Menopause implementation: getting started

This section highlights 3 areas of the menopause guideline that could have a big impact on practice and be challenging to implement, along with the reasons why we are proposing change in these areas (given in the box at the start of each area). We identified these with the help of stakeholders and Guideline Development Group members (see section 9.4 of the manual). The section also gives information on resources to help with implementation.

The challenge: stopping the use of follicle-stimulating hormone tests to diagnose menopause in women aged over 45 years

See recommendation 1.2.5.

The follicle-stimulating hormone (FSH) test is often performed unnecessarily in women aged over 45 years. The evidence underpinning this guideline highlights that hormonal tests should not routinely be used in the diagnosis of menopause and that FSH tests should not be used in women aged over 45 years. This is because FSH fluctuates considerably over short periods of time during the years leading up to menopause and so blood levels are not a helpful addition to what is a clinical diagnosis. If a woman is aged over 45 years and has not had a period for at least 12 months, or has vasomotor symptoms and irregular periods (or just symptoms if she doesn't have a uterus), this is adequate information to diagnose menopause and perimenopause respectively. In younger women, FSH tests should not be used to diagnose menopause in those taking combined oestrogen and progestogen contraception or high-dose progestogen because these affect FSH measurements.

Carrying out this test in this group of women does not improve menopause management and so this is an area of care where considerable savings could be made through disinvestment.

Raising awareness of the need to change practice

There may be staff in primary care services who do not know that FSH tests should not be carried out in women aged over 45 years.

To raise awareness, clinical commissioning groups, practice managers and lead GPs could:

  • Use newsletters, bulletins and education events to help ensure that GPs and other practice staff (in particular practice nurses) are aware of this change in practice and that they understand the evidence underpinning this recommendation.

  • Add a prompt to electronic requesting systems which remind primary care staff that this test should not be requested for women aged over 45.

  • Refer GPs to NICE's clinical knowledge summary for menopause.

  • Use the NICE costing report and template to estimate the local savings that can be made. A sample calculation using this template showed that savings of £16,500 could be made for a population of 100,000.

  • Use the baseline assessment tool to establish current practice in requesting tests and carry out clinical audit so this can be monitored and improved.

Also, laboratory staff and managers could:

  • Engage with their local GP practices. For example, in NHS Lothian a GP/laboratory liaison group meets regularly every 2 months and holds an annual update meeting to which all GPs are invited. This continuing professional development (CPD) accredited meeting provides a good opportunity to promote changes in practice.

  • Encourage GPs to stop requesting FSH tests for women aged over 45 years by drawing attention to the fact that this test is unlikely to be informative and is not recommended. Lab Tests Online UK and the UK National External Quality Assessment Service (UK NEQAS) are also raising awareness of the new NICE guidance.

The challenge: communicating the long-term benefits and risks of hormone replacement therapy

See section 1.5.

It is important to provide information on the benefits and risks of hormone replacement therapy (HRT) to help women make an informed choice about which treatment to use for menopausal symptoms. Media reports about HRT have not always been accurate, so providing healthcare professionals and women with a robust source of information is vital. Before publication of this guideline there was no consensus about the long-term benefits and risks of HRT. Although the Women's Health Initiative found that HRT prevented osteoporotic fractures and colon cancer, it initially reported that HRT increased the risk of having a cardiovascular event as well as the incidence of breast cancer. However, the association between HRT and cardiovascular disease has since been disputed and the results show that the risk varies in accordance with individual factors. One of the aims of this guideline is to help GPs and other healthcare professionals to be more confident in prescribing HRT and women more confident in taking it. A knowledge gap among some GPs and other healthcare professionals could mean that they are reluctant to prescribe HRT because they overestimate the risks and contraindications, and underestimate the impact of menopausal symptoms on a woman's quality of life.

