Dr Jane Davis explains how the NICE quality standard on menopause is expected to reduce variation in care and improve quality of life
Read this article to learn more about:
- diagnosing menopause and premature ovarian insufficiency
- when to review women taking hormone replacement therapy, and what the review should include
- providing information to women undergoing medical or surgical treatments that are likely to cause menopause.
Menopause is defined as: a biological stage in a woman’s life when she stops menstruating and reaches the end of her natural reproductive life.1 On average, menopause occurs at 51 years of age, but onset is early (before the age of 40 years) for approximately 1 in 100 women.1 Women of menopausal age account for a large proportion of the current UK population and approximately 80% of the demographic are employed.2,3 Healthy menopausal women are essential to a healthy society.
Excellent menopause care is simple and inexpensive to achieve, yet the quality of menopause care varies throughout the UK. Barriers to good care are common and include:
- many women and GPs do not recognise menopausal symptoms (see Box 1, below)
- women complain of not being ‘listened to’ by healthcare professionals
- some clinicians may be reluctant to consider hormone replacement therapy (HRT) due to misunderstood safety concerns and a lack of expertise in prescribing
- some women are told that they are too young for menopause or that their blood tests are normal so they cannot be prescribed HRT
- a positive diagnosis of menopause, perimenopause, or premature ovarian insufficiency (POI) is rarely made and recorded
- women experiencing an early menopause have delayed or missed diagnoses
- there may not be a specialist referral service available.
Box 1: Menopause symptoms
Menopausal symptoms include the following:
- no or infrequent periods (taking into account whether the woman has a uterus)
- hot flushes
- night sweats
- mood changes
- memory and concentration loss
- vaginal dryness
- lack of interest in sex
- joint and muscle stiffness.
National Institute for Health and Care Excellence. Menopause. Quality Standard 143. NICE, 2017. Available from: www. nice.org.uk/qs143
NICE has not checked the use of its content in this article to confirm that it accurately reflects the NICE publication from which it is taken
NICE guidance on menopause
In November 2015, NICE Guideline (NG) 23 on Menopause: diagnosis and management was published, providing recommendations for healthcare professionals who care for women in menopause.1 NICE NG23 also includes a section with information for the public, which provides women with information about what to expect from a healthcare professional if they have menopausal symptoms.
NICE Quality Standard (QS) 143,4 published in February 2017, distils the key points from NICE NG23 into measurable statements that can be used to assess the quality of care provided and quantify potential improvements to clinical practice. The five quality statements that make up NICE QS143 are listed in Table 1 (below) and discussed in detail below.
Table 1: NICE quality standard for Menopause—list of quality statements4
Women over 45 years presenting with menopausal symptoms are diagnosed with perimenopause or menopause based on their symptoms alone, without confirmatory laboratory tests.
Women under 40 years presenting with menopausal symptoms have their levels of FSH measured.
Women with premature ovarian insufficiency are offered HRT or a combined hormonal contraceptive.
Women having treatment for menopausal symptoms have a review 3 months after starting each treatment and then at least annually.
Women who are likely to go through menopause as a result of medical or surgical treatment are given information about menopause and fertility before they have their treatment.
FSH=follicle stimulating hormone; HRT=hormone replacement therapy
National Institute for Health and Care Excellence. Menopause. Quality Standard 143. NICE, 2017. Available from: www.nice.org.uk/qs143
NICE has not checked the use of its content in this article to confirm that it accurately reflects the NICE publication from which it is taken
Diagnosing perimenopause and menopause—statement 1
The single greatest change in clinical practice is that clinicians now have the green light to make a positive diagnosis of menopause in healthy women aged over 45 years based on symptoms alone, without the use of laboratory tests; diagnosis can be confirmed in women presenting with:1,4
- perimenopause based on vasomotor symptoms and irregular periods
- menopause in women who have not had a period for 12 months and are not using hormonal contraception
- menopause based on symptoms in women without a uterus.
