Menopause

Please read Menopause for thought to find out more about the menopause.

Perimenopause is a process — a gradual transition. If menopausal symptoms are affecting your day-to-day life you should see your GP. No one test or sign is enough to determine if you've entered perimenopause. We be able to tell if you are in perimenopause or menopause based on your age, symptoms and how often you have periods.

Menopause affects every woman differently. You may have no symptoms at all, or they might be brief and short-lived. For some women they are severe and distressing. Hormones affect every cell in our body so when they are fluctuating leading up to the menopause (perimenopause), this can cause symptoms all over our body, and may include ones you didn’t realise might be due to your hormones, until now. This is why Babylon Menopause Symptoms Checklist is a great and simple way to measure and track your symptoms.

Symptoms can be split into vasomotor (hot flushes, night sweats), psychological (mood changes, difficulty sleeping, lack of interest in sex), physical ( joint and muscle pain, vaginal dryness and vaginal/bladder symptoms (dry vagina, frequent urine infections).

You can still get menopause symptoms if you have had a hysterectomy (an operation to remove your womb). Other natural changes as you age can be intensified by menopause. For example, you may lose some muscle strength and have a higher risk of conditions such as osteoporosis and heart disease.

It’s easy.

You just book an appointment like you normally would;

• tell us the reason for your appointment.

• Book with a:
  • Pharmacist - If you just want a repeat of your HRT
  • GP - For anything else

• Check out their bio for a special interest in menopause - and book!

We may not be able to cover everything you would like to talk about in your initial appointment and if not we can book a further consultation.

Here are some tips to help you make the most of your appointment:

• ‘Tell us more’:

When booking, its helpful to mention what you want to discuss so always put a keyword such as ‘menopause’ ‘perimenopause’ ‘HRT’ and then a little detail such as;

‘I want to know/test if am going through the menopause’

‘I am having symptoms/hot flushes - could it be the menopause?’

‘Is HRT suitable for me?’

‘I’m bleeding on HRT - is this normal?’

‘I need contraception and HRT - what are my options?’

‘I specifically want XXXX HRT - can I have it?’

• Write down your symptoms:

This Babylon Menopause Symptoms Checklist is very helpful for you to complete before your consultation and will help us to personalise your care. If you complete regularly, it can help monitor how your symptoms change with time or with treatments, especially when taking HRT (Hormone Replacement Therapy).

• Bring your menstrual diary:

Recording major changes in your menstrual cycle such as period frequency and flow and any unusual bleeding patters ahead of your appointment is really helpful in guiding us to whether you are in your perimenopause or your menopause.

It would be useful to have the following but don’t worry if you don’t have it all to hand:

• Completing Babylon Menopause Symptoms Checklist
• Your menstrual data - when you last had a period
• Your most recent blood pressure (you can check with a calibrated home monitor or pharmacy)
• Your height and weight so we can calculate your Body Mass Index (BMI)
• Any HRT or other treatments you have taken
• Your medical history with medications you are taking, including contraception
• A brief family history of medical problems – especially breast and ovarian cancer, heart disease, stroke, blood clots, and osteoporosis

We will find out why you booked with us and listen to your current situation and what you hope to achieve. We will work with you to offer evidence-based advice and treatment in line with guidance from British Menopause Society and NICE (National Institute of Clinical Excellence) to help you take control of your menopause. We may not be able to cover everything in 10 minutes, but don’t worry we can follow up with another.

During perimenopause, hormone tests are generally not helpful because hormone levels fluctuate throughout the menstrual cycle, so you are unlikely to need tests. Also, if you are taking any hormonal treatments (for example, to treat heavy periods or contraception that affect your periods) it can be more difficult to know when you have reached menopause.

In women over 45, blood tests are not required to diagnose menopause and diagnosis is ussually taken on symptoms alone.

You may be offered a blood test but only if:

• you are between 40 and 45 and have menopausal symptoms, including changes in your menstrual cycle (how often you have periods)

• you are under 40 and we suspect you are in menopause (also see premature menopause).

