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Menopause - Management
How should I assess a woman with menopausal symptoms?

  • Assess the stage of the menopause:
    • Ask the woman if she is still having periods, to determine whether she is perimenopausal or postmenopausal:
      • If her periods have stopped, record when the last period occurred.
      • If the woman is still having periods, ask about their frequency, heaviness, and duration.
    • Determine if the woman is less than 45 years of age (premature menopause):
  • Assess the symptoms and their severity:
    • Ask which symptoms the woman has, to determine if they would be likely to respond to hormone replacement therapy (HRT) (e.g. hot flushes, night sweats, vaginal dryness), or whether other treatments may be more suitable (e.g. treatment for primary depression or primary insomnia).
    • Determine the severity of the symptoms and the extent to which they are affecting the woman's life.
  • Assess the risk of cardiovascular disease:
    • Women with cardiovascular disease or at increased risk of cardiovascular disease should have their cardiovascular risk factors managed — see the CKS topic on CVD risk assessment and management.
  • Assess the risk of osteoporosis:
  • Discuss the woman's expectations:
    • Ask why she has consulted (e.g. concern regarding the cause of the symptoms).
    • Ask if she would like treatment for her symptoms.
  • Assess what type of treatment may be appropriate:
    • Ask the woman if she would like treatment with HRT or without HRT.
    • For women who would like HRT, check that they are suitable for treatment:
      • Ask if they have any contraindications to HRT (e.g. history of breast cancer, venous thromboembolism).
      • Discuss the risks and benefits of HRT.
      • Record body mass index and blood pressure.
      • Breast examination is not routinely necessary, however the national mammography screening programme and personal breast awareness must be discussed before starting HRT.
      • Pelvic examination is not routinely required unless clinically indicated (past or current disease, symptoms, or family history).
      • Investigations are not routinely indicated.
      • See Managing symptoms with HRT.
    • For women who are not suitable for treatment with HRT (e.g. those who have contraindications to HRT) or do not want to use HRT, see Managing symptoms without HRT.
  • Encourage all women to participate in the national cervical screening programme.
Clarification / Additional information
  • The following are all contraindications to starting hormone replacement therapy:
    • Hormone-dependent cancer (e.g. endometrial cancer, current or past breast cancer).
    • Active or recent arterial thromboembolic disease (e.g. angina or myocardial infarction).
    • Venous thromboembolic disease, pulmonary embolism, or current pregnancy.
    • Severe active liver disease.
    • Undiagnosed breast mass.
    • Uninvestigated abnormal vaginal bleeding.
  • Investigations are not routinely indicated before starting hormone replacement therapy unless:
    • There is sudden change in menstrual pattern, intermenstrual bleeding, postcoital bleeding, or postmenopausal bleeding: consider doing an endometrial assessment.
    • There is a personal or family history of venous thromboembolism: consider doing a thrombophilia screen.
    • There is a high risk of breast cancer: mammography or MRI may be considered (as appropriate for the woman's age).
    • The woman has arterial disease or a high load of other risk markers for arterial disease: a lipid profile may be useful.
Basis for recommendation

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