The Complex Menopause Clinic in the National Maternity Hospital – The Story so Far!
Lately the more positive media coverage of menopausal experiences and the benefits of hormone replacement therapies (HRT) has created a tsunami of interest from patients. Maybe an overstretched health service working through a pandemic is not the ideal setting for a resurgence in menopause complaints and HRT requests – but that is where we are in 2022. Moreover, many common comorbidities can make it difficult for colleagues in primary care to offer treatment. The various Menopause guidance bodies will say, ‘referral to a menopause specialist is advisable’. Well up to this year, no such clinic existed in the public system in Ireland. The new “Complex Menopause Service” in the National Maternity Hospital, Holles ST is the first of many promised clinics.
We are a team of three part- time GP Menopause Specialists and an extraordinarily dedicated full time Clinic Nurse Manager have been accepting referrals and advising patients since late 2021. It is not possible for us to offer a service to everyone going into menopause. This is meant to be a GP skill in any event. We only accept patients meeting specific criteria that can make managing their menopause in the community more challenging. We have a dedicated referral form on the NMH website that lays out those criteria. In the event that a patient is not suitable for our clinic and HRT could be offered in primary care, we try to write back to the referring doctor with suggestions and advice rather than leave them with nowhere to turn.
Some background on Perimenopause and Menopause
As far as controlling perimenopausal (still ovulating sometimes) & menopausal (no longer ovulating) symptoms are concerned, there is only one remedy that will improve most if not all the symptoms with any proven efficacy and that is HRT.
The management of peri/ menopause symptoms and the prescribing of HRT is expected to be part of a GP skillset. Lack of interest in HRT use on the part of our patients can be dated from 2002 when a deeply flawed US study (the Women’s Health Initiative) linked HRT use to breast cancer. The fear generated by this publication was deeply felt by patients and their healthcare providers. Lack of demand for menopause hormonal relief resulted in widespread deskilling among colleagues in both primary and secondary care and even women who requested medical therapy were frequently advised, ‘you don’t want HRT, it causes breast cancer’. Things finally started to swing back toward sanity and a more evidence based approach when in 2015, the UK’s National Institute of Health and Care Excellence (NICE) published their guideline (NG23) on Menopause Care and HRT use; a very positive and reassuring review of modern HRT, its risks and benefits. Thus began the renaissance of menopause consultations and requests for HRT.
Our guidelines for prescribing in the community are fairly clear. Women under 60 yrs. of age without certain & specific comorbidities CAN almost always try HRT- if they like. If it doesn’t help, they stop. If it does, they can choose to carry on. The choice is theirs and for women under 60, benefits almost always outweigh risks.
What is in modern HRT?
HRT is not the Pill. The horse urine estrogen(s) offered in the WHI study are rarely used in Ireland anymore and modern HRT contains low doses of estrogen that is molecularly identical to the 17-beta Estradiol created in a functioning ovary. We often reassure patients, ‘you already have this hormone in your body, we are just going to ‘smooth out’ the peaks and troughs’ of estrogen levels that can cause meno symptoms to flare. Modern progestagens also appear to be ‘kinder’ than the high dose medroxyprogesterone acetate used in the WHI study. We typically offer micronised progesterone (another ‘ovarian – similar’ molecule) or even the synthetic progestagen dydrogesterone to oppose and balance the additional estrogen. These have been shown to have a neutral impact on clotting mechanisms and are less likely to cause side effects than their older, stronger predecessors. For women with contraceptive need or reactive/heavy baseline uterine bleeding we recommend our most loyal of servants, the Mirena IUS. The levonorgestrel molecule carried by the IUS is a strong, synthetic progestagen but very little of it is absorbed systemically and so most patients tolerate it quite well. Sometimes, we turn to testosterone. Androgens are important during the menopause- for some more than others- and the use of supplemental testosterone – in low female doses- is indicated for patients with libido issues that have not been improved by standard estrogen + progestagen HRT. Last but never least, we address pelvic floor and vaginal issues with local vaginal estrogen. Genitourinary issues are typically resistant to systemic estrogen supplements and need their own targeted therapies.
