Menopause: diagnosis and management (NICE Guideline)

Summary of NICE guidance on menopause.

 

 

 

 

See box below for diagnosis and management of premature ovarian insufficiency.

DIAGNOSIS

  • Diagnose the following in otherwise healthy women aged >45 years with menopausal symptoms:
    • perimenopause based on vasomotor symptoms and irregular periods
    • menopause in women who have not had a period for ≥12 months and are not using hormonal contraception
    • menopause based on symptoms in women without a uterus.
  • Do not use the following to diagnose perimenopause or menopause in women >45 years:
    • anti-Müllerian hormone
    • inhibin A
    • inhibin B
    • oestradiol
    • antral follicle count
    • ovarian volume.
  • Do not use serum FSH to diagnose menopause in women using combined contraceptives or high-dose progestogen.
  • Consider using serum FSH to diagnose menopause only:
    • in women 40–45 years with menopausal symptoms, including a change in menstrual cycle
    • in women <40 years in whom menopause is suspected

INFORMATION AND ADVICE

  • Give information covering:
    • stages of menopause
    • common symptoms and diagnosis (vasomotor, musculoskeletal, affective, urogenital and sexual)
    • lifestyle changes and interventions to help general health and wellbeing
    • benefits and risks of treatments (hormonal, non-hormonal and non-pharmaceutical)
    • long-term health implications 
    • need for contraception.

MANAGING SHORT-TERM SYMPTOMS

Vasomotor symptoms
  • Offer HRT as follows:
    • oestrogen and progestogen to women with a uterus
    • oestrogen alone to women without a uterus.
  • Do not routinely offer SSRIs, SNRIs or clonidine as first-line treatment for vasomotor symptoms alone.
Psychological symptoms
  • Consider HRT to alleviate low mood.
  • Consider CBT to alleviate low mood or anxiety.

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

Low sexual desire

  • Consider testosterone supplementation if HRT alone is not effective.
Urogenital atrophy
  • Offer vaginal oestrogen (including to women on systemic HRT) and continue treatment for as long as needed to relieve symptoms; if not effective, consider increasing dose with specialist advice.
  • If systemic HRT is contraindicated, consider vaginal oestrogen after seeking specialist advice.
  • Explain to women that:
    • symptoms often come back when treatment is stopped
    • adverse effects from vaginal oestrogen are very rare
    • they should report unscheduled vaginal bleeding.
  • Advise women with vaginal dryness that moisturisers and lubricants can be used alone or with vaginal oestrogen.
  • Do not offer routine monitoring of endometrial thickness during treatment for urogenital atrophy.

REVIEW AND REFERRAL

  • Emphasise the need to keep up to date with national health screening.
  • Review treatment at 3 months and annually thereafter unless earlier review is indicated.
  • Refer to a specialist if symptoms persist or there are ongoing troublesome side-effects.
  • Consider referral to a specialist if there are contraindications to HRT or uncertainty about the most suitable treatment.

STARTING AND STOPPING HRT

  • Explain to women with a uterus that unscheduled vaginal bleeding is a common side-effect of HRT within the first 3 months of treatment but should be reported thereafter.
  • Explain to women that:
    • gradually reducing HRT may limit recurrence of symptoms in the short term
    • gradually reducing or immediately stopping HRT makes no difference to symptoms in the longer term.

LONG-TERM BENEFITS AND RISKS OF HRT

Venous thromboembolism

  • Explain to women that:
    • the risk of VTE is increased by oral HRT compared with baseline population risk
    • the risk of VTE associated with transdermal HRT at standard therapeutic doses is no greater than baseline population risk.
  • Consider transdermal rather than oral HRT for women at increased risk of VTE (eg, those with a BMI >30kg/m2).
  • Consider referring women at high risk of VTE to a haematologist before considering HRT.

Cardiovascular disease

  • Explain to women that HRT:
    • does not increase cardiovascular disease risk when started <60 years
    • does not affect the risk of dying from cardiovascular disease.
  • Be aware that cardiovascular risk factors are not a contraindication to HRT if they are optimally managed.
  • Explain to women that:
    • HRT with oestrogen alone is associated with no, or reduced, risk of coronary heart disease
    • HRT with oestrogen and progestogen is associated with little or no increase in the risk of coronary heart disease (an estimated 5 additional cases per 1000 current users over 7.5 years vs a baseline population risk of 26.3 cases per 1000 women over 7.5 years).
    • oral (but not transdermal) oestrogen is associated with a small increase in the risk of stroke (up to an estimated 3 additional strokes per 1000 current users over 7.5 years for oestrogen alone, and up to an estimated 6 additional strokes for oestrogen plus progestogen, vs a baseline population risk of 11.3 strokes per 1000 women over 7.5 years).
    • the baseline population risk of stroke in women <60 years is very low.

Type II diabetes

  • Explain to women that HRT (either oral or transdermal) is not associated with an increased risk of developing type II diabetes or an adverse effect on blood glucose control in women with type II diabetes.
  • Take comorbidities into account when considering HRT in women with type II diabetes and seek specialist advice if needed.

Breast cancer

  • Explain to women around the age of natural menopause that:
    • HRT with oestrogen alone is associated with little or no change in the risk of breast cancer
    • HRT with oestrogen and progestogen can be associated with an increase in the risk of breast cancer (up to an estimated 17 additional cases per 1000 current users over 7.5 years vs a baseline population risk of 22.48 per 1000 women over 7.5 years)
    • any increase in the risk of breast cancer is related to treatment duration and reduces after stopping HRT.

Osteoporosis

  • Explain to women that:
    • the baseline population risk of fragility fracture for women around menopausal age in the UK is low
    • the risk of fragility fracture is decreased while taking HRT (up to an estimated 23 fewer cases per 1000 current users vs a baseline population risk of 69 per 1000 women over 3.43 years) and that this benefit decreases once treatment stops but may continue for longer in women who take HRT for longer.

Other issues

  • Explain to women that:
    • the effect of HRT on the risk of dementia is unknown.
    • there is limited evidence that HRT may improve muscle mass and strength.

PREMATURE OVARIAN INSUFFICIENCY

Diagnosis
  • Diagnose premature ovarian insufficiency in women <40 years based on:
    • menopausal symptoms, including no or infrequent periods (taking into account whether the woman has a uterus) and
    • elevated FSH levels on two blood samples taken 4–6 weeks apart.
  • Do not diagnose premature ovarian insufficiency on the basis of a single blood test.
  • Do not routinely use anti-Müllerian hormone testing to diagnose premature ovarian insufficiency.
  • If there is doubt about the diagnosis of premature ovarian insufficiency, refer to a specialist.

Management

  • Offer a choice of HRT or a combined hormonal contraceptive.
  • Explain to women:
    • the importance of starting hormonal treatment and continuing until at least the age of natural menopause
    • that the baseline population risk of diseases such as breast cancer and cardiovascular disease increases with age and is very low in women <40 years
    • that HRT may have a beneficial effect on blood pressure compared with a combined oral contraceptive that both HRT and combined oral contraceptives offer bone protection
    • that HRT is not a contraceptive.
  • Give women with contraindications to hormonal treatments advice, including on bone and cardiovascular health, and symptom management.
  • Consider referral to help manage physical and psychosocial health.

Adapted from: NICE Clinical Guideline NG23 (November 2015) - Menopause: diagnosis and management.


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