Referral of Patients with Menopausal Symptoms

Most women with menopausal symptoms can be managed in primary care.

Referral Criteria

Patients can be referred to the tertiary centre if they meet the following criteria:

• Primary care management has failed to provide sufficient relief in symptoms. Management to-date needs to be adequately documented in the referral letter              OR
• Management is too complex to be undertaken in primary care. Reasons for this need to be carefully documented in the referral letter                                                                   OR
• Where there is Premature Ovarian Failure (<40y) +/- the patient would like to conceive.

Complex conditions to be considered for referral to secondary care:

• Woman seeking HRT after 10 years of menopause or >55 years of age
• Woman with personal history of VTE/ breast/ bowel/ovarian/endometrial cancer or any other gynaecological cancer
• Woman with strong family history of VTE and/or family history of breast cancer under the age of 40 years
• Woman with complex medical history and/or deranged health

Diagnosis of menopause and treatment (both short and long term):

For healthy women >45 years (diagnose menopause without any laboratory tests):

• Vasomotor symptoms and irregular periods
• >12 months of amenorrhoea
• Symptoms in woman without uterus

Consider FSH if:

• The woman is between 40–45 years with menopausal symptoms, including a change in menstrual cycle. FSH may be unreliable in women under 45 with menses.

Use FSH if:

• The woman is younger than 40 years in whom premature menopause is suspected.
• A pelvic examination should only be carried out if clinically indicated and to exclude other possible causes of symptoms. (e.g. rare ovarian tumour, suspected uterine pathology)
• If indicated carry out FSH twice 4-6 weeks apart and consider diagnostic of ovarian failure if the value is 30IU/L or above.

Points to consider:

Consider HRT to manage menopause symptoms including vasomotor symptoms, psychological symptoms (including low mood that arises as result of menopause), altered sexual function and urogenital atrophy.

Ensure benefits outweigh the risks for individual woman. Take a detailed history of the patient and any relevant family history to rule out inherited cancer syndromes.

HRT may be appropriate for prevention of osteoporosis related fractures in women below the age of 60 years or within 10 years of menopause in symptomatic women or if other bone protection medication is contraindicated.

There is no clear evidence that SSRIs or SNRIs ease low mood in menopausal women who have not been diagnosed with depression.

Initiating and managing HRT

Patient assessment:

History of menopause and other symptoms

Menstrual history

Contraceptive needs (HRT is not contraceptive)

Personal and family medical problems, patient risk factors

cancer—breast, bowel, ovarian, endometrial

osteoporosis

venous thromboembolism,

CV risks

other medical problems including migraine.

Concomitant medication including alternative/OTC therapies.

Patient preference for treatment

Check BP, height, weight, BMI and smoking status (advise accordingly)

Choice of route:

Offer patient choice of oral or transdermal

Avoid oral if

• VTE risks or personal /first degree relative with history of VTE (both provoked and unprovoked)
• Poor symptom control with oral
• Bowel disorder /absorption problems /gastric banding,
• Lactose intolerance
• History of migraines
• Stroke risks e.g., BMI>30/smoker/sedentary
• History of or concerns of gall stones.
• On hepatic enzyme inducing agent including OTC preparation

Treatment regime:

The dose and duration should be consistent with safety issues and treatment goals.

Generally, the lowest effective dose is advised for symptom control.

*For women with TAH & BSO for endometriosis, do not commence HRT in the first 6 months.

If there is no recurrence of symptoms, estrogen only HRT can be commenced.

With the symptoms of recurrence, consider combined estrogen and progestogen regime or Tibolone depending on age and other indications.

Review after three months, then annually and earlier if concerns.

The link of BNF for the choice of HRT with cost effectiveness:

Combined sequential: ESTRADIOL WITH NORETHISTERONE | Drug | BNF content published by NICE

Combined continuous: ESTRADIOL WITH NORETHISTERONE | Drug | BNF content published by NICE

The link from BMS for available HRT preparations: HRT-alternatives-04.11.2019.pdf (thebms.org.uk)

Contraindications:

• Current, past, or suspected breast cancer.
• Known or suspected oestrogen-sensitive cancer.
• Undiagnosed abnormal vaginal bleeding.
• Untreated endometrial hyperplasia.
• Current venous thromboembolism (deep vein thrombosis or pulmonary embolism).
• Active or recent arterial thromboembolic disease (for example angina or myocardial infarction).
• Untreated hypertension.
• Active liver disease with abnormal liver function tests.
• Porphyria cutanea tarda.
• Dubin-Johnson and Rotor syndromes (or monitor closely)

Caution with HRT:

• A personal or first degree relative with any history of venous thromboembolism VTE (whether provoked or unprovoked) see local guidelines on HRT and VTE
• Migraines (transdermal preparation starting low dose is advised with dose gradually increased to control symptoms without exacerbating migraines).

Bleeding patterns:

Sequential regime

Usually, heavier initially but get lighter or usual after 3 months.

5-10% of women do not bleed on cyclical HRT due to atrophic endometrium, if there is good symptom response then of no concern, otherwise consider possible poor absorption as reason for amenorrhoea.

Strategies for bleeding problems with cyclical regimes include:

• Consider causes e.g., compliance, drug interactions, GI or other absorption problems, pelvic pathology.
• Heavy or prolonged bleeding – increase or change type of progestogen or reduce oestrogen
• Bleeding early in progestogen phase – increase dose of progestogen or change type.
• Painful bleeding – change type of progestogen.
• Irregular bleeding – change regime or increase progestogen.

Continuous combined (COCO) HRT

Unpredictable irregular bleeding common for 3-6 months, if settling continue HRT.

If heavy or continuing after 6/12 consider investigating.

Investigate if new bleeding after 1 year amenorrhoea.

Bleeding patterns generally better with low oestrogen dose HRT & as women get older.

Strategies for bleeding problems with COCO therapies:

• Bleeding patterns better with lower oestrogen dose.
• Good compliance essential.
• Increase progestogen dose.
• Some women bleed despite atrophic endometrium/normal uterine pathology.

Lack of efficacy:

Consider the following causes:

Too soon for symptom response

Oestrogen dose not high enough

Patient compliance poor

Limited absorption/metabolism

Woman anxious about taking HRT

Symptoms not menopausal

Side Effects:

 

For further information see the West Midlands Menopause Society HRT Guide click link

HRT Flow Chart