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  • The following summary, with the exception of Ovarian cancer is based on NICE Guideline 23 (NG23) Menopause: diagnosis and management

Diagnosis

  • Diagnosis can be made without laboratory tests in otherwise healthy women aged over 45 years with appropriate symptoms:
    • peri-menopause based on vasomotor symptoms and infrequent periods
    • menopause in women who have:
      • not had a period for at least 12 months and are not using hormonal contraception or
      • symptoms in women without a uterus.
  • Consider using a follicle-stimulating hormone (FSH) test to diagnose menopause only:
    • in women aged 40–45 years with menopausal symptoms, including a change in their menstrual cycle
    • in women aged under 40 years in whom menopause is suspected.
  • If possible, test FSH day 2–5 of cycle.
  • Two FSH levels over 30 mIU/ml taken 6 weeks apart in women using hormonal contraception rendering them amenorrhoeic (intrauterine system, progestogen-only pill, etonogestrel implant), can be used to determine when contraception can be stopped (after a further 12 months in women over 50 years).
  • Some women may have normal levels of FSH during the menopausal transition, so this should not exclude peri-menopause as a cause of their symptoms.

Vasomotor symptoms

  • Offer women hormone replacement therapy (HRT) after discussing with them the short-term (up to 5 years) and longer-term benefits and risks.
  • Offer a choice of preparations as follows:
    • oestrogen and progestogen to women with a uterus
    • oestrogen alone to women without a uterus
  • Do not offer selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), or clonidine as first-line treatment for vasomotor symptoms alone. Consider testosterone supplementation for menopausal women with low sexual desire if HRT alone is not effective.

Urogenital atrophy

  • Vaginal oestrogen can be given to women with urogenital atrophy (including those on systemic HRT) and continued for as long as needed to relieve symptoms. Treatment should be started early before irreversible changes have occurred.
  • If vaginal oestrogen does not relieve symptoms of urogenital atrophy, consider increasing the dose after seeking advice from a healthcare professional with expertise in menopause. Vaginal moisturisers and lubricants can be used alone or in addition to vaginal oestrogen.
  • There is no need for monitoring of endometrial thickness during treatment of urogenital atrophy with vaginal oestrogens. But advise women they should report unscheduled vaginal bleeding promptly.

Venous thromboembolism

  • The risk of venous thromboembolism (VTE) is increased (relative risk=2) by oral HRT compared with baseline population risk.
  • The risk associated with transdermal HRT given at standard therapeutic doses (under 50 mcg/24 h) does not appear to be greater than baseline population risk.
  • Consider transdermal rather than oral HRT for menopausal women who are at increased risk of VTE, including those with a body mass index (BMI) over 30.
  • Refer menopausal women at high risk of VTE (e.g. those with a strong family history of VTE or a hereditary thrombophilia) to a haematologist or local specialist/GP with Special Interest in the menopause for assessment, before considering HRT.

Cardiovascular disease

  • HRT does not increase coronary heart disease risk when started in women aged under 60 years, and does not affect the risk of dying from cardiovascular disease.
  • The presence of cardiovascular risk factors is not a contraindication to HRT as long as they are optimally managed.
  • The baseline risk of coronary heart disease and stroke for women around menopausal age varies according to their personal cardiovascular risk factors.
  • HRT with oestrogen alone is associated with no, or reduced, risk of coronary heart disease.
  • HRT with oestrogen and progestogen is associated with little or no increase in the risk of coronary heart disease.
  • Taking oral oestrogen (but not transdermal under 50 mcg/24 h) is associated with a small increase in the risk of stroke, but the baseline population risk of stroke in women aged under 60 years is very low, so the increased risk is non significant.

Type 2 diabetes

  • Taking HRT (either orally or transdermally) is not associated with an increased risk of developing type 2 diabetes.
  • In women with diabetes, HRT is not generally associated with an adverse effect on blood glucose control.

Osteoporosis

  • Give women advice on bone health and discuss any risk factors for osteoporosis.
  • The baseline population risk of fragility fracture for women around menopausal age in the UK is low and varies according to their personal and familial risk factors.
  • Risk of fragility fracture is decreased while taking HRT but increases once treatment stops, although may persist for a while in women who take HRT for longer.

Loss of muscle mass and strength

  • There is limited evidence suggesting that HRT may improve muscle mass and strength, which otherwise tends to decrease after the menopause. Muscle mass and strength is also maintained through daily activities and weight-bearing exercise.

Breast cancer

  • HRT does not affect the risk of dying from breast cancer.
  • The baseline risk of breast cancer for women around menopausal age varies according to the presence of underlying familial and environmental risk factors.
  • HRT with oestrogen alone is associated with little or no increase in the risk of breast cancer.
  • HRT with oestrogen and progestogen can be associated with an increase in the risk of breast cancer, however any increase in risk of breast cancer is related to treatment duration and reduces after stopping HRT.
  • The Woman’s Health Institute study suggests if 1000 women used HRT for 5 years there would be 4 extra cases of breast cancer with combined HRT use, and 4 fewer cases with oestrogen only use, on a baseline risk of 15 cases per 1000 women over 5 years.

