MENOPAUSE REFERRALS AND ADVICE QUERIES SHOULD BE DIRECTED TO THE MENOPAUSE CLINIC AT CHALMERS VIA SCI GATEWAY.
Menopause and HRT: information to support clinical care.
Index
1. Medical eligibility for HRT
1.1 What common medical conditions contraindicate HRT?
1.2 Can I prescribe HRT for individuals with migraines?
1.3 My patient has a family history of breast cancer-can I prescribe HRT?
2. Deciding when to start HRT
3. Diagnostic blood tests (to support diagnosis and to guide use of contraception)
3.1 Do I need to measure FSH levels?
3.2 If serum FSH testing is indicated, when should the test be done?
4. Choosing type of systemic HRT
4.1 HRT regimen
4.1.1 Should I prescribe estrogen-only or combined estrogen & progestogen HRT?
4.1.2 Should I prescribe sequential combined or continuous combined HRT?
4.1.3 When should I switch from sequential combined to continuous combined HRT?
4.2 Systemic estradiol preparation
4.2.1 Should I prescribe HRT containing oral or transdermal HRTestradiol?
4.2.2 What is the equivalent dose of a estradiol patch/gel/spray compared to oral estradiol?
4.3 Progestogen type
4.3.1 How do I choose which progestogen to use for endometrial protection?
4.3.2 Micronised progesterone (Utrogestan®)
4.3.3 How long can a 52mg LNG-IUD be used for as part of HRT? And what about Kyleena® and Jaydess®?
5. HRT and contraception
5.1 Is HRT contraceptive?
5.2 If someone is amenorrhoeic on progestogen-only contraception (e.g., implant, POP), should I start continuous or sequential combined HRT?
6. Duration of use of systemic HRT
6.1 How long can HRT be used for?
6.2 How should HRT be stopped?
7. HRT troubleshooting
7.1 Are there any supply problems with HRT?
7.2 How do I manage bleeding on HRT?
7.3 What investigation is required if someone has used unopposed estrogen (or suboptimally-opposed estrogen)?
7.3.1 Unopposed or suboptimally opposed estrogen with no bleeding
7.3.2 Unopposed or suboptimally opposed estrogen with bleeding
7.4 How do I manage HRT side effects?
7.5 My patient has inadequate control of symptoms despite licensed doses of systemic estrogen – can I increase the estrogen dose further?
7.5.1 My patient’s private Menopause Care provider is requesting that I prescribe higher estradiol doses than are recommended in Lothian. What should I do?
8. ‘Bioidentical HRT’
9. What non-hormonal options do you recommend for menopausal symptoms?
9.1 Non-hormonal medical management options
9.2 Emerging non-hormonal medical management options
10. Low dose local vaginal estrogen
11. Do you see individuals with premature ovarian insufficiency (POI) at the Menopause Clinic?
Please also see: Testosterone in menopause care – to follow.
1 Medical eligibility for HRT
1.1 What common medical conditions contraindicate HRT?
There are few absolute contraindications to HRT use. HRT is, however, generally avoided after (any) breast cancer and after estrogen-sensitive gynaecological cancers (e.g. endometrial cancers, many ovarian cancers). We would also advise discussion with the Menopause Clinic if HRT is to be considered for individuals who have a thrombophilia and/or personal history of VTE, or who have had an MI or thrombotic CVA.
1.2 Can I prescribe HRT for individuals with migraines?
Yes. Migraine (with or without aura) does not contraindicate use of HRT but may affect choice of HRT preparation. Migraine (particularly migraine with aura) is a risk factor for ischaemic stroke. HRT containing transdermal estradiol is associated with lower thrombotic risk than HRT containing oral estradiol. So, for people with migraine (especially migraine with aura), transdermal estradiol is preferable to oral estradiol to minimise associated thrombotic risk.
As changes in hormone levels may trigger migraine, the 52mg LNG-IUD, which avoids the fluctuating progestogen levels associated with sequential HRT, may be a good option for the progestogen component of HRT.
1.3 My patient has a family history of breast cancer – can I prescribe HRT?
Family history of breast cancer (unlike personal history of breast cancer) is not a contraindication to HRT. Using combined HRT does, however, increase risk of breast cancer and this may be additional to inherited increased risk. Women who already have elevated breast cancer risk because of family history or because they carry a BRCA or other relevant gene mutation should take this into consideration when deciding whether or not to take HRT for menopausal symptoms.
