RCGP, RCOG and BMS Position Statement on the Menopause
The menopause is part of a woman’s life that every General Practitioner requires understanding of to enable them to care for their patients, (and their families and carers when appropriate). For many women the impact of the menopause is significant, and for some can be devastating. However, for some women it will pass almost unnoticed, with others simply requiring reassurance and lifestyle advice without needing medication. Ensuring every member of the primary care team is aware of the variable presentation and impact of the menopause is therefore essential.
A personalised approach to care is key to ensure every person receives the right care for them, individualised to their specific needs. This is emphasised in the RCGP curriculum which provides a “women centred life course approach” where every contact throughout a women’s life matters. The menopause and perimenopause is one significant part of this, ensuring we are able to care for and support our patients at every stage of their lives.
Why is a position statement required?
There has recently been an increased interest in the menopause politically, in the media and due to an increased understanding from our patients. NHS England are currently consulting on a women’s health care pathway and NICE have begun the process of reviewing its menopause guidance. In addition, the Women’s Health Strategy (Department of Health and Social Care: DHSC 2022), and the Scottish Women’s Health plan highlight the importance of caring for every aspect of women’s health throughout their lifetime with the menopause being one significant part.
Some patient requests for support can fall outside of current licensing and prescribing guidelines, such as the increasing requests for testosterone and so whilst the guidance and pathways are being updated, we include here the most up-to-date information for primary care to help GPs provide the best care for their patients.
The current NICE guidance for the diagnosis and management of the menopause is the NG23 guideline which was last updated in 2019, and is currently undergoing an update which will focus on managing urogenital atrophy, the long-term benefits and risks of hormone replacement therapy, and cognitive behavioural therapy for managing menopausal symptoms.
This guideline includes recommendations on individualised care, diagnosis of perimenopause and the menopause, the provision of information and advice, managing short-term symptoms, explaining the benefits and risks of hormone replacement therapy, and diagnosing and managing premature ovarian insufficiency.
Improving the care you provide
NICE have developed the menopause quality standards which identifies five key points from the clinical guideline as a priority to improve the care of patients which the RCGP endorsed in 2017 and continue to fully support.
To improve patient care during the menopause, quality standard 1-4 would make excellent primary care audits. They provide a clear way of measuring current practice on each standard and after implementing changes, or providing education to the primary care teams, these can be remeasured aiming to show improvement in care. Quality improvement is an essential part of the revalidation cycle and this is a great opportunity to improve the menopause care that patients receive.
- Quality standard 1: Diagnosis of perimenopause and menopause without the need for confirmatory laboratory tests
- Quality standard 2: Diagnosing premature ovarian insufficiency with follicle stimulating hormone (FSH) tests
- Quality standard 3: Ensuring those diagnosed with premature ovarian insufficiency are treated with HRT or combined hormonal contraceptive
- Quality standard 4: Review of those on HRT initially at 3 months and then at least annually
- Quality standard 5: Ensuring those who may experience a medical or surgical menopause are given information about fertility and the menopause prior to treatment
Treatment review and prescription length
NICE states that treatment should be reviewed at 3 months and then annually, unless there are clinical indications for an earlier review. An individualised approach is therefore required for each patient, aiming for annual reviews once stabilised on treatment. It is important to note however, that this does not indicate the length of prescription to be provided, only the frequency of the clinical review.
Lengths of prescriptions will depend on local system arrangements and will of course be affected by current supply chain issues which have been seen recently with HRT patches and gels in particular, due to the increase in demand for HRT.
For women at higher risk of VTE transdermal products are preferred, but it is important to remember that oral medication is appropriate for many women where VTE risk is not a significant concern. The British Menopause society has produced excellent information on alternatives to the medication out of stock available on the BMS website (PDF file, 170 KB).
We are aware of a recent pledge from DHSC, covered in the media to provide annual prescriptions for HRT and whilst the RCGP fully supports the aims of reducing the prescription costs to women themselves, it is essential this is undertaken in a way that is safe for the patient and does not impact further on the supply chain issues. The RCGP recommended innovative solutions to reducing prescription costs such as prepayment certificates, rather than the provision of a 12-month which script could have made supply chain issues worse. From April 2023, in England, the DHSC has now confirmed that women will be able to pay a one-off charge equivalent to 2 single prescription charges, currently £18.70, for all their HRT prescriptions for a year meaning women can access HRT with more frequency if need be, easing pressure on supply, while keeping the cost of HRT low.
Support from secondary care
With increasing requests in primary care for menopause support from patients, naturally there is an increase in referrals asking for support from secondary care. NICE guidance advises that referral can be considered if there are menopausal symptoms and contraindications to HRT, or if there is uncertainty about the most suitable treatment option for the presenting menopausal symptoms.
Some areas will have a bespoke menopause clinic, in others, this necessitates referring to the general gynaecology clinic. GPs and their teams can also refer internally, within the practice for support if there are clinicians with an interest in the menopause or can use choose and book advice (or equivalent) aiming to ensure the patient receives the best care in the most timely way, as an alternative to formal secondary care referral.
Requests for prescriptions of testosterone for patients experiencing menopausal symptoms have become increasingly more common. NICE guidance does state we can consider testosterone supplementation for menopausal women with low sexual desire, but only if HRT alone is not effective, with women needing to be fully oestrogenised first. The guidance does not support the use of testosterone in any other circumstance.
The BNF states testosterone for low sexual desire in women, can be considered but should only be administered on expert advice. The BNF does not support the use of testosterone in any other circumstance.
Some GPs will feel competent and comfortable issuing these prescriptions, however we would advise that anyone who is not should seek specialist help if you are asked to prescribe and it is outside your area of expertise. If you want to know more about testosterone, the Global Consensus Position Statement on the use of Testosterone can be found on the IM society website.
Educational materials and resources
There is a wealth of educational materials available to support GPs and your teams in ensuring up-to-date knowledge of the menopause.
The RCGP Women’s Heath hub is full of educational resources and guidelines on women’s health that are relevant to GPs and other primary healthcare professionals. It brings together national guidance, resources produced and accredited by the RCGP, and resources from the Royal College of Obstetricians and Gynaecologists (RCOG) and the Faculty of Sexual and Reproductive Healthcare (FSRH).
- PCWHF: Menopause – Guidance on management and prescribing HRT for GPs (PDF file, 185 KB)
- PCWHF: How to manage HRT provision without face to face consultations during COVID-19 healthcare restrictions (PDF file, 172 KB)
- PCWHF: Vulvovaginal atrophy (VVA) Treatment Comparison Table (PDF file, 153 KB)
For patient facing materials see Rock My Menopause.