Debra Holloway discusses NICE Guideline 23, on managing menopausal symptoms, and gives recommendations on how to discuss the issues with patients
Read this article to learn more about:
- symptoms of the menopause
- treatment options, and the risks and benefits, for women going through the menopause
- the role of HRT for women going through the menopause, including those at risk of venous thromboembolism or stroke
The menopause comes to all women. It signifies the end of the reproductive stage of life. However, each woman experiences the menopause in a different way. 'Menopause' is a term that can cover many different processes and changes taking place within a women's body. Some of these symptoms are well known, such as hot flushes and night sweats. These vary in intensity, severity, and frequency between individual women. For some women they can happen 20 times or more per day. Night sweats can result in a poor night's sleep, leading to low mood, forgetfulness, and feelings of being unable to cope, which leads to poor quality of life. Up to 80% of women experience physical symptoms.1 There can also be psychological impacts, negative or positive, associated with the menopause. Many women do not need or want help during this time, however, a proportion do, and in recent years these women have been failed by the healthcare system.
Hormone replacement therapy
In the 1980s hormone replacement therapy (HRT) was in vogue, and it was given to most women going through the menopause, whether they had symptoms or not. In the 1990s it fell out fashion following the publication of several studies that suggested oestrogen and tibolone increase the risk of endometrial cancer and stroke, and that combined oestrogen-progestogen HRT causes a greater increase in breast cancer risk than the other therapies.2 -6 Consequently, healthcare professionals educated during this period had little knowledge of HRT or how to effectively treat the menopause. More recently, studies have shown a more balanced view that, although there are some risks with HRT, there are also some benefits when it is given to the right women at the right time in their reproductive lives.7
NICE Guideline 23
In November 2015, NICE published guidance on the diagnosis and management of the menopause.8 It sets out all aspects of the menopause and is designed to be relevant to the majority of women experiencing this. This clear guidance will enable nurses to better manage women within any care setting. The majority of the guidance is aimed at women in natural menopause, but there are also sections on women with premature ovarian insufficiency (POI) and hormone-dependent cancers. In addition to the full and shortened guidelines, an online pathway helps guide care with the support of evidence statements.9 According to the NICE menopause guidance and pathway, the following considerations are important in the care of women going through the menopause:8,9
- individualised patient care is recommended—this will be a familiar approach for nurses who practice this in other areas of medicine
- in the diagnosis of menopause the greatest change is that routine follicle-stimulating hormone and luteinizing hormone tests are not needed in women over the age of 45 who have menopausal symptoms. This will be useful to nurses when discussing with women why blood tests are not needed or useful within the period
- healthcare professionals should be able to give an explanation of the menopause and its symptoms (see Box 1 below), meaning that they should be up to date and have all of the information needed to have a balanced discussion
- when managing short-term vasomotor symptoms HRT is the treatment of choice; there has been a move away from the selective serotonin reuptake inhibitors as a first-line treatment. There is also some evidence that herbal preparations may work but this is hampered by lack of evidence and uncertainty about the ingredients in each of the preparations
- an important and often neglected area of the menopause is urogenital atrophy. This is often not discussed with women and they often do not feel confident to bring this up. Nurses are in an ideal position to ask questions about painful intercourse, bleeding, and pain when being examined. The guidelines recommend offering vaginal oestrogen to women for as long as they need treatment, without the need for progestogen and monitoring. Lubricant and moisturiser can also be used together or individually
- women should be reviewed at 3 months and any unexpected bleeding discussed.
Box 1: Explaining the menopause and its symptoms to patients8
- The following should be explained to women going through the menopause, and to their family members or carers:
- stages of the menopause, common symptoms, and diagnosis
- lifestyle alterations to promote health and wellbeing
- the benefits and risks of treatments (including hormonal, non-hormonal, and non-pharmaceutical treatments) for menopausal symptoms (including vasomotor, musculoskeletal, emotional, urogenital, and sexual issues) and their long-term health implications.
- Information on the menopause should be given in different ways to help encourage women to discuss their symptoms and needs; give information about contraception to women who are in the peri- or post-menopausal phase.
