Menopause: what the guidelines say

Introduction
What is the menopause?
Symptoms
NICE guidance
BMS survey
NICE quality standards
Conclusion
References

 

Introduction

A survey by the British Menopause Society (BMS) last year found that only half of women surveyed in Great Britain,who are currently experiencing or who have experienced menopausal symptoms within the past 10 years, consult a healthcare professional for any of their menopause symptoms.¹

This was despite women surveyed reporting on average of seven different symptoms and 42% saying their symptoms were worse or much worse than expected.

The BMS hoped that the 2015 published NICE guidance on the diagnosis and management of the menopause² would encourage more women to seek help and access to safe and effective treatments, but they said worryingly only 3% of those surveyed had heard of the guideline.¹

This month NICE has attempted to further address this with the publication of a quality standard for menopause with five quality statements and measures.³

 

What is the menopause?

Menopause is a gradual process that occurs on average for women in the UK at 51 years. An estimated 1.5 million women—around 80% of those going through menopause—experience common symptoms such as hot flushes and night sweats. Other symptoms include mood changes, joint and muscle pain and headaches.

Together these symptoms can severely affect a woman’s life. Yet the effects of menopause are often not fully understood. As a result, women do not always get the help they need from their GP, nurse, practice or hospital specialist to manage their symptoms effectively.

NICE in 2015 provided recommendations on the support, information and treatments available for menopausal symptoms. The guideline covers diagnosis, the drug and non-drug treatments that can help with symptoms, and offers clarity on the risks and benefits of HRT.²

 

Symptoms

Hot flushes are the most common symptom of the menopause, occurring in three in every four menopausal women.⁴ Other common symptoms include night sweats, sleeplessness, vaginal dryness, irritated skin, more frequent urinary incontinence and urinary tract infections, low mood and a reduced interest in sex. Symptoms vary hugely in duration, severity and what impact they have between women.

Formication can be defined as itchy skin or a crawling feeling as though tiny insects are on the body. This usually occurs early in the menopause or soon after the last period and does eventually disappear on its own.

All the common symptoms of the menopause are associated with a decrease in the body’s production of oestrogen. This can affect many parts of the body, including the brain, causing changes in emotional well-being, and the skin, influencing its elasticity and thickness.

Once the ovaries have ceased their production of oestrogen, other changes take place which may have more of an effect on long-term health. Most commonly these changes affect the strength and density of bones, increasing the risk of osteoporosis.⁴

 

NICE guidance

 

Diagnosis

NICE states that a diagnosis of menopause can be given in the following without laboratory tests in otherwise healthy women aged over 45 years with menopausal symptoms:²

• Perimenopause based on vasomotor symptoms and irregular periods
• Menopause in women who have not had a period for at least 12 months and are not using hormonal contraception
• Menopause based on symptoms in women without a uterus.

It adds that a serum follicle-stimulating hormone (FSH) test should only be considered to diagnose menopause only in women aged 40–45 years with menopausal symptoms, including a change in their menstrual cycle and in women aged under 40 years in whom menopause is suspected.

 

Treatment

According to NICE, HRT is a treatment option for menopausal symptoms, yet over the last decade confusion over its safety has led to a decline in its use and variation in practice. It says it is effective for treating several menopausal symptoms and recommends offering HRT for hot flushes and night sweats after discussing the risks and benefits.

HRT should also be considered to alleviate low mood that arises as a result of menopause. Cognitive behavioural therapy should also be considered for this purpose.

The guidance also includes a number of tables that can be used to explain and confirm that HRT does not increase cardiovascular disease when started in women aged under 60 years, and that it does not affect the risk of dying from cardiovascular disease.²

In addition, it says HRT is not associated with an increased risk of developing type 2 diabetes. Furthermore, oestrogen-only HRT has little or no increase in the risk of breast cancer. HRT with oestrogen and progestogen can be associated with an increase in the risk of breast cancer, but any increase risk reduces after stopping HRT.

Other treatment options NICE recommends include offering vaginal oestrogen to women with urogenital atrophy. Moisturisers and lubricants can also be used alone or in addition to vaginal oestrogen for vaginal dryness.

 

Providing information and advice

The guidance is underpinned by recommendations that call for women to have the right to be involved in discussions and make informed decisions about their care. It recommended that healthcare professionals should give information to menopausal women and their family members or carers. This should include:

• An explanation of the stages of menopause
• Common symptoms
• Lifestyle changes that can help their general health and wellbeing
• Benefits of and risks of treatment for menopausal symptoms
• The long-term health implications of menopause.