We cannot, unfortunately, quantify HRT- associated breast cancer risk for any individual based on their family history or gene mutation. For context, lifestyle factors such as alcohol intake and obesity increase breast cancer risk to a similar or greater extent than HRT: this infographic on breast cancer risk from the British Menopause Society may be helpful when discussing risk.
When considering HRT formulation, people with a family history of breast cancer might choose to use HRT that contains micronised progesterone or dydrogesterone as the progestogen component. These preparations appear to confer a smaller increase in breast cancer risk (in the general population) than combined HRT containing some other synthetic progestogens (including the 52mg LNG-IUD).
People for whom estrogen replacement without a progestogen is appropriate can be advised that there appears to be a smaller effect on breast cancer risk than with combined HRT.
2. Deciding when to start HRT
When should I offer HRT?
Offer systemic HRT to medically eligible individuals with e.g. vasomotor, mood, cognitive and musculoskeletal symptoms of menopause, after discussing the short and longer-term benefits and risks and alternative management options. Symptoms may be associated with a change in menstrual cycle – but note that ongoing menstruation does not contraindicate use of HRT. If it is uncertain whether a younger person’s symptoms relate to perimenopause, measurement of serum FSH (+/- estradiol) may be useful to support diagnosis and clinical decision-making (see section 3 below).
If an individual under age 45 has symptoms that could relate to perimenopause, but a normal hormone profile, it is important to remember that there are many other potential medical and psychosocial factors that could contribute to symptoms like those experienced in perimenopause. If other causes have been excluded and the symptoms are typical of perimenopause, a trial of HRT can be considered to assess whether there is symptomatic benefit.
When starting HRT, explain that menopausal symptoms that settle on HRT may well recur when HRT is stopped again, but could be better tolerated at a later stage in someone’s life.
Offer systemic HRT to medically eligible individuals with premature ovarian insufficiency (menopause before age 40) for bone and cardiac protection (even in the absence of menopausal symptoms). Also consider use of HRT for these indications in individuals aged 40-45.
3. Diagnostic blood tests (to support diagnosis and to guide use of contraception)
3.1 Do I need to measure FSH levels?
Elevated serum FSH is consistent with perimenopause/menopause. In the perimenopause FSH fluctuates widely thus FSH measurements can be uninformative: individuals may be symptomatic despite normal FSH, and normal FSH does not preclude a trial of HRT.
FSH (and estradiol) levels should not be checked if the person is already using systemic HRT or is taking combined oral contraception.
- Individuals aged >45 years. FSH measurement is not required to diagnose perimenopause in individuals aged over 45 years with symptoms suggestive of menopause. Do not measure FSH in this circumstance (unless the person is aged over 50 and wishes to stop contraception in which case if FSH is >30nmol/l contraception can be stopped after one further year without a further test).
- Individuals aged 40-45 years. Consider measuring FSH levels in individuals aged between 40 and 45 who have menopausal symptoms, particularly if there is uncertainty about the diagnosis. As FSH levels fluctuate widely in the perimenopause:-
- a normal FSH does not exclude perimenopause as a cause of symptoms or preclude a trial of HRT.
- under age 45 an elevated FSH (even if >30nmol/l) does not exclude future ovulation and ongoing contraception should be recommended
- Individuals aged under 40 years. FSH levels should be measured in individuals under age 40 in whom a diagnosis of premature ovarian insufficiency (POI) is suspected. Careful consideration of other causes of symptoms is advised.
3.2 If serum FSH testing is indicated, when should the test be done?
Blood for serum FSH should be taken in the first few days after onset of a natural period (early follicular sample). If the person does not have a natural menstrual cycle allowing for that, a serum estradiol is helpful to support interpretation of FSH results.
4. Choosing type of systemic HRT
4.1 HRT regimen
4.1.1 Should I prescribe estrogen-only or combined estrogen & progestogen HRT?
Estrogen-only HRT appears to be safer in terms of breast cancer risk than combined HRT, but estrogen can only be used without a progestogen for endometrial protection after total hysterectomy. A progestogen may still be required if there is a history of endometriosis or after subtotal hysterectomy (see below). Note that HRT using a 52mg LNG-IUD like Mirena® or Levosert® as the progestogen component is combined (not estrogen-only) HRT.
