This article considers the diagnosis and management of the menopause, as well as the tell-tale symptoms GPs should be looking out for
Women don’t always attend GP practice saying they are menopausal. Instead, they can come in with a myriad of symptoms, which the GP has to be aware are linked, and to consider they may be climacteric symptoms. Often the women are prescribed antidepressants for their low mood, analgesia for their joint pains and anti-muscarinics for their bladder symptoms. Women are often relieved when all their symptoms can be explained by the menopause and using a symptom check list, such as the Greene Climacteric Score,1 can help them understand many of their symptoms they didn’t think to mention could also be explained.
What is the menopause?
Menopause is diagnosed as 12 months after a woman’s last period. The menopause is based on symptoms in women without a uterus. There is no need for laboratory testing in women over 45 years.2 The symptoms are mostly due to lack of oestrogen in the body. Symptoms can vary between women, and the average length of time for symptoms is seven years. Although the commonest symptoms are hot flushes and night sweats, symptoms such as low mood, anxiety, memory problems, poor concentration and fatigue often have a more negative impact on a woman’s quality of life.
It is always important to discuss lifestyle, as exercise, weight loss and healthy eating can help some of the symptoms, such as musculoskeletal symptoms and lack of energy. It is also important to reduce the risk of cardiovascular disease, which increases as women age. NICE also mention cognitive behavioural therapy, which may help women with menopausal symptoms especially psychological.2
Alternatives to HRT
Many women have tried alternatives from health food shops, such as black cohosh and isoflavones, and there is some evidence they may relieve vasomotor symptoms. However, multiple preparations are available, their safety is uncertain, and interactions with other medicines have been reported. NICE do not recommend offering SSRI, SNRI or clonidine as first line treatment for vasomotor symptoms alone.2
Long term benefits and risks of HRT
There are many benefits of HRT, the main one being symptom control, especially vasomotor symptoms. HRT offers protection against osteoporosis and the risk of fragility fractures are reduced whilst taking HRT and maintained during treatment.3 It also maintains muscle mass and strength. In women under 60, it reduces CHD deaths with a 50% relative reduction in risk.4
The risks of HRT are much less than many women realise, as inaccurate reporting by the media has raised concerns for women and healthcare professionals alike. The risk of thromboembolism is doubled by oral oestrogen, which is still a lower risk than combined hormonal contraception (CHC) or pregnancy. Importantly, there is no increased risk with using standard therapeutic doses of transdermal preparations.5 If women have high risk of VTE such as a hereditary thrombophilia, NICE guidelines state that referral to a haematologist can be considered for assessment before considering HRT.2
Oral (not transdermal) oestrogen offers a small insignificant increase risk of stroke. Risk factors of cardiovascular disease are not a contraindication for HRT. This means that women with hypertension can still safely have HRT, the optimal preparation would be transdermal oestrogen and micronised progesterone.
Many women and healthcare professionals are worried about the risk of breast cancer. NICE clearly states the ‘the risks of HRT are only relevant to women who are over 51 years of age’.2 HRT with oestrogen alone is associated with little or no change in risk of breast cancer. HRT with oestrogen and progestogen can be associated with an increase in the risk of breast cancer – at worst, an extra 4 per 1,000 may get breast cancer taking HRT. The risk is similar to being overweight or drinking two glasses of wine a night. Importantly, there is no increased risk of dying of breast cancer and any risk of breast cancer is related to treatment duration and reduces after stopping HRT. However, other studies have failed to demonstrate any increased risk of breast cancer with HRT. Body identical progestogen (micronised progestogen) has shown it is not associated with breast cancer for the first five years of taking it.6
Which HRT to prescribe?
- If she doesn’t have a uterus, she can be prescribed oestrogen alone
- If she has a uterus, she will need progestogen as well as oestrogen (combined HRT) to protect the lining of the uterus and prevent endometrial proliferation. Progestogen can be given orally, transdermally, or intra uterine
- This can be given sequentially if she is perimenopausal and continuous if menopausal or if she has received sequential HRT for around a year.