Improving knowledge among healthcare professionals

There is a need to improve knowledge about the long-term benefits and risks of HRT. No other treatment has been shown to be as effective as HRT for menopausal symptoms, though the balance of risks and benefits varies among women. Healthcare professionals need to be in a position to be able to support women to make an informed decision about individual benefits and risks of HRT.

NICE is working with the Royal College of Obstetricians and Gynaecologists to ensure that management of menopause, including the benefits and risks of HRT, is covered within the core curriculum. This includes supporting the update and promotion of the advanced training specialist module on menopause and the subspecialty training in reproductive medicine. We are also working with the Faculty of Sexual & Reproductive Healthcare (FSRH) to highlight the menopause special skills theory course and the basic and advanced special skills module.

To improve knowledge, clinical commissioning group prescribing leads could:

  • Help to develop formularies of good HRT prescribing for GPs. This could be done with input from GPs with a specialist interest in menopause and interested consultant gynaecologists.

  • Use briefings and newsletters to help disseminate prescribing knowledge on HRT.

Also, GPs could:

  • Set up local meetings or teaching sessions (particularly those GPs with a specialist interest) to target interested GPs in each practice who can then take the information back to their partners.

  • Use the recommendations in section 1.5 of the guideline and the HRT section of NICE's clinical knowledge summary to ensure that they are informed of the actual long-term benefits and risks of HRT for each individual and are not basing decisions on perceived knowledge.

  • Use materials such as NICE's information for the public, NHS choices and the Women's Health Concern leaflet to help support women to make informed decisions when advising them about HRT.

  • Link with the menopause specialist in their area for advice. This could be by telephone or email about specific cases and/or through training delivered by the menopause specialist.

  • Complete the basic or advanced FSRH special skills course. Practice nurses may also complete this training.

The challenge: providing enough specialist services

See guideline recommendations.

The number of women aged over 45 years in the UK has been steadily increasing and will continue to rise. The associated increase in the number of women going through menopause is expected to result in more new referrals to secondary care of both women needing short-term symptom control and those with associated long-term health issues. There is currently a lack of specialist services and their availability varies nationally. Throughout this guideline there are recommendations to refer certain women to a healthcare professional with expertise in menopause. Currently, there may not be enough services nationally to refer these women to.

Reviewing and redesigning local service provision

In order to address variation and potential gaps in service provision, local health services may need to review, map and redesign local service provision.

To do this, commissioners and clinical commissioning groups could:

  • Use Menopause UK's national menopause map as a starting point. This highlights variations in practice and the lack of overall provision.

  • Clarify current referral routes and communicate them if they are effective.

  • Identify lead clinicians to drive a change in service provision if a gap is identified. Ideally all clinical commissioning groups should have a GP with a specialist interest or a community gynaecologist who could do this.

  • Establish whether current referrals are appropriate. These may be to secondary care (hospitals), community services or a GP with a specialist interest and will vary according to local facilities. Ideally, services should be provided by a dedicated menopause clinic.

  • Confirm that care is provided by a healthcare professional with expertise in menopause (for example, women with breast cancer should have access to a specialist menopause clinic or professional but often receive treatment for menopause from their oncologist who may not have the appropriate training).

  • Consider the feasibility of providing dedicated menopause support by setting up clinics within current gynaecology services.

  • Menopause clinics may be multispecialist and so jointly led by a nurse consultant and a consultant ensuring that when a member of staff is unavailable the clinic may still run.

  • Establish regional menopause clinics if services are unable to have their own.

  • Use the learning from examples of practice where successful services have been set up to help. For example, a primary care service in Essex manages specialist clinic waiting lists through an established agreement whereby a GP with specialist interest accepts emails or written requests from all GPs within a clinical commissioning group. These requests are answered once a week. A specialist service in London has set up a helpline that receives calls outside of clinic times and can allow women to be given support and advice without the need for a clinic appointment.

Need more help?

Further resources are available from NICE that may help to support implementation:

  • National Institute for Health and Care Excellence (NICE)