Ovarian cancer (not in NICE guidelines)

  • A 2015 meta-analysis of 52 epidemiological studies has shown an increased risk of ovarian cancer with oestrogen-only and combined HRT. While this study provides evidence of an association between HRT use and some tumour subtypes, it provides insufficient evidence to claim that HRT causes ovarian cancer.
  • When counselling patients, it is important to discuss these findings in terms of absolute risk.
  • With 5 years of HRT use, there could be 1 additional ovarian cancer per 1000 users and 1 additional death per 1700 users among women of all ages.
  • A better way of framing it is to point out that, after 5 years of HRT there is only a 0.1% increase in ovarian cancer and less than 0.6% additional deaths.

Premature ovarian insufficiency

  • In women with premature ovarian insufficiency (menopause under 40 years) it is important to start hormonal treatment either with HRT or a combined hormonal contraceptive.
  • This treatment should be continued until at least the age of natural menopause (unless contraindicated) to protect against the increased risk of dementia, cognitive decline, cardiovascular disease, and osteoporosis seen in these women.
  • HRT has a negligible effect on blood pressure and beneficial effects on metabolic parameters, when compared with a combined oral contraceptive.
  • Both HRT and combined oral contraceptives offer bone protection.
  • HRT is not a contraceptive.
  • Consider referring women with premature ovarian insufficiency to healthcare professionals who have the relevant experience to help them manage all aspects of physical and psychosocial health related to their condition.

Review each treatment for menopausal symptoms

  • At 3 months to assess efficacy and tolerability.
  • Annually thereafter unless there are clinical indications for an earlier review (such as treatment ineffectiveness, side effects or adverse effects).
Table 1: Progestogens
SYNTHETIC PROGESTOGENSFEATURESNATURAL PROGESTOGENSFEATURES
C19 TESTOSTERONE DERIVATIVES
Norethisterone, norgestrel, levonorgestrel Better cycle control
Androgenic (good for libido)
Unfavourable effect on lipids
Micronised progesterone (Utrogestran) Fewer progestogenic side effects
No androgenic or glucocorticoid activity
No impact on lipids
Less effective cycle control
C21 testosterone derivatives
Medroxyprogesterone acetate Can be added to oral or transdermal oestrogen
(Androgenic so may be good for libido)
Unfavourable effect on lipids
   
Dydrogesterone Non Androgenic
Not available as single preparation
   
IUS=levonorgestrel Replace after 5 years as per FSRH guidance
There is minimal systemic absorption
   
IUS=intrauterine system; FSRH= Faculty of Sexual and Reproductive Healthcare.

 

Figure 1. Flow chart of HRT prescribing

Flow chart of HRT prescribing

NICE Quality Statements 2015:

Statement 1 Women over 45 years 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 premature ovarian insufficiency are offered hormone replacement therapy or a combined hormonal contraceptive.

Statement 4 Women having treatment for menopausal symptoms have a review 3 month 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.

© NICE 2017. Menopause. NICE Quality Standard 143. Available from: www.nice.org.uk/guidance/qs143. All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. See www.nice.org.uk/re-using-our-content/uk-open-content-licence for further details.


PCWHF 10 top tips for everyday practice

  1. The diagnosis of menopause in women aged >40 is clinical. It does not require confirmation with an FSH level
  2. Remember that contraception is needed until infertility can be assumed
  3. Consider menopause as a possibility in women <45 who have amenorrhea and are not using hormonal contraception
  4. HRT should be recommended routinely to women who are menopausal aged <45, even if they are asymptomatic
  5. Provide/signpost good patient information to allow informed and shared decision making between the woman and her HCP
  6. Prescribing is not difficult and decision-making guides are available.
  7. HRT is much safer than you think. NICE clinical guidance (2015) will provide the evidence and reassurance.
  8. Support the woman to initiate and continue treatment and review at 3 months. If stable, annual review is recommended to reassess the risk/benefits of ongoing HRT use for her. There is no arbitrary limit to length of use
  9. The benefits of HRT outweigh the risks for most women who start treatment aged <60
  10. Low dose vaginal oestrogens are safe to use for as long as required in all women who do not have breast cancer.

Further information

  • The Primary Care Women’s Health Forum (PCWHF) is a charity focused on improving the education of healthcare professionals in the area of women’s health. Membership is free and the forum provides tips and useful guides free of charge, along with educational webinars and meetings. To find out more or become a member, head to www.pcwhf.co.uk

full guideline available from…
www.pcwhf.co.uk/documents/pcwhf_menopause_guidelines_2016.pdf

Primary Care Women’s Health Forum. Menopause—guidance on management and prescribing HRT for GPs based on NICE guidance 2015. September 2017.