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Menopause - Management
When should I refer?

  • Refer urgently if the woman presents with clinical features suggestive of cervical or endometrial cancer:
    • Abnormal bleeding (postcoital bleeding, unscheduled vaginal bleeding, especially if heavy, prolonged, or recurrent or a sudden change in menstrual pattern).
    • Postmenopausal bleeding.
    • Persistent intermenstrual bleeding and negative pelvic examination.
    • A palpable abdominal or pelvic mass (refer urgently for ultrasonography).
  • Refer to secondary care women:
    • Who are less than 40 years of age at presentation.
  • Seek specialist advice if a woman would like hormone replacement therapy but has a contraindication to it:
    • 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.
    • Current pregnancy.
    • Severe active liver disease.
    • Undiagnosed breast mass.
    • Uninvestigated abnormal vaginal bleeding.
Basis for recommendation
  • These recommendations are based on published expert opinion [Waller and McPherson, 2003; Monga, 2006; Rees and Purdie, 2006b].
  • The National Institute for Health and Clinical Excellence recommends urgent referral for all women presenting with alarm symptoms of gynaecological cancer [NICE, 2005].
  • Women who are less than 40 years of age require investigations to determine the cause of a premature menopause (e.g. primary ovarian failure) and to discuss fertility if appropriate.

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