Healthcare professionals should also discuss the range of symptoms associated with menopause, and offer information about the types of treatment available.²

 

BMS survey

The British Menopause Society is a specialist society affiliated to the Royal College of Obstetricians and Gynaecologists (RCOG) and the Faculty of Sexual Reproductive Healthcare. It provides education, information and guidance to healthcare professionals specialising in all aspects of post reproductive health. The online survey they conducted last year found that:

• Among those who have not consulted a healthcare professional for their menopause symptoms, more than a third (35%) believe it is something they should have to put up with¹
• The majority of women surveyed experienced hot flushes (79%) or night sweats (70%), but many experienced symptoms they did not expect
• 22% of women surveyed experienced unexpected sleeping problems/insomnia, 20% difficulty with memory/concentration and 18% joint aches
• It is also interesting to note that 35% said they experienced vaginal dryness, with 18% of those experiencing this symptom saying it was unexpected
• The impact of these symptoms has been widespread with half of women surveyed saying their menopause symptoms have affected their home life, their social life (36%), and work life (36%)
• 50% of women surveyed also reported that their sex life was affected, experiencing reduced libido (32%), reduced sex life (22%), painful or uncomfortable sex (16%) and 10% stopped having sex altogether.

 

NICE quality standards

The five quality standards published this month are listed below in Table 1.

TABLE 1 – NICE QUALITY STANDARDS ON MENOPAUSE³

Quality statements

Statement 1: Women over 45 years presenting with menopausal symptoms are diagnosed with perimenopause or menopause based on their symptoms alone, without confirmatory laboratory tests.

Statement 2: Women under 40 years presenting with menopausal symptoms have their levels of follicle-stimulating hormone measured.

Statement 3: Women with premature ovarian insufficiency are offered hormone replacement therapy or a combined hormonal contraceptive.

Statement 4: Women having treatment for menopausal symptoms have a review three months after starting each treatment and then at least annually.

Statement 5: Women who are likely to go through menopause as a result of medical or surgical treatment are given information about menopause and fertility before they have their treatment.

 

Diagnosing perimenopause and menopause

In otherwise healthy women over 45, perimenopause and menopause can be diagnosed based on clinical history alone. In this age group, laboratory tests, particularly FSH, do not help with the diagnosis because hormone levels fluctuate during the perimenopause. Knowing these levels will not change management. Other laboratory tests, for example, blood count or thyroid function tests, may still be needed if non-menopausal causes of symptoms are suspected. Reducing the number of unnecessary tests will reduce stress for women, lead to potential cost savings and empower healthcare professionals to make a clinical diagnosis and provide reassuring support and advice based on their clinical experience.³

 

Diagnosing premature ovarian insufficiency

NICE recommend that women under 40 years presenting with menopausal symptoms have their levels of FSH measured.

 

Managing premature ovarian insufficiency

Women with premature ovarian insufficiency, according to NICE, should be offered HRT or a combined hormonal contraceptive.

 

Reviewing treatments for menopausal symptoms

NICE states that women having treatment for menopausal symptoms need to have a review three months after starting each treatment and then at least annually. This is to ensure that changes to dosage or formulation can be made if there are persistent side effects such as bloating, nausea and breast discomfort. Once treatment is established, further review is needed to assess new or pre-existing health problems, to carry out basic health checks (for example, measuring weight and blood pressure), and to inform and engage women in national screening programmes.

Review should take place at least once a year, but may be needed more often if there are clinical indications for this. For most women, the symptoms of menopause respond well to treatment. However, for some whose symptoms do not improve or side effects are troublesome, review will identify if they need to be referred for help and support from a healthcare professional with specialist training and expertise.³

 

Information for women having treatment likely to cause menopause

According to NICE, women who are likely to go through menopause as a result of medical or surgical treatment should be given information about menopause and fertility before they have their treatment. Awareness of symptoms ensures that women access treatment and services as soon as they need them. This is important because these women are at higher risk of psychological and physical morbidity.

 

Conclusion

The BMS and other women’s health organisations are keen to point out that for all women the menopause is a personal experience, not just a medical condition. Also that the diminishing release of oestrogen from the ovary as women advance into their 40s is often the cause of symptoms that can be distressing and may need medical attention.⁴

Women should be referred to a menopause specialist if there’s no improvement after trying treatments, and a referral considered if a woman has menopausal symptoms, but HRT is contraindicated (for example, in women with hormone-sensitive cancer), or the most suitable option is uncertain.

 

References

1. The British Menopause Society: Data on file. Women’s experience of menopause in Great Britain survey, 2016

2. NICE. https://www.nice.org.uk/guidance/ng23 (accessed 10/02/17)

3. NICE. Menopause quality standard. https://www.nice.org.uk/guidance/qs143 (accessed 10/02/17)

4. https://www.womens-health-concern.org/help-and-advice/factsheets/menopause/ (accessed 10/02/17)