Real life issues & answers: the female hormonal patient

Dr Louise Newson (GP and menopause specialist)

Dr Louise Newson highlighted the need for improved care for women experiencing the menopause.

What are the clinical issues?

She described five key issues in the care of women undergoing the menopause.

  • Menopause care should be undertaken in primary care for as many women as possible
  • Guidelines exist but are often not referred to in practice
  • Many perimenopausal and menopausal women are incorrectly being diagnosed with depression and being given or offered antidepressants
  • Many doctors, nurses and healthcare professionals are scared of prescribing HRT
  • There are health risks from not adequately managing the menopause

Even if women do not experience menopausal symptoms, there are associated health risks including bone loss, osteoporosis, central obesity, raised cholesterol, cardiovascular disease, dementia and depression.  Dr Newson said that, “Doing nothing is not an option” although women are often not getting the appropriate help they need in primary care. It is important that this condition is managed confidently by healthcare professionals.

 

What are the implications and answers?

A recent Primary Care Womens Health Forum survey concluded that although the vast majority (92%) of GPs agree that the menopause should be managed in primary care, far fewer (66%) are confident in prescribing HRT to younger women (under 45 years). There remains much confusion among healthcare professionals over the various modes of administration and doses of HRT, and risks associated with HRT use (Newson K. BJFM 2018) however guidelines from NICE, the International Menopause Society and European Society of Human Reproduction and Embryology (ESHRE) are pragmatic and easy to implement and need to referred to regularly in primary care.

In the majority of women, the menopause is not a biochemical diagnosis. NICE guidance is clear that women over 45 with menopausal symptoms do not need a blood test. However approximately £9.6 million a year is spent on unnecessary FSH testing which could be better used for supporting menopause clinics around the country.

Healthcare professionals continue to be anxious about breast cancer risk with HRT due to exaggerated claims in mass media. It is a sad irony that women going through the menopause often increase alcohol and food intake to help with some of the symptoms they are experiencing, and are often less inclined to take exercise. All these are significant risk factors for breast cancer so these women may be increasing their risk of breast cancer by not taking HRT. Overall, women who are receiving HRT and then improving their lifestyle will be reducing their risk of breast cancer, and this needs to be mentioned to patients as they consider the risks and benefits of taking HRT.

It is worth remembering that there is no increased risk of breast cancer in women who have had a hysterectomy and only take oestrogen, and in those who are under the age of 45. In addition, there is a lower risk of breast cancer in patients who use micronized progesterone and dydrogestone.

Menopausal women are often being prescribed antidepressants when there is no clear evidence for SSRIs or SNRIs to ease low mood (NICE Guidelines NG 23, 2015).

 

Key points to make best practice everyday practice

When prescribing HRT – keep it simple

  • Oestrogen as a patch or gel (to eradicate risk of blood clotting)
  • Progestogen – use micronized progesterone or a levonorgestrel-releasing intrauterine system
  • Testosterone – consider in women with reduced libido despite HRT (NB: no UK marketing authorisation for women. The prescriber should follow relevant professional guidance, taking full responsibility for the decision)
  • Consider need for vaginal oestrogen, moisturisers and lubricants

Useful links:

www.menopausedoctor.co.uk  – valuable online information for healthcare professionals

Newson L, Lass A. Effectiveness of transdermal oestradiol and natural micronized progesterone for menopausal symptoms. Br J Gen Practice 2018;68(675): 499-500  https://bjgp.org/content/68/675/499