The blood test measures a hormone called FSH (follicle-stimulating hormone). FSH is found in

higher levels in menopause.

Some contraceptives affect your natural FSH levels. Therefore if we feel it it is necessary to take your FSH level

• If you are taking a contraceptive containing oestrogen and progestogen (combined pill/ring/patch) we will ask you to stop the contraceptive for 6 weeks before we take the test
• or high-dose progestogen (Depo injection) we will take just before your next injection when it is at its lowest level.

For some women of any age, it may make sense to test for other causes of symptoms that can mimic perimenopause, such as thyroid disease so it is important to discuss your symptoms, your menstrual cycle so we can see what you may need.

For women who seek help for their menopausal symptoms, HRT (hormone replacement therapy) is the most commonly prescribed treatment. HRT helps to relieve symptoms by replacing oestrogen levels that naturally fall in menopause. You can take HRT as tablets or through a patch or gel on your skin.

Although the majority of women usually benefit from taking a type of HRT, this is only one part of treatment for the menopause. Some women choose not to take HRT or cannot take HRT due to medical reasons and so there are alternative treatments available. These will be discussed with you.

We will discuss everything from lifestyle changes and the risks and benefits of HRT, to general health advice which will help manage long-term risks of osteoporosis and heart disease creating a holistic menopause management plan specifically for yor individual circumstances.

It is important to understand the benefits and risks when deciding whether to have hormone replacement therapy (HRT). Studies in the early 2000’s were published highlighting the potential risks and as a result, some women and doctors have been reluctant to use HRT. More recently published findings show that although not entirely risk free, it remains the most effective solution for the relief of menopausal symptoms and is also effective for the prevention of osteoporosis and in certain age groups provide protection against heart disease and possibly even dementia (further research needed).

So, recent evidence says that the risks of HRT are small and are usually outweighed by the benefits.

The risks are usually very small, and depend on the type of HRT you take, how long you take it and your own health risks.

Breast cancer risk:

There is little or no change in the risk of breast cancer if you take oestrogen-only HRT.

Combined HRT (oestrogen and progestogen) may be associated with a small increased risk of developing breast cancer.

The increased risk is related to how long you take HRT, and it falls after you stop taking it.

Young women (under 51 years) taking HRT do not have a greater risk of breast cancer

Blood clots

The evidence shows that:

Taking oral HRT (tablets) can very slightly increase your risk of blood clots

There is no increased risk with transdermal HRT (patches or gels)

Heart disease and strokes

When HRT is started before the age of 60 years, it does not significantly increase the risk of cardiovascular disease (including heart disease and strokes) and may actually reduce your risk.

Taking HRT tablets is associated with a small increase in the risk of stroke, but the risk of stroke for women under age 60 is generally very low, so the overall risk is still small.

Please speak to us about your risk as this will also depend on your own individual circumstances.

If you are GP at Hand then you will pay a normal prescription rate if the HRT is prescribed on the NHS. Currently, a prescription for HRT costs £9.35 – or £18.70 if you need two types of hormones (oesetrogen and progesterone even if in the same tablet). This is often only provided on a short-term basis, meaning that the cost has to be paid regularly, once a month or every three months. Once stable, we will prescribe you up to 6 months at a time. However, there is a new government proposal where HRT prescriptions will be made available on an annual basis, meaning that you only need to pay the prescription charge once a year. This could reduce the cost by between £90 and £200.

We prescribe most HRT on the NHS. If you are wanting a specific type of HRT ( e.g. Androfeme a testosterone that is unlicensed in UK) then this is a private prescription where you will be charged in the pharmacy for the price of the medicine plus a dispensing fee.

Private patients:

We can prescribe most HRT privately. Some may be‌ ‘blacklisted’‌ ‌which means they need to ‌undergo‌ ‌an‌ ‌approval‌ ‌process‌ ‌via‌ ‌head‌ ‌office‌ ‌to‌ ‌issue ensure‌ ‌clinical‌ ‌appropriateness‌.

We can never prescribe any form of testosterone as we do not prescribe controlled medication.