Doing a Menopause ‘MOT’ takes time
We in GP often find a menopause consultation becomes more like a mid-life pit stop which will not be squeezed into a 15-minute encounter no matter how fast you talk. We are often faced with multiple complaints that require investigation and advice. We strive to tweak those modifiable risk factors, giving advice on smoking cessation, physical activity, living with and addressing obesity, diet, etc. We encourage screening uptake, we measure BP and correct hypertension when needed. We often do bloods for lipids, thyroid, etc. and act on the results. We address disorders of mood which can frequently come to the fore around menopause and attempt to intervene if we can. We discuss contraception and sexual health where relevant, we discuss menstrual blood loss and intervene if necessary – I could go on. Thorough menopause consultations can be very time consuming and the HSE does not yet ring fence funding for these visits which in my opinion is unfortunate. Somewhere in that patient visit, we need to provide balanced advice and signpost evidence-based information on menopause strategies including HRT use.
How safe is HRT & with whom should we be more cautious?
Should everyone be using HRT? The current recommendations say no. We do not have enough data to say all women should keep their estrogen levels high – there are many unknowns or “not too sures” surrounding risks of ongoing HRT use in people who do not need HRT for symptom relief.
HRT is not for everyone and is certainly not to be used as a salve for people who know they ought to move more, eat better, drink less and stop smoking! But if a patient is struggling, if they are not well and if they are likely to get more benefits from using HRT than to be exposed to risk, then we offer HRT. If someone is experiencing classic symptoms of ovarian hormone fluctuation/decline, who is also generally healthy and in the typical perimenopause/menopause age group and who – most importantly – would like to try a menopause hormone therapy of some kind, then why not?
And the most important thing to remember is that while individual doctors and attitudes may vary and are worthy of discussion, we have the benefit of UK, European and International guidelines on menopause care. And they all sing from the same hymn sheet – the title of which is individualisation.
There are some cases where the risk/benefit profile of HRT use may be less obvious. The British Menopause Society suggests referral to a menopause speciality for patients with a personal past history; note: NOT family history, of:
• Cardiovascular & Cerebrovascular disease; especially ischemic stroke or MI
• Venous thromboembolism
• Sex- Hormone Sensitive Cancers; especially breast, ovary and uterine lining
• Immunological Diseases including HIV
In these situations, use of HRT is usually allowed if the comorbidity is well managed and the HRT is confined to certain products and used at modest doses. Patients with a background of VTE are arguably the most straightforward & are all offered HRT if they wish to try it but the estrogen component is given at low doses, only through the skin (thus avoiding any impact on clotting activity) and with judicious choice of a nonthrombogenic progestagen.
The most challenging of this group are people who have been diagnosed with
• Breast Cancer
There seems to be a lack of follow on care for women who have been treated for breast cancer with over 50% of our referrals this year coming from GP’s trying to help patients with menopause symptoms after breast cancer. Sometimes the symptoms are coincidental, sometimes the menopause has been induced iatrogenically as part of their breast cancer management but either way there can be ongoing suffering with little support apart from ‘talk to your GP’. This needs to be addressed as more and more of us are being diagnosed with and treated for breast cancer. We are reaching out to colleagues to try and improve this situation. Non-HRT prescription medications and liberal access to Cognitive behavioural Therapy techniques has helped us offer some relief to these patients but it is far from ideal.
These first few months of our Complex Menopause Service have been both challenging and highly rewarding. The feedback from our patents has been very positive- gratitude for a listening ear seems to be the overriding theme. Our ‘to do list’ is endless but key goals include: getting as much information on the NMH. ie website as we can, developing standards of practice for our own Menopause Specialists when it comes to prescribing HRT for patients with comorbidities (and hopefully engaging with the other services around Ireland to keep practices consistent) and inviting colleagues in other hospital specialities to connect with us and help us better serve all of our patients. We are doing some basic research on all of the above so we can get a sense of what might be needed as we go forward. As the next wave of Dublin, Cork, Galway and Limerick Menopause Specialist clinics start to open their doors and enrol patients, we in the NMH hope to expand our referral criteria to include local patients without comorbidities who are struggling to find symptom relief in spite of good GP support. Upward and onward.
For further information, please visit www.nmh.ie
Written by Dr Deirdre Lundy, Clinical Lead, Complex Menopause Service, NMH, Holles StPicture: Gerry Mooney
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