Cognitive behaviour therapy (CBT) should be offered as a treatment option for menopause symptoms, NICE has recommended in updated draft guidance.
Evidence has shown that face-to-face, online, self-help and group CBT sessions can help reduce symptoms including hot flushes and night sweats, depressive symptoms and problems sleeping, the recommendations out for consultation advise.
The draft guidance on menopause in women, trans men and non-binary people registered female at birth last updated in 2015 also includes new information on individualised risks of HRT that GPs should discuss with patients.
Duration of treatment – which should be the lowest effective dose – should be discussed at the outset as well as the risks of prolonged use and the possibility of restarting HRT if symptoms return when its stopped, NICE said.
Two new detailed tables on the risks of combined and oestrogen-only HRT on health outcomes and how it relates to age and personalised circumstances have been developed by NICE to help patients make informed decisions about starting and stopping treatment with their doctor.
And while it is important that individuals are made aware of some increased risks associated with HRT, they should also be made aware that it is unlikely to increase or decrease their overall life expectancy, NICE said.
But more research is needed on the impact of HRT on health outcomes in those who have an early menopause, the guidelines said.
New recommendations also include details on managing genitourinary symptoms such as dryness, painful sex and vaginal discomfort or irritation with a choice of vaginal oestrogen such as cream, gel, tablet, pessary or ring and treatment to continue as long as it’s needed to relieve symptoms and the dose increased if necessary.
Patients should be urged to report any vaginal bleeding to their GP, NICE said.
The recommendations also ask healthcare professionals to be aware that people from ethnic minority backgrounds may experience menopause at a younger age compared with people from White backgrounds.
For people with a history of coronary heart disease or stroke, combined or oestrogen-only HRT should only be, discussed with and, if appropriate, initiated by a healthcare professional with expertise in menopause, NICE added.
Jonathan Benger, chief medical officer at NICE said the impact of menopause symptoms on quality of life could vary hugely.
‘It is important that healthcare practitioners take a personalised approach when discussing treatments, using evidence-based information tailored to individuals’ circumstances.
‘Today’s draft guideline recommends more treatment options for managing menopause symptoms as well as enabling a wider understanding of the risks and benefits of HRT so anyone going through menopause can choose the best care to suit them.’
Professor Gillian Baird, menopause guideline committee chair said the update included important evidence based-information to help both women and healthcare practitioners during their discussions about how best to manage symptoms.
‘This gives women more choice and enables them to make informed decisions for their personal circumstances.”
Minister for the Women’s Health Strategy, Maria Caulfield said: ‘The menopause is a key pillar of our Women’s Health Strategy – and from our work in this area we have already seen over 400,000 women benefit from cheaper HRT prescriptions and receive better access to specialised care through the roll-out of women’s health hubs.
‘NICE’s updated guidance shows why research is so important in women’s health – so we can make sure women are offered the support that is right for them.’
RCGP chair Professor Kamila Hawthorne said: ‘Menopause can be a very difficult time for women, and the impact on their health and wellbeing can be significant. This is something GPs take extremely seriously and will always consider a patient’s individual health factors and circumstances, along with clinical guidelines, when developing a treatment plan, in conversation with them.
‘It’s always helpful for GPs to have access to a range of potential treatments and interventions to help women manage menopause. HRT has been shown to be safe and effective for some women, but it isn’t suitable for everyone, and it’s good to see NICE exploring other options, that evidence suggests may be of benefit, such as CBT. It will be essential that GPs have timely and sufficient access to any interventions that are eventually approved by NICE, so that patients can benefit from them.
‘The RCGP will be considering the draft guideline and responding to NICE’s consultation in due course.’
GPs could be mandated to screen women for menopause within the NHS health check as well as via QOF, a Government minister recently revealed.
In a parliamentary debate last month, health minister Maria Caulfield said it is ‘crucial’ that menopause is incorporated into the health check.
The Department of Health and Social Care has asked the NHS health check advisory group to ‘review the case’ for including the menopause, she said.
And she added that the upcoming QOF consultation will engage GPs on whether the menopause should be included within the quality framework.
Key updated recommendations
1.4.1 When discussing treatment options with people who have troublesome menopause symptoms, explain the risks and benefits associated with those treatments. 
1.4.2 When discussing hormone replacement therapy (HRT) as a possible treatment for troublesome menopause symptoms, talk about the benefits and risks associated with:
• combined versus oestrogen-only HRT transdermal versus oral HRT
• types of oestrogen and progestogen
• sequential versus continuous HRT
• dosage and duration. 
1.4.3 If a person chooses to take HRT:
• Discuss the duration of treatment at the outset, taking account of the benefits and risks.
• Discuss the likelihood of symptoms returning when HRT is stopped, the possibility of restarting treatment if necessary, and the risks associated with prolonged use. 
1.4.4 When discussing CBT as a possible treatment for troublesome menopause symptoms, discuss available options, for example:
• individual face-to-face
• individual virtual
• group sessions
• online. 
1.4.13 For people with a history of coronary heart disease or stroke, ensure that combined or oestrogen-only HRT is discussed with and, if appropriate, initiated by a healthcare professional with expertise in menopause. 
1.4.16 Consider CBT for troublesome vasomotor symptoms associated with the menopause. 
For those with no history of breast cancer
1.4.19 Offer a choice of vaginal oestrogen preparations (oestrogen cream, gel, tablet, pessary or ring) to people with troublesome genitourinary menopause symptoms (including those on systemic HRT) and continue treatment for as long as needed to relieve symptoms. 
1.4.20 When discussing the option of vaginal oestrogen with a person with troublesome genitourinary menopause symptoms, explain that:
• serious adverse effects are very rare
• symptoms often return when treatment is stopped
• some oestrogen is absorbed but, compared with systemic HRT, the
amount is small
• if they choose this option, they should report vaginal bleeding to their
1.4.21 If vaginal oestrogen does not relieve genitourinary symptoms, consider increasing the dosage, within the standard therapeutic range, after seeking advice from a healthcare professional with expertise in menopause.