Can I prescribe estrogen-only HRT after sub-total hysterectomy?
Theoretically, a small amount of endometrial tissue could be left behind in the upper cervical canal after sub-total hysterectomy. Exposing any such tissue to unopposed estrogen could increase risk of endometrial malignancy. It may be possible to obtain advice on the likelihood of this from the individual’s surgeon. If not, a three-month trial of combined sequential HRT may help to clarify – if there is no withdrawal bleeding, it is likely to be safe to switch to estrogen-only.
Can I prescribe estrogen-only HRT if there is a history of endometriosis?
Exposing residual endometriotic deposits to unopposed estrogen may cause endometriosis pain to recur and increases risk of malignancy (endometriotic tissue could be even more sensitive to estrogens than endometrium). Advice from the operating surgeon on the extent of remaining endometriosis can be helpful, but with a history of endometriosis, continuous combined HRT is probably the safest option in most cases.
4.1.2 Should I prescribe sequential combined or continuous combined HRT?
- Published FSRH guidelines now support use of any 52mg LNG-IUD (Benilexa® and Levosert® as well as Mirena®) for 5 years as the progestogen component of HRT (with separate estradiol) to offer a no-bleed continuous combined HRT regimen.
- Otherwise, if someone has menstruated within the last year and therefore likely still has some ovarian activity, sequential HRT should be chosen to reduce the risk of unscheduled bleeding.
- Continuous combined HRT can be used for people whose last period was at least one year ago.
- If someone is amenorrhoeic on progestogen-only contraception we don’t know whether they would still be menstruating. We suggest considering a 52mg LNG-IUD for both contraception and endometrial protection or continuing the progestogen-only contraceptive and adding continuous combined HRT.
4.1.3 When should I switch from sequential combined to continuous combined HRT?
There is no right or wrong answer as to when to switch from sequential to continuous combined HRT – aim to do this when you might reasonably expect normal periods to have ceased. In a 50-year-old having a period every few months, you might give sequential HRT for a year and then trial a switch to continuous combined HRT. In a 45-year-old with vasomotor symptoms but regular periods, you might use sequential for 4-5 years before considering switching. If unscheduled bleeding occurs, try switching back to sequential for another year.
With regard to health risk, continuous combined HRT is associated with a slightly greater increased risk of breast cancer, but a lower risk of endometrial cancer than sequential HRT.
4.2 Systemic estradiol preparation
4.2.1 Should I prescribe HRT containing oral or transdermal estradiol?
HRT containing transdermal estradiol (estradiol patches, gel or spray) appears not to confer an increased risk of VTE or stroke in the general population whereas HRT containing oral estradiol is associated with increased risk of thrombosis. HRT containing transdermal (rather than oral) estradiol is therefore particularly recommended for individuals aged over 60 years and those with risk factors for venous thromboembolism or cardiovascular disease (eg BMI>30, smoker, migraine with aura, diabetes, cancer treatment, reduced mobility). Transdermal estradiol is also preferable for people taking thyroxine and those with liver/gallstone disease. Route of estradiol administration does not appear to affect breast cancer risk.
4.2.2 What is the equivalent dose of estradiol patch/gel/spray compared to oral estradiol?
A medium, 2mg oral estradiol dose is roughly equivalent to a 50mcg/24 hours estradiol patch or 1-1.5mg estradiol gel or 3 sprays of Lenzetto® estradiol spray.
Estradiol doses in different preparations that achieve roughly equivalent serum estradiol levels can be found on the British Menopause Society website in Tools for Clinicians, HRT – Practical prescribing. (Note that higher serum estradiol levels cannot be achieved using more than 3 sprays of Lenzetto® spray).
4.3 Progestogen type
4.3.1 How do I choose which progestogen to use for endometrial protection?
4.3.1.1 Side effects
Different progestogens are associated with different side effects. If an individual has a side effect with one progestogen in HRT, it can be helpful to try a different progestogen. HRT options containing micronised progesterone, norethisterone, dydrogesterone, levonorgestrel (52mg LNG-IUD) and medroxyprogesterone acetate are listed in the East Region Formulary. Micronised progesterone may have fewer progestogenic side effects for some users than some synthetic progestogens.
