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Gold, incentives and meh

Ten tips on managing the menopause

GP Dr Sally Hope offers advice on measuring hormone levels, HRT, herbal remedies and contraception in menopausal women.

GP Dr Sally Hope offers advice on measuring hormone levels, HRT, herbal remedies and contraception in menopausal women.

1 More than 80% of women consulting with menopausal symptoms do not want HRT1,2, but are seeking information and advice, so take advantage of the opportunity.

This enormous workload has not been recognised in the nGMS contract. But the initial consultation is a time when women are open to health promotion advice on diet, exercise, contraception, alcohol consumption, quitting smoking, blood pressure, cholesterol levels, breast awareness and mammography, and cervical smears. For the GP it is an ideal opportunity to tick all the QOF boxes while delivering the information the patient is looking for.

2 There is no point measuring FSH/LH levels in women over 45 as it won't tell you or her anything since levels can fluctuate so wildly – the so-called hormonal chaos.

You can't predict when her periods will stop and it's a waste of NHS resources to try. The only use for FSH/LH levels are in amenorrhoeic women under 45 to see if they have gone though a premature menopause (two FSH results, six weeks apart, of greater than 30IU/l). Women with a premature menopause are advised to take HRT until the age of 50 and then make an informed, evidence-based choice about whether they wish to continue or not.

3 Don't forget contraception in the over-40s, or that amenorrhoea may be due to pregnancy.

There is a very high rate of abortion in the over-40s. Although women are less fertile, they are not deemed infertile until two years after menopause if under 50 years, and one year after menopause if over 50. Some women in this age group may be starting a new relationship after divorce and may not have thought of contraception for years, especially if their ex-husband had a vasectomy. STIs are another possibility. Women over 50 have the fastest rate of increase of STIs in the UK. It's worth discussing safe sex where appropriate.

4 The drug regulator's advice on HRT from 2003 still stands.

The Committee on Safety of Medicines – as it was then called – stated that HRT may be used for severe menopausal symptom relief, if

the woman understands the pros and cons of treatment and HRT is prescribed in the lowest possible dose for the shortest possible time. But it did not define either term. It also stated HRT may not be prescribed as a primary treatment for osteoporosis, because the long-term breast cancer risk is deemed too great3. There was also no distinction made between oestrogen-only HRT, for women with a hysterectomy, and combined HRT – although the breast cancer risks in these two groups are very different and much higher with combined HRT4.

5 Women who decide to come off HRT should be weaned off slowly over six months5.

Halve the dose for two to three months then quarter it for three months and then stop. While on a quarter-dose, women may wish to consider starting a herbal remedy, such as red clover tablets. Patches may be easier for weaning as they can be cut (with clean scissors), which is easier than cutting tiny tablets. Similarly, some women find the gel sachets useful – whatever you choose has to fit in with that woman's daily regime. The oestrogen gels require progestogen in tablet form or the IUS Mirena if the woman has an intact uterus.

6 Natural herbal remedies have become more popular as HRT has fallen out of favour.

But few ‘natural' remedies have been subjected to full randomised controlled trials6,7 and herbal remedies are not subjected to the rigors of a licence. There have been recent reports of hepatotoxicity with Black Kohosh.

7 Women may be taking other herbal remedies in the belief they will improve menopausal symptoms.

There is no good evidence of effectiveness for many herbal remedies in relieving the common symptoms of menopause. Vitamin E, St John's wort and evening primrose oil are all taken by women believing they will help. Red clover does have decent data showing a reduction in hot flushes, but women need to take it for six weeks before it really kicks in. There was a brilliant evidence-based review of herbal medicines for the menopause in a recent Drug and Therapeutics Bulletin7 that my patients found very helpful.

8 The levonorgestrel-releasing IUS Mirena now has a licence for endometrial protection as the progestogenic part of HRT.

It's extremely useful for someone in the perimenopause who still wants effective contraception and a reduction in periods. A small amount of any oestrogen may be added if the hot flushes are a problem.

9 Try low-dose SSRIs.

Fluoxetine 20mg or venlafaxine 37.5mg at night can change the lives of some women who suffer hot flushes but can't or won't take HRT8. Since the cardiac warnings about venlafaxine, it's easier and cheaper to try fluoxetine first-line.

10 Atrophic vaginitis can be a real problem.

Local oestrogen pessaries will help deep dyspareunia. They should be used nightly for two weeks then about two to three times a week. The British Menopause Society reviewed endometrial data and concluded it was safe to continue this regime indefinitely – reflected in a change in the licensing regulations. Any postmenopausal vaginal bleeding must be investigated immediately, as with any woman. Remember this advice does not apply to Premarin cream, which is systemically absorbed and must be used with great caution. Women may not admit to dyspareunia, but may welcome a discussion prompted as a result of an uncomfortable smear. Similarly, opportunistic discussions about pelvic-floor laxity, stress incontinence and pelvic-floor exercises may be appropriate in this consultation and end years of incontinent misery.

Dr Sally Hope is a GP in Woodstock, Oxfordshire, and honorary research fellow at the department of primary healthcare, University of Oxford

Competing interests None declared


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