulations and contraception considerations.
• Advising on the benefits versus risks of HRT, including evidence on long-term health outcomes.
• When testosterone may be appropriate and how to prescribe it.
• How to manage patients started privately on higher than recommended HRT doses. 

1. Women sometimes ask to be ‘tested’ to see if they are in the menopause. How should we respond to this? We know hormone assays are of very limited value, but when are they useful and how should they be interpreted?

The average age of the menopause in the UK is 51 years. The menopause occurs when menstrual periods cease permanently; it is usually diagnosed clinically following 12 months of amenorrhoea. Menopause that begins between 45-55 years of age is considered normal menopause and the diagnosis is based on the clinical presentation. There is no benefit in measuring follicle stimulating hormone (FSH) during this time as it fluctuates hugely and may not reflect the clinical picture.

Menopause onset between 40 and 45 years is considered early menopause and in this situation it may be helpful to measure FSH if there is uncertainty confirming the diagnosis. Menopause before the age of 40 years is considered primary ovarian insufficiency (POI) and it is helpful to measure FSH to confirm the diagnosis. A normal FSH does not mean the woman is not perimenopausal or menopausal; there may be huge fluctuations of FSH during this time. For early menopause and POI an FSH >30 IU/L measured twice four to six weeks apart will confirm the diagnosis.¹

2. Various symptoms are often attributed to the menopause, but some – especially vaguer symptoms such as brain fog, arthralgia and low mood – can have many other causes. How can we decide whether these symptoms are truly caused by the menopause – or does it come down to a trial of treatment?

It is really important to take a thorough history of symptoms. Around 70-80% of menopausal women will have typical vasomotor symptoms which include hot flushes and night sweats. Other symptoms will include fatigue, disturbed sleep, mood changes, brain fog, low libido and genitourinary symptoms. Not all women will have symptoms of the menopause but 80-90% will. The clinical picture varies so an individual approach is needed. It is important to consider red flag symptoms and other potential comorbidities and investigate as appropriate. However, if an agreement is reached that symptoms may be perimenopausal, a trial of treatment may be considered with review at three months to assess effectiveness.¹

3. What were the key changes in the most recent update of NICE’s menopause guidelines?

Since the original NICE guidance in 2015 there have been lots of changes in menopause care. The new NICE guidance has been long awaited and includes some important changes.

The role of cognitive behavioural therapy (CBT) is now more prominent, and menopause-specific CBT is included for managing hot flushes, mood symptoms and sleep problems in addition to HRT, or where HRT is contraindicated or not wanted. Menopause-specific CBT is CBT tailored towards the specific symptoms. The CBT suggested includes self-help options, individual or group sessions. While individual and group CBT in many areas is not readily available the NICE guidance has suggested a self-help book for those who would like to try this route. The book is called ‘Living well through the menopause’ and is written by two psychologists, Myra Hunter and Melanie Smith. This is a well-considered, evidence-based and compassionate book, with lots of information for women on the range of factors that might influence the menopause. The addition of menopause-specific CBT in the guidance may also encourage better service provision.

Genitourinary syndrome of the menopause (GSM) has a larger section in this guidance and is divided into the management of those with and without breast cancer. For women with no history of breast cancer it includes when to use lubricants, moisturisers and local oestrogen. Local oestrogen should be used first line for women with GSM. Lubricants and moisturisers can be used along with local oestrogen. Prasterone, a vaginal pessary containing dehydroepiandrosterone (DHEA), now features in the guidance as a second-line option where local oestrogen alone is not effective. The DHEA converts to oestrogen and testosterone in the vaginal cells. Ospemifene, on oral tablet, is a selective oestrogen modulator with effect just on the vaginal epithelium. It is included for those who are unable to use local treatments because of dexterity issues or disabilities.

For women who have a personal history of oestrogen-receptor negative breast cancer, NICE now supports the use of local oestrogen off licence if non-hormonal treatments have not been effective for GSM. We should inform women that it is unknown if vaginal oestrogen affects recurrence of breast cancer but that very little of the oestrogen is absorbed. However, if the breast cancer is oestrogen receptor positive or if the woman is taking an aromatase inhibitor we should continue to only use non-hormonal options. If symptoms continue despite non-hormonal options liaison with the cancer treatment team should take place to identify further treatment options. There are some excellent flow charts embedded in the guidance which are a really useful visual aid.²

The other area of change is the section on the effects of HRT on specific health outcomes. This is neatly contained within a visual decision aid that can be shared with patients. It looks at the risks of developing IHD, breast, ovarian or endometrial cancer, dementia, osteoporosis and stroke. It compares rates of each health outcome for women who take HRT and those that don’t.³

4. When prescribing HRT, how do I decide on combined versus oestrogen only, and in the former, continuous versus sequential?

A woman with a hysterectomy needs oestrogen-only HRT as there is no endometrium to protect. There are two exceptions to this. If the hysterectomy is for treatment of endometriosis, the British Menopause Society (BMS) has produced guidance which recommends that oestrogen and progestogen is given together to protect any endometrial deposits that remain post-surgery.⁴

If a woman has had a subtotal hysterectomy there may be endometrium present at the top of the cervix. It is recommended to give both oestrogen and progestogen as sequential HRT, to see if there is any bleeding for the first three months; if bleeding occurs, then both hormones will be required as this suggests that there is endometrium remaining. If there is no bleeding, and therefore no residual endometrium, oestrogen alone can be used in the longer term.

For all women who have a uterus, both hormones are required. If the woman is having periods or has had a period in the past 12 months, then it will be best to start her on sequential HRT. This means that she will have a regular monthly withdrawal bleed at the end of the progestogen phase. With the hormone fluctuations the endometrium is unstable in the early stages of the perimenopause and inducing a regular bleed will help reduce any unscheduled bleeding.

If a woman is not having periods, either because they have had no natural periods in the past 12 months or they are amenorrhoeic for another reason such as using hormonal contraception or an endometrial ablation, they can start continuous combined HRT.

It can be difficult to know when to switch from sequential HRT to continuous HRT. BMS guidance suggests that sequential HRT for more than five years is associated with an increased risk of endometrial cancer, so we need to change to continuous combined HRT after five years. However, women can be swapped before this. No withdrawal bleed after the progesterone phase is an indication they may be ready. Once they reach the age of 54 years they can also be swapped. There is no right or wrong and if, on switching to continuous HRT there is unscheduled bleeding they can be swapped back for another year.⁵

Dr Laura Patterson is a portfolio GP and women’s health champion in Gloucestershire and is a Faculty Registered Trainer with the FSRH