Managing the Menopause

The menopause is a challenging time for patients and for healthcare professionals, who for years have been conditioned to advise against using hormone replacement therapy. But the latest NICE guidance encourages us to have an open mind and to take a more balanced approach to evaluating the risks and benefits

You’ve just asked your patient when her last period was during an appointment for cervical screening. ‘Well, now you mention it, they are a bit all over the place. I used to be as regular as clockwork but I think my last one may have been 3, maybe 4 months ago. And so heavy. Before you ask there’s no way I could be pregnant. In truth my libido has all but disappeared. Sex is just too uncomfortable and sore. And then there’s the hot flushes which are waking me up several times a night and my nightclothes seem to stick to every part of my body. I usually have to get up to the toilet, too. Spending half the night awake makes me so grumpy and irritable at work and I can’t seem to concentrate on anything. Then there’s the spiralling arguments I’ve been having with my 15-year-old daughter. No-one else’s mother is so stupid, apparently. Sometimes I just burst into tears with the utter frustration of it all. It’s just not like me. I guess I just have to put up with it.’

The menopause. Symptoms that are embarrassing and debilitating. Symptoms that may have a detrimental affect on relationships. Consequences potentially leading to significant health problems in later life. How many women suffer in silence, unaware that the myriad of symptoms they are suffering are part of the menopause? Equally, are we failing to meet the needs of these women because of our own uncertainty over conflicting advice about hormone replacement therapy (HRT) and other therapies? So, the publication in November 2015 of the NICE guideline in the diagnosis and management of the menopause, with its common sense approach based on expert review of all the available evidence, together with an emphasis on individualised care, has come as a welcome relief to health professionals.¹

INDIVIDUALISED CARE

We live longer. Much longer. In 1850, the average age of the menopause was 45 years, as was a woman’s life expectancy.² Today, with women living well into their 80s, and menopause occurring on average around 51 years, many women spend a third of their life postmenopausally.^1,3 Transition through the menopause is by no means ‘one size fits all’ and the variety and intensity of symptoms differs from woman to woman. For the majority of women the menopause will be a natural event, with gradual ovarian failure resulting in a fall in oestrogen and progesterone. For some women it will be induced as a result of medical or surgical intervention, or occur as a result of premature ovarian insufficiency (POI) before the age of 40 (Box 1). In primary care, we have the opportunity to empower women to make their own decisions about managing their menopause both in the short and long term. Having an awareness of symptoms, a knowledge of expectations, the value of making life-style improvements and understanding the risks and benefits of all treatment options are fundamental to this process. Accessing specialist advice may also be an important aspect of their care. The focus of the NICE guidance is around an individualised approach to help women achieve this goal.

DIAGNOSIS

For the majority of women, the presentation of symptoms is sufficient to form a diagnosis (Box 2). Unnecessary laboratory testing is wasteful to the NHS and is of little value due to the daily variation in Follicle Stimulating Hormone (FSH). NICE makes it very clear that blood tests are not required to diagnose the perimenopause or menopause in healthy women over 45 years. Equally, they should not be used in women taking combined hormonal contraception or high dose progestogen. The guidance recommends diagnosis should be determined on the following criteria:

• Perimenopause: vasomotor symptoms and irregular periods
• Menopause: no period for at least 12 months and not using hormonal contraception
• For women without a uterus: vasomotor symptoms only

However, FSH testing may be considered in the following circumstances:

• In women aged 40-45 years with menopausal symptoms
• In women aged under 40 years in whom premature ovarian insufficiency is suspected

It is also worth noting guidance from the Faculty of Sexual and Reproductive Healthcare (FSRH), which warns that an elevated FSH level indicates a degree of ovarian failure but it is not predictive of when final sterility has been reached.⁴

MANAGEMENT OF SHORT-TERM SYMPTOMS

Early menopausal symptoms may last from 2-5 years. Introducing and adapting treatment will be dependent on changing symptoms and personal preference.

Lifestyle

Although NICE advocates lifestyle changes and interventions to improve general wellbeing as important part of menopausal management, the guidance doesn’t offer specific recommendations. Discussing factors such as weight, diet, exercise and smoking is clearly common sense. Eating a healthy diet, including calcium-rich foods, and taking regular weight-bearing exercise can help women to cope with their menopausal symptoms as well protecting against cardiovascular disease and osteoporosis. Reducing triggers such as spicy food, hot drinks, caffeine and alcohol can improve the frequency and intensity of hot flushes and night sweats. Additionally, obesity and smoking can increase vasomotor symptoms.⁵ On a daily basis, practical measures such as layering cotton clothing, the use of cooling scarves, cool pillows and fans at night can help to manage vasomotor symptoms.⁶

Hormone Replacement Therapy

Confident to prescribe, confident to take

One of the most significant aspects of the 2015 NICE guideline is its clarity on offering HRT. It gives clear evidence-based guidance on the long-term benefits of HRT with an evaluation of its risks. This instills confidence in its use in the prescriber and enables practitioners and patients alike to make informed choices. Table 1 gives details of the preparations currently available.