- Support and information on the menopause and fertility should be offered to women who are likely to go through the menopause as a result of medical or surgical treatment—such as women with cancer, women at high-risk of developing hormone-sensitive cancer, or those having gynaecological surgery—before their treatment, and they should be referred to a healthcare professional with expertise in menopause.
Treatment—long-term benefits and risks
Often, the most difficult conversations with patients are about long-term risks and benefits. When discussing HRT with patients, it is important to cover the following points:8
- the risk of venous thromboembolism associated with transdermal HRT given at standard therapeutic doses is no greater than baseline population. Transdermal, rather than oral, HRT should be considered for women going through the menopause who are at increased risk
- HRT does not increase the risk of cardiovascular disease (CVD) when started before the age of 60, nor does it increase the risk of dying from CVD
- there is a small increase in risk of stroke with oral—but not transdermal—HRT with oestrogen
- providing cardiovascular risk factors are managed they are not a contraindication to HRT
- HRT does not increase the risk of developing type 2 diabetes, and it is not normally associated with adverse effects on glucose control
- there is little or no change in the risk of breast cancer associated with HRT with oestrogen alone; there can be an increase in the risk of breast cancer associated with HRT with oestrogen and progestogen—any risk increase reduces after stopping HRT, and is related to treatment duration (see Table 3, www.nice.org.uk/ng23)
- HRT reduces the risk of fragility fractures while it is taken but the protective effects decrease once treatment is stopped.
Premature ovarian insufficiency
The NICE guideline includes a separate section for women with POI—a disorder that has far-reaching consequences. In a study performed in the US, this disorder was found to affect 1% of the cross-sectional study population.10 As well as symptoms of the menopause, women with POI have to deal with the possibility of infertility and, if left untreated, an increase in risk of CVD and osteoporosis. The guidance is clear that HRT or the combined oral contraceptive pill should be used up to the average age of natural menopause at 51, and that this group of women would benefit from referral to a specialist in menopause.8
In conclusion, NICE Guideline 23 provides some welcome clarity on a subject that is changing constantly and has much publicity associated with it. As nurses, is it essential to be up-to-date, which brings the challenge of ensuring there is educational budget for it within the healthcare setting. Other challenges include changing the mind-set of clinicians who are often reluctant to consider HRT as a therapeutic option. Referral to specialist services may also be a barrier, as in many areas they simply do not exist.
- Brown L, Bryant C, Judd F. Positive wellbeing during the menopausal transition: a systematic review. Climacteric 2015; 18 (4): 456–69.
- Beral V, Bull D, Reeves G. Million Women Study Collaborators. Endometrial cancer and hormone-replacement therapy in the Million Women Study. Lancet 2005; 365 (9470): 1543–51.
- Beral V. Million Women Study Collaborators. Breast cancer and hormone-replacement therapy in the Million Women Study. Lancet 2003; 326 (9382): 419–27.
- Rossouw J, Anderson G, Prentice R et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA 2002; 288 (3): 321–33.
- Rossouw J, Prentice R, Manson J et al. Postmenopausal hormone therapy and risk of cardiovascular disease by age and years since menopause. JAMA 2007; 297 (13): 1465–77.
- Women's Health Initiative Steering Committee. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy. JAMA 2004; 291 (14): 1701–12.
- Schierbeck L, Rejnmark L, Tofteng C et al. Effect of hormone replacement therapy on cardiovascular events in recently postmenopausal women: randomised trial. British Medical Journal 2012; 345: e6409.
- NICE. Menopause: diagnosis and management. NICE Guideline 23. NICE, 2015. Available at: www.nice.org.uk/guidance/ng23 (accessed 18 May 2016)
- NICE. Menopause overview. NICE, 2016. Available at: pathways.nice.org.uk/pathways/menopause (accessed 18 May 2016)
- Luborsky J, Meyer P, Sowers M et al. Premature menopause in a multi-ethnic population study of the menopause transition. Human Reproduction 2003; 18 (1): 199–206. G