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Menopause - Management
What follow-up is required?
- Review 3 months after starting hormone replacement therapy (HRT) and once each year thereafter.
- At the initial 3-month review:
- Assess the effectiveness of treatment and adjust to achieve symptom control.
- Enquire about any adverse effects and manage appropriately.
- Check blood pressure and body weight.
- Once each year:
- Check effectiveness of treatment and adjust to achieve symptoms control.
- Check for adverse effects and manage appropriately.
- Interrupt treatment with intravaginal oestrogen to re-assess the need for continued use.
- Re-assess the need for continuing systemic HRT.
- Explain that some of the risks (e.g. ovarian cancer) associated with oestrogen-only HRT increase with longer duration of HRT. The risk decreases after stopping HRT.
- Perform a breast examination if indicated by personal or family history.
- Encourage breast awareness and participation in the national breast screening programme as appropriate for their age.
- Pelvic examination is required only if clinically indicated (e.g. if there is unscheduled bleeding, especially if heavy, prolonged, or recurrent).
- Check blood pressure.
- Oestrogen levels are rarely indicated.
Clarification / Additional information
- Measurement of estradiol is rarely indicated but may be of use if the clinical response (i.e. symptomatic relief) to transdermal HRT is poor [Smellie et al, 2006]:
- To establish whether absorption of transdermal HRT is adequate. If poor absorption is confirmed, prescribe oral HRT.
- To ensure that oestrogen levels have fallen before implant replacement in women, to avoid supraphysiological concentrations and possible tachyphylaxis.
- Rarely, in women with persisting symptoms where poor compliance is suspected.
Basis for recommendation
- These recommendations are based on published expert opinion [Working Group on Breast and Pelvic Examination, 2001; RCPE, 2003; AACE Menopause Guidelines Revision Task Force, 2006; Rees and Purdie, 2006a; MHRA and CHM, 2007b; Roberts, 2007].
- Review at 3 months:
- An initial review is recommended at 3 months, as most menopausal symptoms respond by then:
- Vasomotor symptoms: improvement is usually noted within 4 weeks. Usually, hormone replacement therapy (HRT) is used for less than 5 years [BMS, 2006a].
- Urogenital symptoms: vaginal dryness, soreness, superficial dyspareunia, and urinary frequency and urgency respond well to topical or systemic oestrogens. Improvement may take several months, and symptoms may recur if treatment is stopped. Long-term treatment is often required [BMS, 2006a].
- Annual review:
- An annual review is recommended because the risks and benefits of HRT for each woman change over time and need to be discussed regularly.
- Blood pressure measurement is not routinely needed, but opportunistic screening is useful.
- Measurement of follicle-stimulating hormone:
- Measurement of oestrogen:
- This recommendations is based on Best Practice in primary care pathology [Smellie et al, 2006].
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