As with all private prescriptions you will be charged in the pharmacy for the price of the medicine plus a dispensing fee. We cannot determine the cost of a private prescription, as this will differ between pharmacies. Please contact your local pharmacy for the cost of your private prescription. You may contact other pharmacies to compare the cost of your prescription.

We are happy to initiate HRT with you but we would like you to continue your ongoing care with your NHS GP, therefore, we will normally only prescribe a maximum of 3 months HRT at a time. Since most of the HRT we prescribe is available through the NHS it is advisable to continue your care with your NHS GP.

As the consultation times are the same 10min appointment time as a normal appointment we may not be able to get through everything and will follow up with you. We may give you some resources to explore whilst we decide on next management steps.

If you have started a new treatment such as HRT we would like to see you after three months as this gives time for the HRT to work and for any side effects to settle. If you’d like to be seen before three months, then, of course, you can book an appointment at an earlier date.

Following the initial follow-up, we recommend a digital first review every 6-12 months thereafter to continue to get prescriptions.

If you are prescribed testosterone (only if you are an NSH/GP at Hand patient) you will need a follow-up appointment and blood test at three months and then 6 to 12 months thereafter to continue to get prescriptions.

The term ‘bio-identical’ literally means the product has the same molecular structure as the hormones produced in the body;

• Regulated bioidentical hormones (rBHRT) - these are what might be referred to as Body Identical HRT - they are hormones derived from plants and produced by pharmaceutical companies and undergo strictest testing and regulations. These regulated HRT products are the only products that are available on the NHS which we will prescribe for you and if you are a private patient it means you can continue your HRT treatment through your NHS practice.

• Compounded bioidentical hormones (cBHRT) are produced by a compounding pharmacy for private clinics and here the term ‘bio-identical hormone therapy’ is often misused and is widely marketed as a ‘natural’ alternative to conventional HRT.

This type of HRT is not regulated with the rigorous licensing standards which apply to normal pharmaceutical products. There is no evidence to support this way of testing the compounds and no regulations to support their safety in the UK. A further limitation is that quite worryingly the transdermal (cream) micronised progesterone may not protect your uterine lining. Mainstream scientific, clinical and regulatory bodies in women's health advise against the use of these products. Additionally, this costly practice of complex blood and saliva tests and the compounded products are significantly more expensive than the cost of private or NHS prescriptions. Paying more does not mean better. We do not prescribe these.

Testosterone is an important female hormone and levels naturally decline throughout a woman’s lifespan but particularly profound after a surgical and medical menopause and premature ovarian insufficiency. Testosterone deficiency can contribute to a reduction in your libido, sexual arousal but also a reduction in energy levels, cognitive function often described as ‘brain fog’ and joint pains.

There are no testosterone products for female use licensed in the UK.

NHS (GP at Hand patient):

We can prescribe a testosterone gel on an NHS prescription. AndroFeme is not available on the NHS, but if appropriate, can be issued as a private prescription.

Private patients:

Unfortunately if you are a private patient we will not be able to prescribe this for you due to it being a controlled drug.

If we have suggested that you may benefit from testosterone treatment, you will have heard us mention that it will be prescribed ‘off-licence.’ You may also hear the terms ‘unlicensed medicine’ or ‘off-label’. So what do they mean?

A drug company must have a product license to advertise and sell a medicine and this licence will state which illness or condition the medicine has been approved to treat.

Unlicensed and ‘off-label’ medicines are only prescribed after careful consideration and should be supported by appropriate evidence and experience.

Off-label use is when the medicine has a licence, but it’s not for the condition that you have and is being used in a way that is different to the licence. While testosterone gel isn’t licensed for use in women, only men, it has been prescribed off-label for treating menopausal symptoms for some time and it’s also endorsed by the National Institute of Clinical Excellence Guidelines on the menopause.

Unlicensed use means a medicine has a licence in other countries but not the UK. It has to be imported because it is not available in the UK. AndroFeme is unlicensed in the UK but can be written as a private prescription.