4.3.1.2 Safety
Limited evidence suggests that HRT containing micronised progesterone (Utrogestan®or the combined oral estradiol/ micronised progesterone product Bijuve®) and HRT containing dydrogesterone (Femoston® oral HRT products) could confer a smaller increase in risk of breast cancer and VTE than HRT containing some other synthetic progestogens.
Individuals with risk factors for breast cancer should consider these options first line. For individuals with risk factors for venous or arterial thrombosis, micronised progesterone in combination with transdermal estradiol may be the HRT combination with least effect on thrombotic risk.
4.3.1.3 Other considerations
Some people may prefer the convenience of a combined patch or a 52mg LNG-IUD, for example. The 52mg LNG-IUD has the additional benefits that it provides highly effective contraception and good bleed control. Note that HRT using the 52mg LNG-IUD for endometrial protection still constitutes combined HRT (NOT estrogen-only).
4.3.2 Micronised progesterone (Utrogestan®) is on the East Region Formulary. It can be prescribed in primary care as a standard option for endometrial protection as part of HRT without need for discussion with the Menopause Clinic or specific formulary request. Currently recommended Utrogestan® doses are given below.
1. For estradiol doses up to and including 75mcg/24 hours patch/ Oestrogel® 3 pumps daily/ Sandrena® 2mg/ oral estradiol 3mg (maximum estradiol spray doses are lower than this)
- Continuous combined regimen: Utrogestan® 100mg po od (nocte) continuously
- Sequential combined regimen: Utrogestan® 200mg po od (nocte) for 14 consecutive days per 28-day cycle.
2. With higher estradiol doses (or if there is unscheduled bleeding with the standard Utrogestan® dose)
- Continuous combined regimen: Utrogestan® 200mg po od (nocte) continuously
- Sequential combined regimen: Utrogestan® 300mg po od (nocte) for 14 consecutive days per 28-day cycle.
It is suggested that Utrogestan® is taken at night as it can cause sleepiness (which can be a useful effect if taken then).
Micronised progesterone may have fewer side effects for some people than some synthetic progestogens. Someone who has significant side effects with a range of progestogens including oral micronised progesterone could consider using Utrogestan®oral capsules vaginally rather than orally at the same dose and in the same regimen.
Utrogestan® is not licensed for vaginal use for this indication, thus vaginal use should be considered only in this specific situation, after trialling alternatives. The user would have to be aware that such use is off-label and that although vaginal Utrogestan appears to offer adequate endometrial protection there is not robust study evidence to confirm this. Unscheduled bleeding after the first 3-6 months of use should prompt an increase in dose.
4.3.3 How long can a 52mg LNG-IUD be used for as part of HRT? And what about Kyleena® and Jaydess®?
Any 52mg LNG-IUD will be effective for 5 years for endometrial protection as part of HRT (regardless of the person’s age at the time of insertion). If someone who is using HRT had their 52mg LNG-IUD inserted after age 45 and does not wish to have it replaced after 5 years, they can retain the device for contraception until age 55, but must also use combined HRT (rather than estrogen only) from 5 years after 52mg LNG-IUDinsertion.
Kyleena® and Jaydess® contain lower doses of LNG and should not be used for endometrial protection as part of HRT.
- HRT and contraception
5.1 Is HRT contraceptive?
It is established practice that contraception can be stopped at age 55 years.
Sequential HRT is not contraceptive. Continuous combined HRT may offer a contraceptive cervical mucus effect but should not be considered reliably contraceptive.
The 52mg LNG-IUD offers both contraception and endometrial protection as part of HRT. Other progestogen-only contraceptives (progestogen-only pill, the etonogestrel implant, the progestogen-only injectable, and lower dose LNG-IUDs like Kyleena® and Jaydess®) should not be used for endometrial protection but can be used for contraception in addition to standard sequential or continuous combined HRT. Please see FSRH Clinical Guideline: Contraception for Women Aged over 40 Years (August 2017, amended September 2019) – Faculty of Sexual and Reproductive Healthcare.
5.2 If someone is amenorrhoeic on progestogen-only contraception (eg implant, POP), should I start continuous or sequential combined HRT?
