Menopause Advice & Guidance (A&G) Service (Pilot) - Devon

Key Messages

The Devon Menopause A&G Service (Pilot) will provide specialist advice and guidance support relating to the management of menopause symptoms to Primary Care Clinicians across Devon.

This service will be provided by Sexual and Reproductive Health Consultants and British Menopause Society trained GPs.

The response time back to General Practice will be within two weeks. This will be extended to three weeks in the case of reduced service capacity or excessive demand, verified by the commissioner (NHS Devon ICB).

Please include all relevant recent investigation results (for example but not limited to ultrasound reports, hormone profiles and histology results) and clinic letters

This service does not have access to results, letters or healthcare records.

Guidance on the management of menopause can be found here:

Guidance on the management of menopause - South & West (devonformularyguidance.nhs.uk)

Scope

Patients whose symptoms are not controlled after two HRT preparations tried for a minimum of 3 months per preparation
Patients with complex histories where safe prescription of HRT is unclear
Patients under the age of 40 with confirmed diagnosis of premature ovarian insufficiency (iatrogenic or spontaneous) where management advice is required
Patients with persistent unscheduled bleeding on HRT with endometrial thickness less than 4mm on continuous combined HRT who have failed to respond to primary care management
Patients with persistent unscheduled bleeding on HRT with endometrial thickness less than 7mm on sequential HRT who have failed to respond to primary care management
Patients with persistent unscheduled bleeding less than six months after starting HRT or less than three months after changing HRT preparation in patients without risk factors for endometrial cancer (see unscheduled bleeding pathway)

Please see the ‘Red Flags’ section to ascertain if urgent suspicion of cancer referral is required.

Out of Scope

Postmenopausal bleeding – please see Postmenopausal Bleeding (no HRT) and Unscheduled Bleeding on HRT CRGs
Bleeding where there is suspicion of cancer or risk factors for cancer.

Please see the ‘Red Flags’ section to ascertain if urgent suspicion of cancer referral is required.

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History

medical history (including details of menopause symptoms, treatments trialled etc.)
current medication
any allergies
smoking status
relevant family history (breast cancer, ovarian cancer, Lynch syndrome, VTE, Cowden syndrome, endometrial hyperplasia/cancer)

Examination

recent blood pressure
BMI

Symptoms suggestive of:

Endometrial cancer – refer on Urgent Suspected Cancer Pathway

Not taking HRT - women with an intact uterus with post-menopausal bleeding (unexplained vaginal bleeding more than 12 months after menstruation has stopped because of the menopause)

Taking HRT - unscheduled bleeding with concern of endometrial cancer:

Risk factors for endometrial cancer include:

MAJOR risk factors – any of:

BMI 40 or more
Unopposed oestrogen more than 6 months (in women with a uterus)
Sequential HRT more than 5 years when started after age 45
Inadequate progestogen more than12 months*
Familial risk (Lynch/Cowden syndrome)

MINOR risk factors: 3 or more of:

BMI 30-39
Diabetes
PCOS (or other causes of anovulatory cycles)
Unopposed oestrogen 3-6 months
Inadequate progestogen 6-12 months*

*Inadequate progestogen includes:

Tricycling HRT (quarterly progestogen)
Norethisterone or Medroxyprogesterone acetate for less than 10 days/month
Micronised progesterone for less than 12 days/month
Expired LNG-IUS
Tamoxifen use

Possible underlying disease, e.g. liver cirrhosis, oestrogen producing tumour

Please consider an up-to-date FBC prior to referral

Please include all relevant recent investigation results (for example but not limited to ultrasound reports, hormone profiles and histology results) and clinic letters

This service does not have access to results, letters or healthcare records

Guidance on the management of menopause:

South & West Devon Prescribing Formulary

Guidance on the management of unscheduled bleeding on HRT:

2024 BMS Joint Guideline

Referral Criteria

Patients whose symptoms are not controlled after two HRT preparations tried for a minimum of 3 months per preparation
Patients with complex histories where safe prescription of HRT is unclear
Patients under the age of 40 with confirmed diagnosis of premature ovarian insufficiency (iatrogenic or spontaneous) where management advice is required
Patients with persistent unscheduled bleeding on HRT with endometrial thickness less than 4mm on continuous combined HRT who have failed to respond to primary care management
Patients with persistent unscheduled bleeding on HRT with endometrial thickness less than 7mm on sequential HRT who have failed to respond to primary care management
Patients with persistent unscheduled bleeding less than six months after starting HRT or less than three months after changing HRT preparation

Please see the ‘Red Flags’ section to ascertain if urgent suspicion of cancer referral is required.

Referrals submitted without this information may be returned.

History

medical history
current medication
any allergies
smoking status
relevant family history (breast cancer, ovarian cancer, Lynch syndrome, VTE, Cowden syndrome, endometrial hyperplasia/cancer)
relevant recent investigation results (for example ultrasound, bloods and histology) and clinic letters (DMS does not have access to results, letters or healthcare records)

Examination