HNY Policy and Pathway Repository - York

Menopause - Diagnosed clinically and retrospectively after 12 months of amenorrhea. Diagnosis is based on signs and symptoms only, FSH levels are not required.

Perimenopause- The time prior to the cessation of periods where menopausal symptoms may appear due to fluctuating hormone levels.

Early Menopause – When menopause occurs between 40-45 years of age.

Premature ovarian insufficiency - Signs and symptoms occur before 40 years of age

Postmenopausal bleeding (PMB) is bleeding>12 months after last period (see guidelines on PMB on RSS - pathway under review)

Heavy/irregular bleeding (see guidelines for polymenorrhagia on RSS - pathway under review)

Diagnosis

FSH levels may be considered if menopause is suspected between 40-45 years but is essential if occurs before 40 years of age. Also useful in women using hormonal contraception rendering them amenorrhoeic and can help to determine when to stop contraception (after further 12 months if over 50 years).

Two levels of FSH are required 6-8 weeks apart and levels above 30 IU/L are diagnostic.

FSH levels can be used as a marker of the perimenopause as well as patient’s age, menstrual cycle and symptoms. FSH levels can be raised for 5-10 years before the menopause. Symptoms may start with fluctuations in the hormone levels and ovarian function and may require earlier treatment for symptom relief.

Exclude other causes like hypo/hyperthyroidism.

 

Management 

Follow NICE guidelines: Menopause: Diagnosis and Management Dec 2019. This guideline should enable most women to be managed in primary care.

Offer systemic HRT for the whole range of menopausal symptoms after discussing with them the short-term (up to 5 years) and longer-term benefits and risks.

Wellspring Health website has evidence-based, person-centered HRT advice which is easily accessible for use within consultation. However please use the North Yorkshire and York Menopause Guidance - HRT for drug choices and here on testosterone for low libido.

 

Follow Up

After 3 months, symptoms are usually either fully or partially resolved. In some circumstances, there is no symptoms improvement.

Symptoms fully resolved; continue current regimen and review annually

Symptoms partially resolved; check for problems with use of gel or patch, if no issues with use, then increase dose of oestrogen and review in 3 months. Doses should be balanced with unwanted symptoms and increased until vasomotor symptoms are absent.

No symptoms improvement; exclude problems with medication as before. Check estradiol levels to ensure adequate transdermal absorption (blood taken just prior to application of gel or day 4 of patch). Estradiol >250pmol/l reflects adequate transdermal absorption. Dosage should be titrated upwards. Consider alternative diagnosis for symptoms

Local Urogenital Treatment Options for symptomatic urogenital atrophy

1. Estring (vaginal ring) , E2 (7.5 mcg), silicone ring, replaced 3 monthly
2. Vagifem (vaginal tablet), E2 (10 mcg), chalky tablet with plastic inserter tube, every night for 2 weeks and twice weekly thereafter
3. Ovestin (vaginal cream), Estriol (0.1%/1 mg), cream drawn into plastic inserter tube (also option of external application)

Moisturizers and lubricants can be used alongside, routine monitoring of endometrial thickness is not required, can be continued for as long as required

Testosterone non-licensed use for menopausal women with low sexual desire (recognized by BMS/NICE)

Tostran 2 % gel in a cannister containing 60 g.
Starting dose 1 metered pump = 0.5 g = 10 mg on alternate days, delivering 5 mg/day
Each cannister should last 120 days

Free Androgen index advised as a baseline then at 3 months and 6 months

1. Request Advice & Guidance if symptoms are not settling with tailored regimes as above
   Include a thorough history and examination findings. History of medical conditions, DVT/PE, and treatments to date. Surgical history of total/subtotal hysterectomy or endometrial ablation. Personal / family history of cancers relating to breast, ovary, uterus and bowel Contraceptive and smear history.
   BMI, Blood Pressure, smoking status.
    
2. Refer to secondary care or specialist menopause clinic
   Suspected premature menopause
   Complex co-morbidities and risks e.g. VTE, CVD, migraines with aura
   Persistent side effects
   Lack of efficiency
   Unscheduled bleeding after trial of multiple HRT options (refer hysteroscopy clinic)
   Consideration of Testosterone therapy if unhappy to initiate

 

Information to include in referral letter – Consider Advice & Guidance

• Describe problem and length of symptoms
• Current contraception/hormone therapy
• If bleeding problems, findings of vaginal and speculum examination
• Smear History
• BMI
• Smoking status delete

Patient information leaflets/ PDAs

• menopausematters.co.uk 
• Dr Louise Newson Balance
• RCOG leaflet - for patients who cannot or do not want to take HRT
• Menopause information for people with learning disabilities
• Testosterone gel (Tostran 2%) in menopausal and post-menopausal women for low sex drive - patient information leaflet
   

Primary care information leaflets

• Topical testosterone for management of low libido in menopausal and post-menopausal women - primary care prescribers leaflet

 

References

• NICE Guidance Menopause: Diagnosis and management Dec 2019
• NICE Quality Standard Menopause
• Menopause - NICE CKS
• FSRH Clinical Guidance – Contraception for women over 40 years – Sept 2019
• Primary Care Women's Health Forum Guidance on Menopause and HRT
• British Menopause Society