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Menopause – Information for GPs
The menopause is a transition period when menses start to space and is characterised by falling estrogen levels, of which a woman may be symptomatic.
The definition of Post-menopausal state is given retrospectively after 12 months of amenorrhoea from age 50 or 24months of amenorrhoea under age 50. This is particularly relevant for contraceptive needs.
FSH levels can be used as a marker or the perimenopause as well as patient’s age, menstrual cycle and symptoms. NICE do not recommend using this test after age 45, unless it is for contraceptive purposes: for example when a patient has a LARC causing amenorrhoeae.
FSH levels can be raised for 5-10 years before the menopause. Symptoms may start with fluctuations in the hormone levels and ovarian function and may require earlier treatment for symptom relief.
Red flag symptoms
- Postmenopausal bleeding (PMB) is bleeding >12 months after last period over age 55yrs of age
- Under age of 55yrs with PMB, NICE advises if the bleeding is abnormal in nature (not menstrual like) or there are risk factors present (such as obesity/ Type2 DM or family history of endometrial cancer), then an USS should be considered
- For PMB – see guidelines on RSS website
- Heavy/irregular bleeding – see other guidelines for menorrhagia etc. – if on HRT, stop and consider ultrasound if does not settle
Before referral for management of the menopause consider advice and guidance for help with management of any of the following problems:
- Symptoms not settling on standard regimes
- Complex risk factors e.g. cancer, CVD, increasing migraine
- Unusual symptoms
The following key recommendations are taken from the FSRH Clinical Guidance – Contraception for Women over 40 – July 2010.
- 1. Women using non-hormonal methods of contraception can be advised to stop contraception after 1 year of amenorrhoea if aged over 50 years, 2 years if the woman is aged under 50 years
- 3. After counselling (about declining fertility, risks associated with insertion, and contraceptive efficacy), women who have a Cu-IUD containing ≥300mm2 copper, inserted at or over the age of 40 years, can retain the device until the menopause or until contraception is no longer required
- 1. Women who continue to use their IUD until contraception is no longer required should be advised to return to have the device removed
- 1. Women using exogenous hormones should be advised that amenorrhoea is not a reliable indicator of ovarian failure
- 1. In women using contraceptive hormones, follicle-stimulating hormone (FSH) levels may be used to help diagnose the menopause, but should be restricted to women over the age of 50 years and to those using progestogen-only methods
- 1. FSH is not a reliable indicator of ovarian failure in women using combined hormones, even if measured during the hormone-free interval
- 1. Women over the age of 50 who are amenorrhoeic and wish to stop POC can have their FSH levels checked. If the level is ≥30 IU/L the FSH should be repeated after 6 weeks. If the second FSH level is ≥30 IU/L contraception can be stopped after 1 year
- 1. Women who have their LNG-IUS inserted for contraception at the age of 45 years or over can use the device for 7 years (off licence) or if amenorrhoeic until the menopause, after which the device should be removed
Hormone Replacement Therapy (HRT) and Contraception
- 3. Women using HRT should be advised not to rely on this as a contraception
- 1. Women can be advised that a progestogen-only pill can be used with HRT to provide effective contraception but the HRT must include progestogen in addition to oestrogen
- 2. Women using oestrogen replacement therapy may use the LNG-IUS to provide endometrial protection. When used as the progestogen component of HRT, the LNG-IUS should be changed no later than 5 years after insertion (the licence states 4 years) irrespective of age at insertion
Grading of recommendations
1 = Good practice point where no evidence exists but where best practice is based on the clinical experience of the multidisciplinary group
2 = evidence based on randomised controlled trials
3 = Evidence is limited but the advice relies on
Advice for women on stopping contraception
Information to include in referral letter
Consider Advice & Guidance
- Describe problem and length of symptoms
- Current contraception/hormone therapy
- If bleeding problems, findings of vaginal and speculum examination
- Smear history
- Relevant past medical / surgical history
- Current regular medication
- Smoking status