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A raised FSH should be repeated for confirmation , six weeks after the first test . No other blood test needs to be done ( unless symptoms suggest another diagnosis ) – in particular , we should not request anti-Müllerian hormone ( AMH ) in primary care . 2 It is sometimes requested by women concerned about their fertility at this time of life , but should only be done in secondary care as part of fertility investigations .
Miss P ’ s symptoms are all consistent with the menopause . As well as vasomotor symptoms ( hot flushes / night sweats ), the menopause can cause cognitive impairment , mood disorders , urogenital symptoms , altered sexual function , sleep disturbance , joint pain , headaches and fatigue .
You explain that you think she is going through the perimenopause and ask if she wants to start HRT . She looks horrified and says she has heard HRT gives you breast cancer . It would be good idea if you are familiar with the statistics about HRT and breast cancer so you can reassure her .
The link between HRT and breast cancer periodically hits the headlines , usually in a badly reported and oversensationalised way . This last happened in 2019 after the publication of a paper in The Lancet 4 and invariably the reporting uses relative risk ( eg ‘ increases by one-third ’) rather than absolute risk ( eg one extra case in 50 women ). Relative risks make better headlines .
Before discussing this in detail , it is important to know about the different types of HRT available . It is the lack of oestrogen that causes menopausal symptoms , and symptoms will improve if a woman is given oestrogen alone .
However , over many years , unopposed oestrogen will cause proliferation of the endometrium , which can lead to endometrial cancer . Women who still have their uterus therefore need to have progesterone , either cyclically or locally in the form of a Mirena intrauterine system ( IUS ), to protect their endometrium . Those who have had a hysterectomy can usually have oestrogen-only HRT ( although this may not be the case if they have endometriosis ). Miss P would need combined HRT and as she is within a year of her last period , she should have cyclical rather than continuous progesterone to minimise the risk of irregular bleeding .
Detailed discussion of different preparations is impossible in a short module such as this , but an option would be oestrogen gel ( as we know that topical HRT carries a lower risk of venous blood clots than oral ) with the progesterone in the form of micronised progesterone tablets for two weeks every month , or a Mirena IUS . The latter would also provide Miss P with contraception , which she will need for two years after her last period ( this drops to one year if the last period occurs after the age of 50 ).
The risks of breast cancer for five years ’ use of HRT for women aged between 50 and 69 are as follows :
One extra case per 50 women taking combined HRT with daily progesterone .
One extra case per 70 women taking combined HRT with cyclical progesterone . One extra case per 200 women taking oestrogen alone . As the background risk of breast cancer is approximately three out of 50 in this age group , it is technically correct to say that an extra case is ‘ an increase of one-third ’, but the absolute figure puts the risk into greater perspective . 5
It is also worth discussing that HRT has not been associated with an increase in mortality from breast cancer 6 and that the risk of breast cancer is increased by much more due to factors such as obesity , a sedentary lifestyle and alcohol use . It is likely this risk will fall further in years to come , with increasing use of the Mirena and micronised progesterone in HRT regimens , but there are as yet no data to confirm this .
Miss P says she is strongly considering HRT , but wants to think about it a bit more . Give her any information you may have , and tell her about non-hormonal alternatives .
If a woman cannot take HRT ( for example , a history of breast cancer is usually an absolute contraindication ) then there are alternatives . These include fluoxetine , gabapentin , venlafaxine or clonidine for vasomotor symptoms , cognitive behavioural therapy or antidepressants for low mood and vaginal lubricants for genital symptoms . 1 Women for whom systemic HRT is contraindicated can often also use topical HRT to the genital area , but if a woman has a history of breast cancer it is always worth checking with her oncologist . It is difficult to advise on herbal and alternative therapies – primary care professionals are not trained , and arguably not indemnified , to do so , and two different preparations may have very different amounts of the active ingredient . However , there is information out there about herbal medicines for the menopause and so a woman can be advised to do her own research . You might direct her to the RCOG ’ s patient-facing site 7 or the women ’ s health concern factsheet on alternative and complementary . 8 For general information , a woman could try the ‘ Rock my menopause ’ site 9 by the Primary Care Women ’ s Health Forum , the RCOG information hub 10 or the leaflets available on the Patient website . 11
Miss P thanks you for your advice and decides to go away to consider options . She returns a week later to ask for a prescription for HRT . Three months later you review her and are delighted to hear that she is ‘ like a new woman ’, has been promoted at work and is now making it her mission to tell all her friends about HRT .
October is Menopause Awareness Month , with October 18 designated World Menopause Day . Visit the international Menopause Society at imsociety . org for further information
References 1 NICE . Clinical knowledge summary . Menopause . London : NICE , 2020 . bit . ly / 3t3OKWk 2 NICE . Menopause : diagnosis and management . London : NICE , 2019 . nice . org . uk / ng23 3 South Tees Hospital . Follicle stimulating hormone . bit . ly / 3kEWeLO 4 Collaborative group on hormonal factors in breast cancer . Type and timing of menopausal hormone therapy and breast cancer risk : individual participant meta-analysis of the worldwide epidemiological evidence . Lancet 2019 ; 394 ( 10204 ): 1159-1168 5 Climént-Palmer M and Spiegelhalter D . Hormone replacement therapy and the risk of breast cancer : How much should women worry about it ? Post Reproductive Health 2019 ; 25 ( 4 ): 75-178 6 Primary Care Women ’ s Health Forum , 2020 . Menopause – guidance on management and prescribing HRT for GPs bit . ly / 3zKc91y 7 Royal College of Obstetricians and Gybaecologists . HRT and alternatives . London : RCOG . bit . ly / 38I5QA5 8 Womens Health Concern . Factsheet : Complementary and alternative therapies . Non-hormonal prescribed treatments . bit . ly / 3jyC3Qy 9 Primary Care Women ’ s Health Forum . Rock My Menopause . rockmymenopause . com 10 Royal College of Obstetricians and Gynaecologists . Menopause and women ’ s health in later life . London : RCOG . bit . ly / 2V3eV37 11 Patient . Menopause . bit . ly / 3mQizJ4
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