Menopause NICE

Question 1

Symptoms of menopause

Answer 1

Vasomotor symptoms - hot flushes and sweats
Genitourinary symptoms - vaginal dryness
Mood - depressive symptoms
Musculoskeletal symptoms - joint and muscle pain)
Sexual difficulties - low sexual desire).

Question 2

Important bits of info not to miss out in consultations

Answer 2

Contraception up to age 55 - copper coil, mirena coil (8 years contraception, 4 years endometrial protection in HRT), implant, POP
AVOID depot in over 50s as associated with small loss of bone mineral density
AVOID COCP in over 50s due to VTE risk and be mindful in over 40s (if obese, smoker, VTE Fhx, CVD risk factors then avoid)

Bone health
Maintaining muscle mass and strength through exercise
Psychological support if needed

Question 3

How to identify perimenopause

Answer 3

Recent vasomotor symptoms and any change in menstrual cycle

Question 4

How to identify menopause

Answer 4

No period for >12 months and no hormonal contraception

Question 5

When can you consider using FSH to confirm menopause?

Answer 5

40-45 years with menopause symptoms (inc change in menstrual cycle)

<40 years if menopause suspected

Question 6

What complementary therapies might patients use in menopause?

Answer 6

Isoflavanes or black cohosh

May relieve vasomotor symptoms but explain that safety is uncertain and may interact with other meds

Question 7

How to treat vasomotor symptoms?

Answer 7

Offer HRT
Offer CBT
Don’t routinely offer SSRIs as 1st line

Question 8

How to treat genitourinary symptoms?

Answer 8

Vaginal oestrogen - gel, cream, tablet, pessary, ring.

Non-hormonal vaginal lubricants/moisturisers

Question 9

Can you use vaginal oestrogen if the patient has a history of breast cancer?

Answer 9

If personal history of breast ca, try non-hormonal moisturisers first and consider vaginal oestrogen if it doesn’t work. It is unknown if vaginal oestrogen affects the risk of breast cancer recurrence - minimal amounts of oestrogen are absorbed into blood stream (much less than oral HRT)

If breast cancer was oestrogen receptor negative, then vaginal oestrogen unlikely to increase risk of recurrence.

Question 10

How to treat depressive symptoms in menopause?

Answer 10

Consider HRT if symptoms started at same time as other menopause type symptoms

Consider CBT

Question 11

How to manage sleep symptoms in menopause?

Answer 11

Menopause specific CBT + HRT

Question 12

Treatment for low libido?

Answer 12

Consider testosterone if HRT alone not effective

Question 13

How to manage menopause in women with increased VTE risk?

Answer 13

Use transdermal oestrogen (rather than oral), including if BMI >30

If hereditary thrombophilia consider haematology input

Question 14

How to manage menopause in women with ischaemic heart disease?

Answer 14

Non-hormonal therapy is 1st line
Shared decision making
Low dose, non-oral estrogen + non-androgenic progesterone

Avoid oral HRT due to BP and VTE risk

It is possible that oestrogen may have a positive effect on these women (e.g. arterial health/vascular function) but we don’t have data to demonstrate this

Can use vaginal oestrogen

Question 15

How to manage menopause in patients who have had a stroke?

Answer 15

Avoid HRT

Ensure modifiable stroke risk factors addressed (tend to be underaddressed in women)

Question 16

What are HRT options?

Answer 16

Combined HRT
-sequential during perimenopause as it reduces risk of breakthrough bleeds
e.g evorel sequi (2 weeks evorel 50, followed by 2 weeks evorel conti)
OR elleste duet tablets (2 colours in pack)

-continuous if menopausal
e.g. evorel conti

Oestrogen only HRT ONLY if hysterectomy

Question 17

Risks of combined HRT

Answer 17

Increase in breast cancer risk
- rises with longer duration of use

Slight increase in ovarian cancer risk

Question 18

Benefits of combined HRT

Answer 18

Reduces endometrial cancer risk

Reduces risk of fragility fractures during treatment period