Menopause is when a woman stops having menstrual periods as she reaches the end of her natural reproductive life. The resulting drop in the level of the sex hormone oestrogen can cause problems like hot flushes and vaginal dryness, and can also lead to long-term conditions including brittle bones (osteoporosis) and cardiovascular disease. The symptoms of menopause may severely affect a woman’s quality of life, requiring medical help from a GP or hospital specialist. Around 80% of women experience some symptoms, which typically continue for around 4 years after the last period. But for around 10% of women, symptoms can last for up to 12 years.   

The average age of menopause in the UK is 51 but the age can vary widely – and premature menopause affects 1 in 100 women under the age of 40. The age of menopause varies by ethnicity: studies found that early menopause (between 40 and 45 years of age) affected 3.7% of African–American women, 2.9% of white women, 2.2% of Chinese women and 0.8% of Japanese women. 

The draft guideline covers when blood tests or imaging can help diagnosing menopause, and when treatments like hormone replacement therapy or other therapies should be offered.

Professor Mark Baker, Centre for Clinical Practice Director at NICE, said: “Menopause affects millions of women, and its symptoms can severely upset a woman’s day to day life. The effects of menopause are often misunderstood and underestimated – it can result in problems ranging from hot flushes to brittle bones, joint stiffness and cardiovascular disease.  

“When women seek medical help for their symptoms, there is considerable variation in what is offered to them. So NICE is pleased to be developing the first guideline for the NHS on diagnosing and managing menopause, to help improve the lives of women affected by it.” 

Draft recommendations include which tests can be used to diagnose menopause, and advice on offering holistic, individualised care that takes into account the woman’s symptoms and preferences. The draft guideline also highlights that clinicians should give support and advice to women who are likely to go through menopause as a result of medical or surgical treatment, including women with cancer, at high risk of hormone-dependent cancer or having gynaecological surgery. To help women and clinicians decide on what approaches are right for each individual, drug and non-drug treatment options are covered. This includes draft recommendations based on the benefits and risks of treatment with HRT, with specific information provided for women in various clinical circumstances. For example, it’s often considered that women at risk of hypertension or other cardiovascular conditions should not take HRT, but the draft recommendations propose that they shouldn’t automatically be prevented from taking it.

NICE welcomes comments from stakeholders on the draft recommendations as part of our public consultation.

Draft recommendations include:

• Diagnose the following without laboratory tests in otherwise healthy women aged over 45 years with menopausal symptoms:
  • perimenopause (the lead up to menopause) based on vasomotor symptoms (like hot flushes) and irregular periods
  • menopause in women who have not had a period for at least 12 months
  • menopause based on symptoms in women without a uterus (womb)
  • the benefits and risks of treatments for menopausal symptoms.
• Consider cognitive behavioural therapy (CBT) for alleviation of low mood and anxiety in menopausal women
• Ensure that menopausal women and healthcare professionals involved in their care understand that HRT:
  • does not increase cardiovascular disease risk when started in women aged under 60 years
  • does not affect the risk of dying from cardiovascular disease

• Offer holistic, individualised care that takes into account the woman’s symptoms and preferences. Give information to menopausal women and their family members or carers (as appropriate) that includes:
• an explanation of the stages of menopause
• common symptoms and diagnosis
• lifestyle changes and interventions that could help general health and wellbeing

• Ensure that menopausal women and healthcare professionals involved in their care understand that HRT does not affect the risk of dying from breast cancer, and explain to women that:
• that HRT with oestrogen alone is associated with little or no increase in the risk of breast cancer, but that HRT with oestrogen and progestogen can be associated with an increase in the risk of breast cancer
• any increase in risk of breast cancer is related to treatment duration and reduces after stopping HRT.

The public consultation on the menopause draft guideline runs until 13 July.

ENDS

For more information call the Dr Tonya Gillis at the NICE press office on 0300 323 0142, or out of hours on 07775 583 813.

Notes to Editors
About the draft NICE guideline, ‘Menopause: diagnosis and management’
1. The draft guideline is available for public consultation at www.nice.org.uk/guidance/indevelopment/gid-cgwave0639/consultation from Monday 1 June. The consultation closes on 13 July 2015.
2. Menopause is the biological stage in a woman's life that occurs when she stops menstruating and reaches the end of her natural reproductive life. Usually it is defined as starting 1 year after the last menstrual period for women reaching menopause in middle age. The changes associated with menopause occur when the ovaries stop functioning. Menopause occurs after the eggs in the ovaries stop maturing, and the secretion of the sex hormones oestrogen and progesterone stop.
3. As a woman approaches menopause, usually her periods don’t stop suddenly, but can become less regular with gaps of months in between. This phase of irregular periods is called perimenopause, and lasts until one year after her final period, at which point she has reached menopause.
4. As well as a change in their menstrual cycle, women may experience a variety of symptoms associated with menopause, including:
• vasomotor symptoms (for example, hot flushes and sweats)
• musculoskeletal symptoms (for example, joint and muscle pain)
• effects on mood (for example, low mood)
• urogenital symptoms (for example, vaginal dryness)
• sexual difficulties (for example, low sexual desire.
5. The draft menopause guideline references two published NICE guidelines within its recommendations for women with, or at high risk of, breast cancer. Some of the existing published recommendations follow:

• The NICE guideline ‘Early and locally advanced breast cancer, CG80’ makes a number of recommendations regarding HRT and women with breast cancer in section 1.13, including:
“- Discontinue hormone replacement therapy (HRT) in women who are
diagnosed with breast cancer.
- Do not offer HRT (including oestrogen/progestogen combination) routinely to
women with menopausal symptoms and a history of breast cancer. HRT may,
in exceptional cases, be offered to women with severe menopausal symptoms
and with whom the associated risks have been discussed.
- Offer information and counselling for all women about the possibility of early
menopause and menopausal symptoms associated with breast cancer
treatment.”
See the full recommendations at nice.org.uk/cg80.

• The NICE guideline ‘Familial breast cancer, CG164’ makes a number of recommendations regarding HRT and women at high risk of breast cancer in section 1.7, including:
“ - Women with a family history of breast cancer who are considering taking, or
already taking, HRT should be informed of the increase in breast cancer risk
with type and duration of HRT.
- Advice to individual women on the use of HRT should vary according to the
individual clinical circumstances (such as asymptomatic menopausal
symptoms, age, severity of menopausal symptoms, or osteoporosis).
- HRT usage in a woman at familial risk should be restricted to as short a
duration and as low a dose as possible. Oestrogen-only HRT should be
prescribed where possible.
See the full recommendations at www.nice.org.uk/cg164 .