This is a new guideline from Nice on managing the menopause, both in women undergoing premature ovarian failure and in women going through it at a more normal age.
There isn't much earth shattering in this, but they are encouraging us to offer HRT routinely and to avoid doing unnecessary FSH tests. I'll highlight what they say about diagnosis and then some of the points I found new or interesting.
You do not need to do bloods in women over 45 with:
- vasomotor symptoms and irregular periods (perimenopause likely).
- no periods for over 12m if they are not on hormonal contraception (menopause likely).
- symptoms if they do not have a uterus (menopause likely).
When are bloods useful?
- Women under 40 with menopausal symptoms (use a raised FSH on at least 2 readings taken 4 - 6 weeks apart).
- Consider it in women 40 - 45 with symptoms, including a change in their cycle
- Among all the other symptoms, aches and pains are apparently common, which I had forgotten.
Advice to give women
- Among other advice, we should be telling women about all the treatment options, including HRT, non-hormonal treatments and non medication treatments (eg CBT).
- There are some excellent leaflets on patient.co.uk.
Managing menopausal symptoms
- Vasomotor symptoms.
- Offer HRT. There is some evidence that black cohosh or isoflavones or St John's wort can help, but you need to give women all the normal warnings regarding complementary therapies.
- Low mood.
- Consider HRT. Consider CBT. There is no evidence that SSRI or SNRI help if depression has not been diagnosed.
- Low libido.
- If HRT alone is not sufficient, consider adding in testosterone.
- Urogenital atrophy.
- Vaginal oestrogen can be used alongside HRT. Use it for as long as needed to control symptoms. Risks are low. If HRT is contraindicated, seek advice from a specialist before using vaginal oestrogens.
Menopause in women with familial breast cancer
- NICE released guidance previously on this. Basically HRT should be used at the lowest dose, for the shortest time possible. Use oestrogen only HRT if possible.
Women with a history of breast cancer.
- Do not offer HRT, tibolone or progestogens. They do advise that HRT can be considered in exceptional cases, eg where menopausal symptoms are severe.
- Paroxetine and fluoxetine should not be used with tamoxifen.
- Clonidine, venlafaxine and gabapentin can be considered for vasomotor symptoms.
- Isoflavones and black cohosh shouldn't be used.
Risks of HRT
I am just highlighting the bit that was new for me here. Remember the excellent table in the BNF that can be used to help counsel women on the risks. This guideline also has separate tables to look at risks.
Venous thromboembolism: there is no increased risk with transdermal HRT, so consider this route for women at increased risk of VTE or with BMI over 30.
Managing premature ovarian failure
- HRT or the COC can be used.
- HRT may be associated with less effect on BP