The most commonly used laboratory test is follicle-stimulating hormone (FSH); however, evidence suggests that FSH testing does not reliably aid a diagnosis of menopause in women aged over 45 years because levels of this endocrine marker fluctuate considerably in the years leading up to menopause.1
Approximately 70% of FSH tests are currently received by women over the age of 45 years, but with implementation of Quality Statement 1 it is expected that this will fall to around 15%.5 This recommendation also has the potential to bring significant cost savings to the NHS.5 At approximately £15 per test, an estimated national saving of £9.6 million is predicted by reducing unnecessary FSH testing.5
Audit is recommended to measure the proportion of women aged over 45 years for whom a diagnosis of perimenopause or menopause is made based on symptoms alone, without the use of laboratory tests.
Correctly defining and recording a diagnosis of menopause, perimenopause, or POI is essential to initiating discussions about HRT, if deemed appropriate. The benefits and risks of HRT are discussed in detail in NICE NG23.1
Diagnosing and managing premature ovarian insufficiency—statements 2 and 3
About 1% of women experience POI (menopause before the age of 40 years), either naturally or as a result of medical or surgical treatment.1,4 If a woman aged under 40 years presents with menopausal symptoms, absent or infrequent periods, and raised FSH levels on two blood samples taken 4–6 weeks apart, then POI can be diagnosed.4 If in doubt, then referral should be made to a specialist with experience in POI.1
Timely diagnosis reduces morbidity and mortality4 and makes it more likely that women with POI will have a positive experience of their diagnosis.
Women diagnosed with POI should be offered sex steroid replacement (unless contraindicated), for example, HRT or combined hormonal contraceptive, to reduce menopausal symptoms and improve health outcomes.4
A clear local referral management pathway to a specialist with expertise in menopause is essential for cases where there is uncertainty in the diagnosis and management of POI.1
Reviewing treatments for menopausal symptoms—statement 4
Most women find that their menopausal symptoms respond well to treatment; however, some women find that their symptoms do not improve or they experience unpleasant side-effects. A review should take place 3 months after starting each treatment, and annually thereafter unless there are clinical indications for an earlier review (such as treatment ineffectiveness, side-effects, or adverse events).1,4 This review mechanism gives the opportunity for referral to a specialist if necessary.1
In the author’s opinion, it is important to assess the following factors at review:
- tolerability and treatment compliance
- suitability of the regimen (e.g. cyclical or continuous regimen, oral or transdermal preparation, stopping HRT, contraceptive requirements)
- biometrics (e.g. body mass index, blood pressure)
- change in medical or sexual history
- change in venous thromboembolic risk.
At annual review the importance of keeping up to date with national screening programmes should also be discussed.1
Information for women having treatment likely to cause menopause—statement 5
Certain medical or surgical treatments, such as cancer treatments and gynaecological surgery, can affect fertility and induce menopause.1,4 It is important that women who require treatment of this kind are provided with information about menopause and fertility before they have their treatment, as they may be younger than women experiencing natural menopause and therefore less likely to be aware of menopausal symptoms.
Left untreated, menopause symptoms can lead to long-term poor health outcomes and potential psychological trauma.6 Promoting awareness of menopausal symptoms increases the likelihood that women will access treatment and services as soon as they need them, and empowers women to make an informed choice about their ongoing hormonal status.
Implementing NICE QS143 in primary care
In the author’s opinion, the current lack of menopause expertise in both primary and secondary care is the single biggest hurdle to overcome in implementing NICE QS143. The Faculty of Sexual and Reproductive Health offers special skills modules in basic and advanced menopause care.6 Training a menopause lead for each practice and providing a local menopause specialist service could lead to a range of improvements (see Box 2, below).
Box 2: Potential improvements following implementation of a local menopause specialist service
Implementation of a local menopause specialist service could lead to improvements in:
- diagnosis of perimenopause and menopause through—
- a reduction in FSH testing for diagnosis of menopause in women over 45 years
- use of electronic prompts for FSH laboratory requests
- liaison with local pathology optimisation groups
- diagnosis of premature ovarian insufficiency through—
- encouraging GPs to consider POI in women aged under 40 years
- providing a referral pathway for a specialist service, if there is doubt
- recording positive diagnoses through—
- creating adequate Read codes for menopause, perimenopause, and premature ovarian insufficiency
- constructing disease registers
- the management of POI—
- promoting the use of HRT promptly and up to natural age of menopause, unless contraindicated
- review of treatments for menopausal symptoms through—
- initiating medication reviews 3 months after starting treatment, annually thereafter
- providing information for women having treatment likely to cause menopause through—
- working with secondary care to ensure access to and understanding of appropriate information prior to treatment.
