The following is based on NICE Guideline NG23 (November 2015) which has been summarised by Dr Rachel Brown, GPSI in gynaecology.
Useful Tools for clinicians can also be found on the British Menopause Society website.
Menopause occurs on average at 51y, but early onset (before 40 y) happens in approximately 1 %. Many women and GPs do not recognise some menopausal symptoms (eg mood changes ,memory and concentration loss ,vaginal dryness and dysuria ,lack of interest in sex, headaches, joint and muscle stiffness). Some clinicians are reluctant to prescribe HRT due to misunderstood safety concerns and a lack of expertise in prescribing.
Women over 45 years presenting with menopausal symptoms should be diagnosed with perimenopause or menopause based on their symptoms alone, without confirmatory laboratory tests. Diagnosis of peri-menopause is based on vasomotor symptoms and irregular periods. Menopause is defined as those women who have not had a period for 12 months and are not using hormonal contraception or menopause based on symptoms in women without a uterus. Checking FSH levels in these groups is not recommended.
Do not use a serum follicle-stimulating hormone (FSH) test to diagnose menopause in women using combined oestrogen and progestogen contraception or high-dose progestogen.
Consider using a FSH test to diagnose menopause only:
in women aged 40 to 45 years with menopausal symptoms, including a change in their menstrual cycle
in women aged under 40 years in whom menopause is suspected.
Hormone Replacement Therapy
Risk can be presented as either relative or absolute; relative risk often gives rise to greater anxiety, especially with breast cancer and VTE. The use of risk charts to demonstrate absolute risk can be helpful.eg British Menopause Society website or NICE NG23.
Unlicensed bioidentical hormone therapies (“natural hormone therapies”) are perceived by patients to be lower risk and are not available on the NHS. Bioidentical therapies claim to be safe because they are of natural plant origin but there is no evidence to support these claims.
Bioidentical HRT has been available on the NHS for some years. Unlike many COPs which use synthetic ethinyl oestradiol, the 17-β oestradiol found in most HRT options is bioidentical to ovarian oestrogen, and can be administered as a patch, gel, tablet, or implant. The only exception is the equine-derived conjugated oestrogens found in some therapies. Note that these are not contraceptive.
Route of administration
Oral drugs are most commonly prescribed. NICE NG23 recommends that women with significant CVD risk should use transdermal oestrogen. The transdermal route also allows for a more natural delivery, using lower doses while maintaining efficacy through greater dosing flexibility. Oral micronised natural progesterone also has favourable safety data, which showed no significant increase in breast-cancer risk compared with non-users.
Tailor the dose
Often the lowest available dose is prescribed, at the expense of symptom relief or long-term health benefits. The goal of therapy is to establish a dose that effectively treats symptoms, and also offers bone protection. Standard doses, as recommended in the British National Formulary, are suitable for women around the age of the menopause. Hence women under 40 years of age often need higher doses to achieve symptom relief or to ensure adequate bone protection. This higher dosage needs to be maintained until the average age of the menopause, 51 years, and brings no known associated increase in risks. Conversely, symptomatic women over 60 years initiating HRT may need to be started on suboptimal transdermal doses due to the higher VTE risk observed in the first year. The dose may be slowly increased over time until therapeutic symptom relief is achieved.
Vaginal oestrogen used either concurrently or on its own, can effectively alleviate many vaginal atrophy symptoms. Vaginal oestradiol tablets or cream may be considered for long-term use due to low systemic absorption; there is little concern regarding endometrial stimulation. Topical oestrogens are very safe and can be used by most women with vaginal symptoms alone and adverse effects are very rare. The only absolute contraindications are active breast cancer and undiagnosed vaginal bleeding. The systemic absorption of oestrogen from recommended doses of topical oestrogens over 1 year contains the same dose as taking a single tablet of oral HRT. It is unlikely to affect the endometrium and additional progestogens are not necessary. Maximum benefit with these products is usually achieved after around 1–3 months but it can take up to 1 year in some women. Treatment with topical oestrogen should be continued for as long as needed to relieve symptoms as symptoms will often return after treatment is stopped. Systemic oestrogen restores normal vaginal pH levels, thickens and revascularises the epithelium, and also increases vaginal lubrication;however, around 10–25% of women who take systemic HRT will have urogenital symptoms that persist. These women can safely be given vaginal local oestrogen in addition to taking HRT.
Progestogen for endometrial protection
Progestogens should always be prescribed for uterine protection against endometrial hyperplasia and risk of malignancy. These must always be combined with oestrogen, either sequentially(for 12 days of the month) for the perimenopause or continuously after 12 months of amenorrhoea. If there is a history of progestogenic side-effects reported with prior use of the COCP or PMS then natural progesterone can be better tolerated. Androgenic progestogens (e.g. norethisterone) are more likely to cause PMS-type side-effects. With PMS-type side-effects, a low-dose regimen may be more suitable.
Depression or anxiety associated with the menopause
Depression and anxiety are common presentations of the perimenopause and also later on in the menopause. Severe menopausal depression may also follow a history of premenstrual syndrome (PMS) and postnatal depression. The new evidence supporting the use of HRT, especially in the perimenopause, and the fact that the risks associated with HRT do not generally apply to women under the age of 50 years should encourage earlier use of HRT in this group.
Contraception and the Menopause
Many perimenopausal women also suffer with menorrhagia, and may still require contraception. The IUS is a good option and being low-dose local progestogen it may also benefit women with PMS.
Although not licensed within HRT use, it is possible to use the POP in conjunction with a combined HRT. The POP cannot be used without HRT progestogen as it does not provide adequate endometrial protection. Contraceptives containing endogenous oestradiol, rather than ethinyl oestradiol, may be suitable for symptomatic perimenopausal women requiring contraception.