The video version of this podcast can be found here:
· https://youtu.be/2sD5P3AfRq0
This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.
NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review a section of the NICE guideline on Hypertension in adults, always focusing on what is relevant in Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer:
The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.
In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
Primary Care guidelines podcast:
· Redcircle: https://redcircle.com/shows/primary-care-guidelines
· Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK
· Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148
There is a YouTube version of this and other videos that you can access here:
- The Practical GP YouTube Channel:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The NICE clinical guideline on Menopause: identification and management
[NG23] can be found here:
· https://www.nice.org.uk/guidance/NG23
The link to the visual aid on HRT and the likelihood of some medical conditions can be found here:
· https://www.nice.org.uk/guidance/ng23/resources/incidence-of-medical-conditions-with-and-without-hrt-a-discussion-aid-pdf-13553199901
The FSRH Guideline: Contraception for Women Aged Over 40 Years can be found here:
· https://www.cosrh.org/Common/Uploaded%20files/documents/fsrh-guideline-contraception-for-women-aged-over-40-years.pdf
The recommendations by the British Menopause Society on the management of unscheduled bleeding on hormone replacement therapy (HRT) can be found here:
· https://thebms.org.uk/publications/bms-guidelines/management-of-unscheduled-bleeding-on-hormone-replacement-therapy-hrt/
Transcript
If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description.
Hello and welcome, I’m Fernando, a GP in the UK. Today we are reviewing the NICE guideline on the menopause, always focusing on what is relevant in Primary Care only.
Today we will focus on early menopause, and premature ovarian insufficiency.
In the previous three episodes, we covered diagnosis, symptom management and HRT risks and benefits in people aged 45 and over.
Right, let’s jump into it.
In terms of disease prevention, NICE says we should not offer combined or oestrogen-only HRT for the primary or secondary prevention of cardiovascular disease or for the purpose of dementia prevention.
For cardiovascular risk reduction, and dementia prevention we should follow the relevant NICE guidelines on those subjects.
Now let’s look at premature ovarian insufficiency, which applies to people under 40.
Premature ovarian insufficiency is diagnosed in people under 40 based on symptoms, including no or infrequent periods and elevated FSH levels on 2 blood samples taken 4 to 6 weeks apart. We should not diagnose premature ovarian insufficiency based on a single blood test.
If there is doubt about the diagnosis, we should seek specialist advice.
For premature ovarian insufficiency, NICE says we should offer sex steroid replacement, unless it is contraindicated. This can be either HRT or a combined hormonal contraceptive.
We should explain the importance of hormonal treatment until at least the age of natural menopause, unless there is a contraindication.
We should advise that both HRT and combined oral contraceptives offer bone protection and that HRT may have a beneficial effect on blood pressure compared with a combined oral contraceptive.
On the other hand,HRT is not contraception, so contraception still needs to be discussed if pregnancy is possible and not wanted.
We should also explain that the baseline population risk of diseases such as breast cancer and cardiovascular disease increases with age, and is very low in people under 40.
If hormonal treatment cannot be taken, we should still give advice on bone health, cardiovascular health, and symptom management and consider specialist referral if necessary.
Let’s now look at early menopause, which is defined as menopause between the ages of 40 and 44.
Here the benefits and risks of taking or not taking HRT are likely to sit between those for premature ovarian insufficiency and those for people aged 45 or over.
In premature ovarian insufficiency, that is, before 40, the potential benefit of HRT is usually greater, because we are not only thinking about the risks of HRT but also the risks of not taking it, particularly in respect of bone health. As we know, HRT helps reduce fragility fracture risk.
In early menopause, between 40 and 44, the same issue still applies, but to a lesser extent, so the balance of risks and benefits sits between premature ovarian insufficiency and menopause at 45 or over.
In simple terms, the younger the person is at menopause, the more important it is to consider the health effects of not taking HRT. As always, the discussion should be tailored to the person’s age, circumstances, and individual risk factors.
Now let’s look at starting and stopping HRT.
Firstly, if the person has a medical condition that may be affected by HRT, we should consider seeking specialist advice before starting it.
For symptoms control, we should offer combined HRT to people with a uterus and oestrogen-only HRT to people who have had a total hysterectomy and use the lowest effective dose.
For people with a uterus, we should explain that vaginal bleeding is a common side effect during the first 6 months of taking systemic HRT, or within 3 months of changing the dose or preparation.
They should also be advised to seek medical help promptly if unscheduled vaginal bleeding happens beyond these timeframes.
There is limited evidence for unscheduled bleeding while on HRT, and NICE signposts the British Menopause Society guidance on unscheduled bleeding on HRT.
Let’s have a look at what they say:
The British Menopause Society guidance say that we should first assess the patient fully, including, amongst other things, the bleeding pattern, adherence, examination, BMI, and individual risk factors for endometrial cancer.
Major risk factors include a BMI of 40 or more and some hereditary conditions. Minor risk factors include a BMI between 30 and 39, diabetes, and polycystic ovarian syndrome.
In people at low risk, if bleeding occurs within 6 months of starting HRT, or within 3 months of changing it, we will adjust the progestogen or HRT preparation, for 6 months in total, before arranging further investigations.
If unscheduled bleeding continues in low-risk women, after six months of adjustments, we could request an urgent transvaginal ultrasound. We should also do this if bleeding first occurs more than 6 months after starting HRT, or more than 3 months after changing treatment, and also if bleeding is heavy, prolonged, or if there are 2 minor risk factors.
An urgent suspected cancer referral is recommended if there is 1 major risk factor or 3 minor risk factors for endometrial cancer, regardless of bleeding pattern or timing.
Now let’s go back to the NICE guideline and look at stopping HRT.
NICE says we should offer a choice between gradually reducing treatment or stopping it immediately. Gradually reducing it may decrease recurrence of symptoms in the short term but it makes no difference in the long term.
Finally, systemic HRT should be stopped in people diagnosed with breast cancer.
What should we cover during an HRT review?
We should encourage nationally recommended health screening and, at 3 months, we should review the effect of HRT on menopausal symptoms.
After that, treatment should be reviewed annually, unless there is a clinical reason to review sooner, such as poor response or side effects. If HRT is not effective or tolerated, we should seek specialist advice.
So that is it, a review of a section of the NICE guideline on the menopause.
We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.
Thank you for listening and goodbye.