Oestrogen only preparations
Oestrogen only preparations can come in gels, patches, and implants. Topical vaginal oestrogens can come in creams, pessaries and rings. Topical vaginal oestrogens can be given in addition to systemic HRT.
Combined sequential preparations
A combined sequential preparation is usually prescribed if a woman has a uterus and has had a period in the last 12 months. This may come as a combined tablet or patch. It may come as an oestrogen-only preparation with an adjunctive progestogen i.e. Mirena, micronised progestogen. For the first 14 days she will take oestrogen alone and then for the next 12-14 days (dependant on the preparation) progestogen will be added to the oestrogen and she will subsequently have a bleed. Mirena is the exception as the progestogen is continuous. She may have regular periods again with this preparation.
Continuous combined preparations
If she has a uterus, and hasn’t had a period for a year, she will usually be prescribed a combined continuous preparation, such as a tablet or patch containing progestogen and oestrogen. Or an oestrogen only preparation with an adjunctive progestogen such as Mirena or micronised progestogen.
Body identical progestogen
Micronised progestogen is the same structure as progestogen in our bodies so has very few side effects. It can be given continually with oestrogen as a continuous combined preparation or for 12 days of the cycle with oestrogen for sequential combined combination. Studies have shown that it is not associated with an increased risk of breast cancer for the first 5 years taking it.6
The results from a systemic literature review on the impact of micronised progestogen on breast cancer risk are as follows:
- Oestrogens combined with micronised progestogen do not increase the risk of breast cancer for up to 5 years of treatment duration
- There is limited evidence that oestrogens combined with oral micronised progesterone applied for more than 5 years are associated with an increased breast cancer risk
- Counselling on combined HRT should cover breast cancer risk.6
Vaginal oestrogen is effective for urogenital atrophy, including those already on systemic HRT.7 They can continue treatment for as long as needed to relieve symptoms. However, the symptoms often come back when treatment is stopped. Adverse effects are rare, but they should report unscheduled vaginal bleeding to their GP. They can also use moisturisers and lubricants in addition for vaginal dryness. If systemic HRT is contraindicated, advice should be sought from a health care professional with expertise in menopause.
Consider does she still need contraception; HRT is not a contraception
A woman is considered potentially fertile for one year after their last period if over 50 years of age, and for two years if under 50 years of age. Sterility can usually be assumed at 55 years old. Many women in their late 40’s will have a LARC or permanent contraception such as male or female sterilisation.
If a woman is not using a reliable form of contraception or having perimenopausal menorrhagia, as long as another cause has been excluded, a Mirena IUS is an excellent option. It is a long-acting, reliable contraception and is also licensed for heavy menstrual bleeding and HRT. It is licensed for four years although can be used as endometrial protection for five years.8
Combined hormonal contraception (CHC) is not advised over 50 as UKMEC3. Current recommendations are that injectable progestogens, such as Depo Provera or Sayana Press, is recommended only to 50 years old. However, other progestogen-only methods of contraception can be used up to 55 years of age, such as desogestrel pill and SDI (Nexplanon). However, they cannot be relied on for the progestogen arm of the HRT and need to be taken alongside the combined HRT. If a woman is taking continuous HRT and not having periods then she usually does not need additional contraception.
After providing the initial prescription, follow up is usually after three months. Explain to women with a uterus that unscheduled vaginal bleeding is a common side effect or HRT in the first three-six months of treatment, but should be reported at the three month review or promptly if it occurs after the first three-six months. If symptoms are relieved, the method tolerated and no side effects reported, an annual review is advised. Annually, ask about any menopausal symptoms, monitoring cardiovascular risk factors, such as taking blood pressure, general lifestyle advice, check has contraception and discuss any relevant risks. Blood pressure annually is recommended only for cardiovascular risk factor monitoring.
How long to prescribe for?
NICE say that it is the women themselves who will decide, at some stage, if they wish to continue or discontinue taking it.2 There is no upper age or maximum length of time stated in the NICE guidance. Many women continue to take HRT in the long term because of the osteoporosis and cardiovascular disease risk reduction it affords.
Dr Elizabeth Ordway
This article was first published in our sister publication British Journal of Family Medicine