FSH=follicle-stimulating hormone; POI=premature ovarian insufficiency; HRT=hormone replacement therapy
For many women, menopause symptoms can be incapacitating and have long-term health consequences. At present, provision for menopause healthcare is poor due to a lack of expertise and specialist support.
NICE QS143 highlights areas where efforts should be focused in order to simply and effectively improve the quality of health care for women experiencing menopause. With implementation of NICE QS143:
- women experiencing menopause are more likely to—
- hold positive views about their experience of diagnosis and management
- be healthier and able to contribute more to society
- women taking HRT for menopausal symptoms will be monitored more safely4
- POI will be identified and treated in a more timely fashion4
- women undergoing treatments likely to induce menopause will be better informed and prepared for possible early onset of menopause.4
If the quality statements from NICE QS143 are successfully put into practice in primary care, the future of menopause care has the potential to be much more positive.
- Menopause symptoms can be debilitating
- A positive diagnosis of menopause, perimenopause, or POI should be recorded in the patient’s notes
- In women aged over 45 years, menopause should be diagnosed based on symptoms alone, without the use of laboratory tests
- POI should be considered in women aged under 40 years presenting with menopausal symptoms:
- FSH tests should be used to aid diagnosis of POI in this group
- Women taking treatment for menopausal symptoms should be reviewed:
- 3 months after starting a new treatment
- routinely every 12 months
- Ensure that women undergoing treatments which can induce menopause have received and understood information about menopause prior to receiving treatment
- Refer to NICE NG23 for information about risks and benefits of HRT
- Refer the patient to a menopause specialist if in doubt about diagnosis or treatment.
POI=premature ovarian insufficiency; FSH=follicle-stimulating hormone; NG=NICE Guideline; HRT=hormone replacement therapy
GP commissioning messages
written by Dr David Jenner, GP, Cullompton, Devon
- NICE Guideline 23 and Quality Standard 143 provide the basis for commissioners to produce and design local care pathways for the diagnosis and management of menopause
- Commissioners could require specific reasons for requesting an FSH test from local pathology labs (that would exclude diagnosis of menopause) in people aged over 45 years, to save resources on unnecessary tests
- A care pathway should outline the importance of patient information about the relative risks and benefits of HRT, with links to patient information leaflets to inform shared decision making
- Local formularies should include a choice of HRT preparations and identify cost-effective products as well as safety profiles for transdermal versus oral formulations:
- this local pathway could include a template for annual HRT reviews, which could be adopted as an ‘autoconsultation’ into GP computer systems to ensure all required interventions are followed and recorded
- A referrals system for specialist advice should be identified locally, using either conventional outpatient clinics or possibly telephone or e-mail ‘advice and guidance services’.
FSH=follicle-stimulating hormone; HRT=hormone replacement therapy
NICE. Menopause: diagnosis and management. NICE Guideline 23. NICE, 2015. Available at: nice.org.uk/ng23
Office for National Statistics (ONS). Overview of the UK population: March 2017. ONS, 2017. Available at: www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/articles/overviewoftheukpopulation/mar2017
Office for National Statistics (ONS). Women in the labour market: 2013. ONS, 2013. Available at: www.ons.gov.uk/employmentandlabourmarket/peopleinwork/employmentandemployeetypes/articles/womeninthelabourmarket/2013-09-25
NICE. Menopause. NICE Quality Standard 143. NICE, 2017. Available at: nice.org.uk/qs143
NICE. Costing report: menopause: diagnosis and management—implementing the NICE guideline on menopause (NG23). NICE, 2015. Available at: www.nice.org.uk/guidance/ ng23/resources/costing-report-pdf-556376653
Kotz K, Alexander J, Dennerstein L. Estrogen and androgen hormone therapy and well-being in surgically postmenopausal women. J Womens Health (Larchmt) 2006; 15 (8): 898–908.
Faculty of Sexual and Reproductive Healthcare. Special skills modules. www.fsrh.org/careers-and-training/special-skills-modules (accessed 17 May 2017).