HRT is the most effective treatment for relieving vasomotor symptoms, as well as providing benefits to low mood and anxiety, which affect a woman’s quality of life. NICE recommends that all women should have the opportunity to discuss its short term use (up to 5 years) in relation to the risks and benefits. The following preparations are recommended by NICE (excluding premature ovarian insufficiency):

• Oestrogen and progestogen to women with a uterus
• Oestrogen alone to women without a uterus
• SSRIs, SNRIs and clonidine are not recommended as first line treatment
• Some evidence exists for the use of isoflavones or black cohosh (with caution)

NICE advises on HRT starting and stopping regimes, recommendations for review (3 months then annually as appropriate) and suggests when referral would be warranted. Maintaining screening through the national screening programmes should also be discussed. Specific guidance is also given on the management of premature ovarian insufficiency.

HRT RISKS AND BENEFITS

The NICE guideline clearly presents the long-term benefits and risks of HRT particularly in relation to venous thrombosis (VTE), cardiovascular disease, type 2 diabetes, breast cancer, osteoporosis and dementia which will help the decision-making process for both practitioner and patient. NICE provides statistical evidence which can be used effectively during consultations. In summary:

Venous Thrombosis risks (VTE)

• Oral HRT: increased risk of VTE compared with baseline population risk
• Oral HRT: increased risk of VTE compared with transdermal preparations
• Transdermal HRT (at standard dose): no greater risk than baseline population risk

Consider transdermal HRT for women with a BMI of 30kg/m2 and above

• Refer women with high risk VTE (including family history, hereditary thrombophilia)

Cardiovascular disease (CVD)

• HRT, started in women under 60 years, does not increase CVD
• HRT does not affect the risk of dying from CVD
• Well controlled CVD risk factors are not a contraindication to HRT
• HRT with oestrogen alone is associated with no risk or reduced risk of coronary heart disease (CHD)
• HRT with oestrogen and progestogen is associated with little, or no, increased risk of CHD
• Oral HRT (not transdermal) is associated with a small increase in the risk of stroke (baseline risk of stroke under 60 years is very low)

Type 2 diabetes

• HRT is not associated with an increased risk of developing type 2 diabetes
• HRT is not associated with an adverse effect on blood glucose control
• Specialist advice may be needed when considering type 2 diabetes and co-morbidities

Breast cancer

• The baseline risk of breast cancer for perimenopausal women varies according to underlying risk factors
• 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
• Any increase in the risk of breast cancer is related to treatment duration and reduces after stopping HRT

Osteoporosis

• The baseline population risk of fragility fracture is low and varies from woman to woman
• The risk of fragility fracture is decreased while taking HRT
• This benefit is maintained during treatment but decreases once stopped
• Such benefit may continue for longer in women who take HRT for longer

Dementia

• The likelihood of increased risk of dementia with HRT use is unknown

VAGINAL AND UROGENITAL PROBLEMS

Vaginal symptoms are often underreported but have a significant impact on a woman’s physical and psychological wellbeing. Oestrogen deficiency affects the structure of the vagina, its elasticity, and reduces sensitivity, lubrication and sexual response. Vaginal dryness, irritation, discharge and bleeding are not uncommon. Pelvic floor atrophy can cause bulging vaginal walls and cervical descent. Furthermore, the urinary tract is also affected leading to dysuria, frequency, urgency and nocturia, and is often mistreated as cystitis. It is no wonder that women suffer pain during vaginal sex, which can lead to avoidance, and result in relationship issues.

NICE recommends offering vaginal oestrogen to women with symptoms of urogenital atrophy, whether or not they are already on systemic HRT. Although side-effects of vaginal oestrogen are rare, women should be warned about the slight increase of vaginal discharge. Even with women who have contraindications for systemic HRT, vaginal oestrogen may still be considered. Vaginal moisturisers and lubricants can also be of benefit either on their own or together with topical oestrogen. Women do, however, need to be advised that symptoms usually return when treatment is stopped and essentially, to report any unscheduled vaginal bleeding. Women may find talking about this aspect of their menopause difficult and as practice nurses we have a responsibility to address this significant issue.

Sexual Health

The sexual health of women, together with contraceptive requirements, are of paramount importance during this challenging time in a woman’s life. Sexuality and psychological wellbeing are interwoven and the menopause can throw up a variety of physical, emotional and external factors that can affect a woman’s sexual health. We need to be able to offer women support, advice and treatment strategies to deal with its consequences. Along with HRT, consideration may be given to testosterone for low libido, although its use in women is currently unlicensed in the UK and hence specialist advice may be required. NICE also highlights the changes in contraceptive requirements in the menopause and the FSRH guidance on contraception for women over 40 years is a useful tool.⁴

Psychological

The effects of the transition through the menopause should not be underestimated. From a treatment perspective, the NICE guidance highlights the benefits of Cognitive Behavioural Therapy (CBT) in alleviating low mood and anxiety, as well as HRT. Referral to mental wellbeing services and therapies may be also appropriate. The guidance suggests that the use of selective serotonin reuptake inhibitors (SSRIs) or serotonin-noradrenaline reuptake inhibitors (SNRIs) has not been shown to improve mood for women going through the menopause who have not been diagnosed with depression.

