Menopause and beyond

Menopause word cloud

Key facts

There is much confusion about management of the menopause and although it is an inevitable occurrence for women many continue to suffer in silence. An estimated 40% of women reported that the symptoms were worse than they had anticipated1 with 45% reporting that menopause symptoms had a negative impact on their work.2

Premature ovarian insufficiency is classified as menopause in women aged less than 40. The risk of cardiovascular disease, osteoporosis and dementia is increased in this cohort of women and HRT is recommended as ‘replacement’ therapy as well as for symptom control3.

Female urinary incontinence becomes increasingly problematic in women post-menopausally and as they age, caused by pelvic floor muscle weakness and/or detrusor muscle over activity. The recently updated NICE guidance4 clearly outlines management and includes a section on management of pelvic floor prolapse for the first time.   

Ovarian cancer has low survival rates because the vague symptoms result in late presentation. Earlier diagnosis and a low threshold for considering testing are required to make significant difference to the poor outcomes5.

Vulval disorders become more problematic as women age and require examination and early treatment to reduce the long-term consequences of scarring and malignant transformation.

References:

  1. British Menopause Survey, National Survey
  2. A woman’s relationship with the menopause is complicated…, British Menopause Survey
  3. European Society of Human Reproduction and Embryology Guideline on the management of premature ovarian insufficiency. Published date: December 2015.
  4. NICE guideline: Urinary incontinence and pelvic organ prolapse in women: management (NG 123) Updated June 2019.
  5. NICE guideline. Ovarian cancer: recognition and initial management (CG122)  Published 2011 

Resources for training and appraisal

Training resources

  1. The International Menopause Society Professional Activity for Refresher Training, (IMPART) on line training aimed at both primary care practitioners and hospital specialists. IMPART comprehensively provides practitioner training in managing both acute menopausal symptoms and the long term consequences of the changes that occur at menopause. It provides guidance in midlife preventative health care, including when and what basic health checks should be performed to prevent and detect bone loss and osteoporosis, cardiovascular disease, gynaecological cancers, and impaired mental health.
  2. RCGP e-learning.  Bloating and other symptoms:  Could it be ovarian cancer? A 30 minute e-learning module developed in conjunction with Target Ovarian Cancer aiming to increase knowledge and confidence in deciding when to assess women with bloating and other abdominal symptoms for ovarian cancer.  This session covers the presentation and diagnosis of ovarian cancer in primary care through the use of case studies.

Top tips for menopause management in primary care

Adapted from Primary Care Women’s Health Forum top tips, with permission

  1. The diagnosis of menopause in women aged > 45 is clinical and based on symptoms. It does not usually require confirmation with an FSH level.
  2. Remember that contraception is needed until infertility can be assumed. The use of intra-uterine progestogen offers endometrial protection and contraception.  Refer FSRH CEU Guideline Contraception for women over 40 for further information.
  3. Consider menopause as a possible cause of amenorrhoea in women < 45 who are not using hormonal contraception once pregnancy is excluded.
  4. Recommend Hormone Replacement Therapy (HRT) routinely to women who are menopausal aged < 45, even if they are asymptomatic, to reduce the consequences of long-term hypo-oestrogenism such as osteoporosis and cardiovascular disease.
  5. Provide/signpost women to reliable patient information (i.e.menopause matters and manage my menopause) to allow informed and shared decision making between the woman and her healthcare professional.
  6. Prescribing is not difficult and decision-making guides are available. Read the Easy HRT prescribing guide on management and prescription of HRT in primary care, Primary Women's Health Forum.
  7. HRT is much safer than you think. NICE Clinical Guidance (2015); Diagnosis and Management provides the evidence and reassurance for use.
  8. Support the woman to initiate HRT and continue with a review after three months. Once stable review annually 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. Women with any cardiovascular or thrombotic risk factors who are eligible for HRT would benefit from a transdermal preparation.
  10. Low dose vaginal oestrogens are safe to use for as long as required in most women. Some women will require the use of vaginal oestrogen in addition to their systemic HRT to control their genito-urinary problems.

Top tips and useful resources

Guidelines and Pathways

  • NICE Menopause:  diagnosis and management. (NG23, November 2015, updated 2019). This guideline covers the diagnosis and management of menopause, including in women who have premature ovarian insufficiency.  The guideline aims to improve the consistency of support and information provided to women in menopause. The guideline was amended in December 2019, following the MHRA safety alert on hormone replacement therapy (HRT) and the risk of breast cancer, to include the MHRA’s advice on risks and benefits.
  • The NICE NG23 guideline includes a pathway for improving diagnosis and management of menopause. 
  • The British Menopause Society website hosts a series of consensus statements which address key disorders and controversial topics in post-reproductive health.  These statements are developed from evidence review and informal consensus to support healthcare professionals to provide quality post-reproductive healthcare including:
    • Hormone Replacement Therapy
    • Non-hormonal based treatments for menopausal symptoms
    • Premature ovarian insufficiency
    • Bioidentical HRT
    • Urogenital atrophy
  • European Society of Human Reproduction and Embryology published a guideline on the management of premature ovarian insufficiency (POI).This guideline offers best practice advice on the care of women with premature ovarian insufficiency, both primary and secondary. The patient population comprises women younger than 40 years (which includes Turner Syndrome patients) and women older than 40 years, but with disease onset before 40.
  • NICE  Ovarian cancer:  Recognition and initial management (CG122,  April 2011). Guideline covering detection, diagnosis and treatment of women aged 18 or older who have, or are suspected of having, epithelial ovarian cancer, fallopian tube cancer, primary peritoneal cancer or borderline ovarian cancer.  It aims to enable earlier detection of ovarian cancer and improve initial treatment. The NICE CG122 guideline includes a pathway to support the recommendations.
  • NICE Suspected cancer: recognition and referral (NG12, June 2015, updated July 2017). Guideline including recommendations to improve recognition and referral of symptoms that could be caused by cancer.  Included is a section specifically aiming to help people understand what to expect if they have symptoms which may suggest cancer. The recommendations are organised by:
  • NICE  Urinary incontinence and pelvic organ prolapse in women: management  (NG123  April 2019, updated: June 2019). This guideline is an update covering assessment and management of urinary incontinence in women and includes for the first time a section on management of pelvic organ prolapse.The guideline also covers sections on the assessment and management of MESH related problems.  This section will be updated following the independent review. The NICE NG123 guideline includes a pathway to support the recommendations.

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