Bleeding pattern is unpredictable when HRT is added to a progestogen-only contraceptive, but addition of continuous combined HRT may be more likely to result in continued amenorrhoea than addition of sequential combined HRT. Use of a 52mg LNG-IUD for both contraception and endometrial protection as part of HRT should be considered as a good option to achieve amenorrhoea and to avoid using two progestogens.
6. Duration of use of systemic HRT
6.1 How long can HRT be used for?
Use of HRT should be reviewed on an annual basis. HRT-associated health risks (particularly breast cancer) increase with age and duration of use. However, there are also HRT-associated health benefits and there is no maximum age or duration of use and if an informed individual without medical contraindications considers that HRT benefits outweigh risks for them, continuation can be supported.
6.2 How should HRT be stopped?
Menopausal symptoms tend to recur on stopping HRT, and many individuals find it helpful to gradually reduce the estradiol dose over several months when stopping HRT. This can be easiest to achieve with a patch or gel preparation.
7. HRT troubleshooting
7.1 HRT supply problems
Recent years have seen supply problems with various preparations of commonly prescribed HRT. The British Menopause Society publishes up-to-date advice on this on its website, and also guidance on appropriate dosages when using available alternatives.
7.2 How do I manage bleeding on HRT?
New onset unscheduled bleeding in the first 3-6 months of use of HRT (or after a change of HRT) does not generally require investigation.
Heavy bleeding, bleeding associated with other gynaecological symptoms, bleeding that persists for more than 6 months after starting or switching HRT and new onset bleeding during established use of HRT may need to be investigated, particularly if the individual has risk factors for endometrial pathology (e.g. obesity, diabetes, hypertension, polycystic ovary syndrome) – please refer to RefHelp section on abnormal uterine bleeding or post-menopausal bleeding. Please also note that the post-menopausal bleeding (PMB) pathway generally requires an initial referral to radiology and not Chalmers.
Always check that HRT is being used correctly (including asking about any patch adherence problems), check for interacting drugs, consider pregnancy testing and STI risk assessment, check smear status and examine the vulva/vagina/cervix.
If pathology has been excluded, a 52mg LNG-IUD could offer better control of bleeding. Alternatively, if there is erratic bleeding on continuous combined HRT, consider switching to sequential HRT to establish a regular bleeding pattern.
7.3 What investigation is required if someone has used unopposed estrogen (or suboptimally-opposed estrogen)?
Decisions should be made on a case-by-case basis taking into consideration additional endometrial risk factors like obesity, history of PCOS and diabetes, duration of unopposed use and if there has been any bleeding.
7.3.1 Unopposed or suboptimally opposed estrogen with no bleeding
Refer patients who have been using unopposed systemic estrogen for 12 months or more to Chalmers for transvaginal pelvic ultrasound scan (TVUSS)+/-endometrial biopsy. This includes individuals that have continued to use a 52mg LNG-IUD for endometrial protection for 12 months beyond the recommended 5-year duration of use for this indication. Start a progestogen at the time of referral if the person wishes to continue to use estrogen.
Generally, no investigation is required if the unopposed estrogen has been used for less than 12 months and there is no bleeding. In this situation commence combined HRT or replace the 52mg LNG-IUD. Referral for investigation may be considered if the patient has additional risk factors for endometrial hyperplasia e.g., obesity, PCOS, diabetes,
7.3.2 Unopposed/suboptimally opposed estrogen with bleeding
People who are using or have recently used unopposed (or sub-optimally opposed) estrogen and have vaginal bleeding should be referred for TVUSS via the post-menopausal bleed pathway regardless of duration of unopposed estrogen use.
7.4 How do I manage HRT side effects?
Breast tenderness, bloating and headache are common when HRT is started and often settle with time. If symptoms persist, try reducing the estradiol dose, changing the route of estradiol administration, or changing the progestogen (micronised progesterone or dydrogesterone – the progestogen in Femoston® products – can be good options. See the section on micronised progesterone above).
Side effects like acne and adverse effect on mood (sometimes limited to the progestogen-containing phase of sequential HRT) may respond to a change of progestogen.
7.5 My patient has inadequate control of symptoms despite licensed doses of systemic estrogen – can I increase the estrogen dose further?