In addition to the physical and psychological effects that the menopause brings, women may also be coping with external life changes and stresses such as looking after ageing parents, teenage children or children leaving home, separation and divorce, work and financial pressures.

COMPLEMENTARY THERAPIES AND UNREGULATED PREPARATIONS

There is an abundance of alternative and complementary therapies that may be beneficial to women suffering menopausal symptoms (Box 3). Many of these claim to alleviate symptoms. They include herbal medicines, techniques such as acupuncture, reflexology and homeopathy, and complementary therapies such as aromatherapy. It is vital that women know which therapies may be helpful but NICE advocates caution. Non-prescribed treatments – including black cohosh, agnus castus and magnetism – may not always be regulated and will not necessarily have the evidence to support their use. However, phytoestrogens (plant substances that have similar effects to oestrogen) found in soybeans, red clover, legumes and nuts and oilseeds may be helpful. Women in Japan, whose diets are high in isoflavones – a type of phytoestrogen – have been shown to experience fewer vasomotor symptoms.⁷ NICE’s view is that women should be advised that the efficacy and safety of alternatives are not always known and that quality, purity and constituents of products cannot be vouched for. NICE specifically advises caution regarding St John’s wort, with its potential for serious drug interactions, in relation to women with a high breast cancer risk.

THE CHALLENGE AHEAD

NICE has highlighted three specific ‘challenges’ for practice. We need to consider how they impact on our practice and what improvements we, as practice nurses, can make.

Challenge 1. Stopping the use of FSH tests to diagnose menopause in women aged over 45 years

• Are unnecessary FSH tests being carried out in your practice?
• Do staff in your practice need to be made aware of the guidance on diagnosing the menopause and the evidence behind it?
• Could you undertake an audit to determine current practice with regards to FSH testing?

Challenge 2. Communicating the long-term benefits and risks of hormone replacement therapy

• Do you have the knowledge and confidence to help women make an informed choice about treatments for menopausal symptoms?
• Can you identify a training need within your team?
• How can you help to implement the NICE guidance within your practice?
• What supportive documentation would you give to women regarding treatments?

Challenge 3. Providing enough specialist services

This challenge is predominantly for commissioners to look at service provision and local services, but

• Are you aware of the specialist menopausal services in your area?
• Can you access a variety of services such as secondary care, community menopause clinics or GP specialist clinics?

CONCLUSION

The challenges are clear, but how confident are we at managing the menopause in our own practice? The scenario at the beginning of the article or similar cases must be familiar to most of us. But do we have the knowledge and resources to guide women? Maybe we need to get better about asking our patients about their symptoms. We can’t say we don’t have the opportunity in primary care to address women’s concerns. As practice nurses we need to be at the forefront of updating our own knowledge, examining our practice and addressing any misconceptions about menopausal management in order to deliver individualised care. We now have clear evidence-based guidance to improve women’s health and wellbeing as they transit through the turmoil that to a greater or lesser extent, is the menopause.

REFERENCES

1. National Institute for Health and Care Excellence. Menopause: diagnosis and management. NICE guidelines [NG23]. November 2015. Available at: https://www.nice.org.uk/guidance/ng23/chapter/recommendations

2. NHS Health Education England. e-Learning for Healthcare .e-GP Women’s Health: Care of Women. 3.06a_06 What is the Menopause. Updated 31 October 2014. Available at: http://www.e-lfh.org.uk/home/

3. Office for National Statistics. Statistical bulletin: National Life Tables UK 2012-14. 23 September 2015. Available at:

http://www.ons.gov.uk/ons/rel/lifetables/national-life-tables/2012-2014/stb-life-tables-2012-2014.html?format=print

4. Faculty of Sexual & Reproductive Healthcare. Contraception for women aged over 40 years. Clinical Effectiveness Unit. July 2010. Available at: http://www.fsrh.org/pdfs/ContraceptionOver40July10.pdf

5. Rees S, Stevenson J, Hope S, et al. Management of the menopause (5th Edition) London: Hodder Arnold; 2011

6. NHS Health Education England. e-Learning for Healthcare .e-GP Women’s Health: Care of Women. 3.06a_07 Managing the Menopause. Available at: http://www.e-lfh.org.uk/home/

7. Royal College of Obstetricians & Gynaecologists. Alternatives to HRT for the management of symptoms of the menopause. Scientific Impact Paper No 6. 2010. Available at: https://www.rcog.org.uk/globalassets/documents/guidelines/scientific-impact-papers/sip_6.pdf

8. Mims. Hormone Replacement Therapy. Comparison table containing key information on HRT preparations. February 2016. Available at: http://www.mims.co.uk/hormone-replacement-therapy-hrt/womens-health/article/882443

9. Women’s Health Concern. Factsheet: Complementary & alternative therapies and non hormonal prescribed treatments. December 2015. Available at: https://www.womens-health-concern.org/_wpress/wp-content/uploads/2015/12/WHC-FACTSHEET-Complementary-And-Alternative-Therapies.pdf