There is a concerning message in the media currently, that all symptoms in women aged >40 years are due to oestrogen and/or testosterone deficiency. We must question this. Primary care clinicians are well placed to know a woman’s history and to provide holistic care in the context of a patient’s background; these are the strengths of general practice. We highjacked the title for this editorial from a BJGP editorial on artificial intelligence (AI).1 While optimal AI could help women to manage the menopause transition and beyond, we should acknowledge that menopause management is an historic issue, which long predates AI, social media, and misinformation. GP education, mentorship, and support are likely to be the better solution, with human factors needed to counter the impact of menopause on quality of life and to ensure individualised care.2
Optimism
The average age of menopause (1 year after a women’s last menstrual period) in the UK is 51 years, compared to 46 years for perimenopause. For most women, this is an inevitable life stage, and it is important that women receive accurate information from educated clinicians rather than influencers, long before menopause occurs, to enable them to make an informed choice in relation to treatment options, of which there are many. A well-informed primary care consultation, supported if needed by specialists in secondary care, offers women holistic care, likely associated with better outcomes.
The BMS’s ‘Management of the Menopause Certificate’ is now available.5 This is a comprehensive online education package, including peer-reviewed information and assessment, with certification on successful completion of the programme, done at the learner’s own pace. This removes the ‘bottle neck’ associated with the lack of certified menopause trainers and enables all registered medical practitioners to access the necessary information to ensure that the most up-to-date advice is shared with patients and individualised care is supported, as recommended by the National Institute for Health and Care Excellence.6
All women are entitled to high-quality NHS care to support their reproductive health. Improved access to the right care with the opportunity to reset risk, where possible by engaging in manageable lifestyle changes, has the potential to support women to accept rather than fear menopause. Critical thinking in relation to the current evidence base ensures patient safety, and patients need to be able to trust their clinician.
The perimenopause bridges the gap between reproductive life and post-reproductive life. This transition can be associated with wide fluctuations in hormone levels, due to persistent and sometimes intermittent production of oestrogen by the ovaries, which also continue to produce eggs intermittently. Oestrogen spikes in this population can result in common oestrogenic side effects, such as headache, nausea, and breast pain. In susceptible women, estradiol peaks may be a trigger for migraine and seizures.7,8 For women presenting with potential menopausal symptoms in their early 40s, it is important to consider that they are potentially fertile and to factor in whether pregnancy is a wanted outcome. If not, then there are a range of pills containing natural oestrogens, which can, in eligible women9 who decline a levonorgestrel intrauterine device, provide both contraception and hormone replacement.
For menopausal women, it’s helpful to consider early, intermediate, and long-term consequences associated with low levels of oestrogen. Vasomotor symptoms (VMS) are the commonest acute symptom of menopause, with around 50% of women still experiencing symptoms after many years.10 Oestrogen is the best treatment in eligible women who want treatment. Progestogens are added to prevent endometrial hyperplasia and cancer in women with an intact uterus and for some women who have undergone hysterectomy, where the cervix has been conserved or where there is a history of endometriosis.
The neuroendocrine antagonist drugs, which recently came to market, with fezolinetant (Veoza)10 available currently on private prescription, are a non-hormonal treatment option and a welcome addition to clonidine, the only other alternative licensed non-hormonal treatment option for VMS. Other non-hormonal treatment options to manage VMS include selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, oxybutynin, and gabapentin/pregabalin. Additional common acute menopausal symptoms include mood-related issues and musculoskeletal problems. These may be caused or exacerbated by menopause and are less directly linked to menopause, when compared to VMS and sleep disturbance.
Genitourinary syndrome of menopause (GSM) can first occur several years after menopause and the relationship with reduced oestrogen levels may be lost. Women may fail to disclose symptoms including vaginal dryness, itching, burning, pain with sex, and bladder problems. Local oestrogen therapy can be very effective but needs to be continued long term before moving to second line options such as dehydroepiandrosterone and ospemifene.11
GSM and relationship issues are important when considering hypoactive sexual desire disorder and use of testosterone for women. Testosterone is not an essential hormone for women but rather a female hormone that declines with age. Use of the descriptive term ‘deficiency state’ is incorrect. It is reasonable to consider the addition of testosterone once HRT has been optimised and some women benefit while others do not.12 Therefore, the media storm suggesting that all women need testosterone is misleading. The BMS’s ‘Tools for Clinicians’ is freely accessible to primary care clinicians and offers supportive advice to GPs.13 However, prescribing testosterone for women may be limited by local area prescribing committee guidelines, which influence practice-based decision making. A further challenge is the lack of a licensed testosterone product for women in NHS health care, but potential benefits with use are associated with a high placebo response and testosterone for women may have been overpromoted.
Long-term consequences of low levels of oestrogen can include cardiovascular disease and osteoporosis.
Blood tests are rarely needed to diagnose the menopause or to monitor response to HRT. Overprescribing of high-dose oestrogen, sometimes with minimal progestogen, has been associated with an increase in referrals for bleeding.14 We must be mindful that resources are being wasted and urge clinicians to continue to question whether they are doing the right thing for their patients.
Misplaced patient expectations, particularly in older women with comorbidities, may lead to inappropriate prescribing of HRT, potentially putting such patients at risk of harm. Primary care clinicians have access to the full patient record and with this resource are best placed to individualise care, engaging pragmatism, caution, and optimism, in association with realism.