Vasomotor symptoms generally respond well to HRT, but other menopausal symptoms like mood change and ‘brain fog’ do not always respond as reliably, even if estradiol dose is increased.
Once other causes of symptoms have been excluded, a trial of increasing estradiol dose above the standard 50mcg/24 hours estradiol patch/ Sandrena® gel 1mg or Oestrogel® 2 pumps transdermal daily/ 2mg oral estradiol daily can be considered if symptoms that are likely to relate to the menopause have not responded (or have responded incompletely) to standard estradiol doses. Younger individuals in particular often require higher estradiol doses.
We recommend stepwise dose increases at 3-monthly intervals, to maximum estradiol doses of 100mcg/24 hours estradiol patch/ Sandrena® gel 3mg or Oestrogel® 4 pumps transdermal daily/ 4mg oral estradiol daily.
If you have already increased the estradiol dose without benefit, try switching to an alternative route of estradiol administration (if clinically suitable) – some individuals seem to respond better to tablets than patches or gels, and vice versa. We very rarely recommend checking serum estradiol levels, and we do not recommend increasing estradiol doses above those given above (see also section 7.5.1 below).
Note that the maximum estradiol dose that can be achieved with Lenzetto® spray (3 sprays daily) gives serum estradiol levels equivalent only to a 50mcg/24 hours patch.
7.5.1 My patient’s private Menopause Care provider is requesting that I prescribe higher estradiol doses than are recommended in Lothian. What should I do?
Published evidence for health outcomes associated with use of HRT is based on studies that consider people using quite modest estradiol doses no higher (and often lower) than those that we recommend in Lothian. In Lothian, therefore, we recommend titrating estradiol dose against symptoms up to a standard maximum dose of estradiol 100mcg/24 hours patches, Oestrogel® 4 pumps transdermal daily or Sandrena® 3mg transdermal daily. (We would generally avoid use of doses of oral estrogen above 2mg if possible because thrombotic risk with oral estradiol may be dose related).
We do NOT check serum estradiol levels as there is no optimum level that correlates with symptom control and the evidence relates to the estradiol dose administered, NOT to the serum estradiol level achieved. Instead, we adjust dose within the standard range according to response of symptoms.
Some patients may have misconceptions that very high serum estradiol levels are normal pre-menopause and that they need to replicate these with HRT. They may be encouraged to use several estradiol 100mcg/24 hours patches at the same time, or to combine different preparations e.g. ‘topping up’ with gel in addition to patches. While high estradiol levels are experienced for a few days in the middle of a menstrual cycle, average serum estradiol levels across the cycle are quite modest. Thus, estradiol levels for some patients receiving care outside the NHS are supraphysiological. We do not have evidence for safety of such high sustained serum estradiol levels, risk of tachyphylaxis is a consideration, and we don’t know how effective standard endometrial protection would be in this situation.
These high estradiol doses are essentially experimental, and we do not support their use. We suggest that you follow this local guidance which generally aligns with British Menopause Society guidance, and do not exceed the maximum doses listed in the East Region Formulary.
8. ‘Bioidentical HRT’
What is ‘bioidentical HRT’, and is it recommended by the Menopause Clinic?
Information from the British Menopause Society on bioidentical HRT is available on its website at https://thebms.org.uk/publications/consensus-statements/bioidentical-hrt/
Regulated ‘bioidentical HRT’ (use of which is supported by the British Menopause Society) contains estradiol in combination with micronised progesterone (Utrogestan®) rather than a synthetic progestogen for endometrial protection. This combination can be offered in primary care as a standard HRT option.
Non-regulated custom compounded ‘bioidentical HRT’ is not supported by current guidelines. As a service, Chalmers does not offer any such option and cannot give guidance on use. Ongoing care of individuals using compounded ‘bioidentical HRT’ regimens should be undertaken by the provider of their HRT.
9. What non-hormonal options do you recommend for menopausal symptoms?
Some people don’t want to take HRT or have been advised against it for medical reasons. Vasomotor symptoms (often flushes and sweats) generally improve with time, but non-vasomotor symptoms (e.g. cognitive and mood symptoms, musculoskeletal symptoms, urogenital atrophic symptoms) may not improve or may worsen with time.
