In the latest in our CPD series, ANP and menopause specialist Ruth Bailey explains how to put the recently updated NICE menopause guidelines into practice when discussing treatment options with patients. Complete the full module on Nursing in Practice 365 today.
This module will support you to:
- Gain an understanding of the updates across three areas of management.
- Describe treatment options for genitourinary symptoms of menopause.
- Introduce the new discussion aids to support patient decision making.
- Be able to discuss evidence around HRT benefits and risks with patients.
The experience of perimenopause and menopause affects over half the population, with women spending more than a third of their lives in the post reproductive phase.
Women are increasingly seeking help for managing symptoms of menopause which include hot flushes, night sweats, mood swings, anxiety, brain fog, joint aches, irregular periods, heavy menstrual bleeding and genitourinary problems. It is therefore important that nurses in general practice are conversant with the latest evidenced-based guidance to deliver best practice.
This article assumes background knowledge in diagnosing and managing menopause and is a discussion on the guidance rather than the whole topic – see the resources section below for further reading on identifying and managing menopause.
NICE first published guidance on menopause in 2015 and since then research and practice have progressed. However, the fundamental principles of providing an individualised, holistic plan of care has not changed. This means that patients should have a thorough assessment and be given evidenced-based information and support to enable shared decision making to develop a person-specific management plan. The updated guidance includes a requirement to discuss the long-term health risks and benefits of using hormone replacement therapy (HRT) and advice that symptoms may return if HRT is stopped, but it can be restarted if necessary.
What’s new in the latest NICE guidance?
The updated guideline acknowledges that women from ethnic backgrounds and those with long term conditions may experience menopause earlier than the age in the UK of 50-51, highlighting the importance of individualised assessment.
It recommends that women experiencing early menopause (aged 40-45 years) are offered psychological support if they are distressed by the diagnosis or its consequences.
It also addresses the needs of trans and non-binary people and recommends that those experiencing menopause symptoms are referred to a menopause specialist if they have used hormonal gender affirming treatments in the past.
The guidance recommends in some circumstances management should be discussed with a healthcare professional who has ‘expertise in menopause’. This is defined as a professional with specialist knowledge, skills and training which is recognised by the British Menopause Society, Faculty of Sexual Reproductive Healthcare or Royal College of Obstetricians and Gynaecologists.
There are three main areas where specific recommendations have been updated as follows:
- The use of cognitive behavioural therapy (CBT) as a treatment option.
- The management of genitourinary syndrome of menopause (GSM) including options for women with a history of breast cancer.
- Discussion of the long-term impact of HRT on health outcomes.
1. Recommendations on use of CBT
The updated guidance now includes a recommendation to consider CBT, including menopause-specific CBT, as an effective treatment for managing all symptoms of menopause including vasomotor symptoms, sleep disorders and psychological disorders. CBT can be considered in conjunction with hormone replacement therapy (HRT), or as an alternative when HRT is not an option or women choose not to have HRT.
All options including face-to-face, remote, individual, group and self-help CBT provision should be discussed.
The availability of CBT, particularly menopause-specific CBT, is limited across the NHS and it is anticipated that commissioners will consider this when planning services.
Clinical practice point
- Identify local CBT services and referral pathways.
- Collate evidence-based self-help resources on menopause and mental health that can sent electronically to women.
2.1 Recommendations for managing GSM
GSM is a collection of genitourinary symptoms caused by localised effects of oestrogen deficiency on the genital and urinary tract. Symptoms include vaginal dryness, itching or burning, pain during sex and increased urinary frequency and urgency.
The updated guidance now states that vaginal oestrogen should be offered to patients experiencing GSM, including those using systemic HRT. (See special considerations in women with a history of breast cancer in section 2.2 below).
The guidance stresses that women who are offered vaginal oestrogen should be given a choice of pessary, tablet, gel or ring and advised that these can be used with non-hormonal moisturisers or lubricants.
Treatment efficacy should be reviewed at 3 months and then annually.
Two new non-oestrogen products are now recommended as second-line treatment for patients who have symptoms that do not respond to first-line treatment or for whom the treatment options are not acceptable:
- Prasterone is a vaginal pessary containing dehydroepiandrosterone (DHEA) which is converted by the enzymes produced by vaginal tissues into small amounts of oestrogen and contraindicated for those having treatment for breast and endometrial cancer.
- Ospemifene is a selective oestrogen receptor modulator (SERM) and the only oral treatment available for GSM. It is not a hormonal treatment and has the advantage of being an option for those with a history of breast or endometrial cancer if treatment has been completed.
Ruth Bailey is Chair of the RCN Women’s Health Forum and FSRH Council Nurse Representative
To complete the full module and log 1.5 CPD hours visit Nursing in Practice 365
