Diagnosis of menopause in women aged over 45 is clinical – there is no need to use a serum follicle stimulating hormone (FSH) test or other tests.
– Consider a serum FSH test to diagnose menopause only in:
– Women aged 40 to 45 years with menopausal symptoms, including a change in their menstrual cycle
– Women aged under 40 years in whom menopause is suspected.
Information and advice
Explain stages of menopause, common symptoms and diagnosis, that lifestyle changes and improvements in general health and wellbeing can help; the benefits and risks of treatments for symptoms; long-term health implications.
Managing short-term menopausal symptoms
For women at natural menopause, offer HRT for vasomotor symptoms after discussing with them the short-term (up to five years) and longer-term health benefits and risks.
– 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.
Explain isoflavones or black cohosh may help but preparations may vary, safety is uncertain and they may interact with other medicines.
For psychological symptoms, offer HRT to alleviate low mood; consider cognitive behavioural therapy (CBT) to alleviate low mood or anxiety – explain there is no clear evidence for SSRIs or SNRIs in low mood in menopausal5 women not diagnosed with depression.
For urogenital atrophy – offer vaginal oestrogen and continue as long as needed; vaginal oestrogen can also be given if HRT is contraindicated, after seeking expert advice.
Women with altered sexual function may be offered testosterone supplementation if HRT alone is not effective.
Long-term benefits and risks of HRT
Explain venous thromboembolism (VTE) risk is increased by HRT, with the risk greater with oral preparations than transdermal patches; consider patches in women at increased risk of VTE – including those with a BMI above 30 kg/m2 – while those at high risk, eg with strong family history or a hereditary thrombophilia, should be referred to a haematologist for assessment first
Explain HRT does not increase the risk of cardiovascular disease when started in women under 60; also presence of CVD risk factors is not a contraindication if they are optimally managed; however oral oestrogen alone associated with small increase in stroke risk – though baseline risk in those under 60 very low
HRT is not associated with any increased risk of type 2 diabetes or blood glucose control
Explain baseline risk of breast cancer** varies, that HRT with oestrogen alone is not associated with any increase in risk of breast cancer, but HRT with oestrogen and progesterone can increase the risk – although this relates to treatment duration and reduces after stopping HRT.
**For women with, or at high risk of, breast cancer – HRT should not be offered routinely, but may in exceptional cases be offered to women with severe symptoms; HRT should be restricted to as short a duration and low a dose as possible in women at familial risk. See NICE guideline CG80 Early and locally advanced breast cancer, Section 1.13; NICE guidelines CG164 Familial breast cancer, section 1.7 .
Diagnosis and management of premature ovarian insufficiency
Diagnose in women aged under 40 years based on:
– Menopausal symptoms, including no or infrequent periods AND
– Elevated FSH levels on two blood samples taken four to six weeks apart.
If in doubt about diagnosis, refer to a specialist.
Offer sex steroid replacement with choice of HRT or combined hormonal contraceptive, unless contraindicated, eg if woman has hormone-sensitive cancer.
– Baseline risk of diseases such as breast cancer and CVD very low in women under 40
– HRT may be beneficial for blood pressure when compared with contraception
– Both HRT and combined oral contraceptives offer bone protection.