It can help to avoid vasomotor triggers like alcohol, caffeine, hot drinks and spicy foods, to layer clothing and bedding and to use fans. Cognitive behavioural therapy and mindfulness techniques are beneficial for vasomotor symptoms, low mood, anxiety and sleep disturbance. The Women’s Health Concern fact sheet on CBT for menopausal symptoms and the self-help book ‘Managing hot flushes and night sweats: a cognitive behavioural self-help guide to the menopause’ by Myra Hunter and Melanie Smith can be very useful tools.
Online resources and apps for mindfulness and sleep are useful – please see Sleepio. Other commercial apps and resources are available to support self-management. Exercise and maintaining a healthy weight can help hugely with symptoms and with self-esteem, as well as being important for a healthy body. After menopause muscle strength is lost and bone density reduces. Exercise and a good diet containing plenty of calcium and vitamin D can help to maintain muscle and bone strength to maintain mobility and protect bones from osteoporosis. Exercise doesn’t have to be strenuous – walking and climbing stairs are what suit some people best; others might opt for yoga or Pilates or swimming (or something completely different that makes people feel good).
9.1 Non-hormonal medical management options include:-
- SNRI/SSRI (eg venlafaxine 37.5mg po od/bd or citalopram 10-20mg po od) used off label for vasomotor and mood symptoms (note that fluoxetine and paroxetine should not be used in combination with tamoxifen).
- Gabapentin 100-300mg tds po used off label for vasomotor symptoms
- Oxybutynin 2.5mg po up to qds as tolerated for drenching sweats. (Note potential adverse effect on cognition for older users).
- (Clonidine is rarely used for vasomotor symptoms as there is not usually sustained benefit)
A good lubricant is recommended for intercourse, but in addition, a regular vaginal moisturiser can make the vagina much more comfortable: please see the Formulary for further detail. Soap and shower gel can dry and irritate the external genital skin, so washing with water or an emollient is helpful. Many people can, however, use low dose local vaginal estrogen even if they cannot (or prefer not to) use systemic HRT (see section 11 below).
9.2 Emerging non-hormonal medical management options
It is expected that a new class of non-hormonal drugs that are effective for some menopausal symptoms (vasomotor symptoms and possibly sleep disturbance) may become available in the UK in the next year. These are neurokinin-3 antagonists. We will provide information about them if they become available on the NHS.
10. Low dose local vaginal estrogen
Low dose local vaginal estrogen is extremely effective for urogenital atrophic symptoms (vaginal dryness/ discomfort and lower urinary tract symptoms), although it can take 3-6 months of use for benefit to be noticeable, and long-term continuation is advised to prevent symptom recurrence. Vaginal estrogens can be used safely alongside systemic HRT. There is no maximum length of time for which low dose local vaginal estrogen can be used.
Systemic absorption of low dose local vaginal estrogen products is negligible and thus vaginal estrogen is considered safe for most individuals. HOWEVER, use of local vaginal estrogen by individuals with a history of estrogen-sensitive breast or gynaecological cancer should generally be discussed with the Menopause Clinic or the individual’s oncology team. Low dose local vaginal estrogen is generally acceptable during tamoxifen use but is not (usually) recommended during use of an aromatase inhibitor e.g. letrozole, anastrazole, exemestane.
Local vaginal estrogen is available as low-dose vaginal estradiol tablets an estradiol vaginal ring and estriol cream as per the patient’s preference and East Region Formulary advice. There are also ultra-low preparations available. These may be recommended for specific patients on specialist advice.
11. Do you see individuals with premature ovarian insufficiency (POI) at the Menopause Clinic?
Yes. We welcome referrals for individuals with POI. (Please refer those who wish to explore fertility options to Reproductive Endocrinology at the Edinburgh Fertility Clinic, where POI can be managed, and they can also receive advice on assisted conception).
Individuals with POI should be offered HRT until the average age of natural menopause (50-52 years) for bone and cardiovascular protection (unless there is a clear contraindication to HRT use). HRT for younger individuals can be in the form of COC or HRT according to their preference and medical eligibility. At age 50-52, the individual may opt to trial stopping HRT or to continue for ongoing symptom control.
We offer tests for Fragile X premutation, Turner karyotype and autoantibody testing (thyroid, ovary and adrenal) to individuals with spontaneous menopause before age 40 to exclude associated conditions.
Chalmers Menopause Clinic: SH and EG
