A modern take on menopause

Old scare stories about hormone replacement therapy and lack of training among healthcare professionals mean that many women are missing out on treatments for debilitating symptoms of menopause. NICE’s new guidance says HRT can be effective and offers advice aimed at healthcare professionals and patients.

Picture credit: Alamy

Kathy Abernethy likes to ask healthcare professionals attending her menopause training course to put their hands up if they have received a training update in this area. Usually, few hands go up.

‘There are some nurses and GPs who have never had one,’ says Ms Abernethy, a menopause specialist nurse who works in an NHS clinic and runs an education programme aimed at those who regularly advise women on their menopause. ‘Knowledge is hugely variable. Nurses and GPs can be similarly unaware. It has been a closed area.’

Now that lack of information has been addressed with the release of comprehensive new guidance by the National Institute for Health and Care Excellence, covering everything from diagnosis to drug and non-drug treatments for symptoms. It also provides clarity on the risks and benefits of hormone replacement therapy.

Hot flushes

‘It is good news for women,’ says Ms Abernethy. ‘They need information to be able to make choices.’ In the past, women were likely to receive either a blanket prescription for HRT, be referred to a website, or be told there was nothing else to do but get on with it, she says. ‘But this guidance tells us that is just not good enough.’

The NICE guidance recognises that menopause symptoms can severely affect a woman’s health and her quality of life. For example, around eight out of ten women experience hot flushes and night sweats. Other symptoms include sleeplessness, vaginal dryness, mood changes, depression, joint and muscle pain, urinary problems and a reduced interest in sex.

Patients do not always get the help they need from healthcare professionals – including nurses – to manage their symptoms effectively, says NICE.

Debra Holloway, a nurse consultant in gynaecology at Guy’s and St Thomas’ NHS Foundation Trust in London, helped to develop the guidance. ‘Menopause is not given a high priority,’ she says, ‘but the new NICE guidelines will help a lot.’

Many women have had to cope with symptoms on their own, she says. ‘For some, menopause is a natural event that happens smoothly, with no concerns, but for those women who need to talk to someone, many do not know where to turn.’

Among the difficulties is that symptoms can vary so much between women, with different presentations of even the most common, such as hot flushes, says Ms Holloway. Gaps between periods can also be difficult to manage, as women are unsure about what changes in bleeding they might expect. ‘Sometimes women just need to know that what they’re experiencing is normal,’ she says.

Additionally, research into HRT from more than a decade ago continues to generate widespread uncertainty and confusion – for patients and healthcare professionals – leading to variations in practice. The two largest studies – published in 2002 and 2003 – raised concerns about the safety of HRT in relation to breast cancer and heart disease risk. The findings attracted much publicity, creating panic for some women, with many doctors deciding not to prescribe HRT.

‘For most women, HRT is a low-risk medication… but currently many women are missing out because of fear’

At the time, UK regulatory authorities issued urgent safety restrictions recommending the lowest dose of HRT for symptom relief, advising against its use in asymptomatic postmenopausal women and saying it should only be a second-line treatment for the prevention of osteoporosis. The result was a 66% drop in the number of women taking HRT, according to the charity Women’s Health Concern.

‘Many doctors and nurses have grown up with the findings of these studies,’ says Ms Holloway, who is chair of the RCN Women’s Health Forum. ‘They haven’t kept up to date with newer research, so still hold the perception that HRT is bad. It doesn’t help their patients.’

Ms Abernethy agrees: ‘We’ve known for several years now that HRT is a lower risk than was thought at the time of these scares,’ she says. ‘For most women, HRT is a low-risk medication, although some are not appropriate for it. It’s an individual choice, but currently many women are missing out because of fear.’

The new NICE guidance says HRT is effective for treating several menopause symptoms and recommends offering it for hot flushes and night sweats, after discussing risks and benefits. HRT should also be considered for low mood. ‘There’s information for patients that gives clear guidance about the evidence,’ says Ms Holloway. ‘My hope is that women will use it to trigger conversations.’

According to NICE, women who start HRT before they reach 60 have no increased risk of cardiovascular disease, while oestrogen-only HRT causes little or no change in their risk of breast cancer. HRT that includes progestogen may increase the risk of breast cancer, and this may be higher for those who take it for longer periods. But the risk falls when HRT is stopped, says NICE. In addition, HRT carries no increased risk of developing type 2 diabetes.

Discuss the options

The guidance for healthcare professionals includes the use of tables that can help convey this information as clearly as possible.

NICE recommends healthcare professionals be able to explain the stages of menopause and its common symptoms; talk about lifestyle changes to help general health and wellbeing; discuss the benefits and risks of different treatments; and highlight the longer-term health implications of menopause. ‘Practice nurses are key to getting education out there,’ says Ms Holloway. ‘I would like to see them using the guidance to improve their own knowledge.’

She is especially concerned about women who have had an early menopause – before the age of 40. This can occur naturally or be caused by treatment for hormone-dependent cancer. ‘There can be little support for this group in particular,’ says Ms Holloway. ‘Women themselves often feel so grateful they have survived cancer that they don’t complain about the lack of support for their menopausal symptoms. As we are looking more towards survivorship, I think we’re starting to get better at dealing with this aspect, but there’s still more to do.’

For Ms Abernethy, NICE’s focus on helping the individual woman make a choice that is best for her, based on evidence, is welcome. ‘This guidance spells out the range of care,’ she says.

‘I see it as a personalised menopause plan to help women decide what they want’.

How you can help

Talk to women about their menopausal symptoms. ‘And don’t forget vaginal issues, such as dryness and painful sex,’ says nurse consultant in gynaecology Debra Holloway.

Make links with your local menopause specialist, so you can refer women who might need extra support.

Look out for resources that can help and guide you, including reading the NICE guidance – NICE Menopause: diagnosis and management nice.org.uk/guidance/ng23

Take advantage of cervical screening. ‘It’s the perfect opportunity to discuss symptoms and HRT,’ says menopause specialist nurse Kathy Abernethy.

Remember it’s not all about whether to prescribe HRT or not. ‘Sometimes women just need reassurance about some symptoms, such as mood changes or forgetfulness,’ says Ms Holloway.

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