Title: The Initial Menopause Consultation
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Menopause consultations are becoming more complex because of the various therapies and the controversies regarding hormone replacement therapy (HRT). The following details useful information from the patient and any assessment that may be required.
Patient history
1. Periods, symptoms and contraception
- Date of last menstrual period [could she be pregnant?]
- Frequency, heaviness and duration of periods
- Hot flushes and night sweats?
- Vaginal dryness?
- Other symptoms?
- Contraception
2. Personal or family medical problems
a] Breast/ ovarian/ bowel cancer in close family members
- in parents, sisters or brothers or the patient?
- at what age did they develop it?
b] Deep vein thrombosis or pulmonary embolism
- in parents, brothers or sisters or the patient
- when and why: was it after a hip or knee replacement?
- was the person on the “Pill” or pregnant?
- did they have any test to confirm the clot?
- were they treated with warfarin?
c] Risk factors for heart disease and strokes?
- has the patient had a heart attack or stroke already ?
- have her parents, brothers or sisters had a heart attack or stroke and if so at what age?
- smoking and if so how many?
- hypertension or diabetes?
- high cholesterol level?
d] Risk factors for osteoporosis
- was the menopause before the age of 45?
- systemic corticosteroids for 6 months' or more?
- anorexia or significant weight loss?
- family history (especially mother or sister) ?
- low calcium or Vitamin D intake or deficiency, or malabsorption disorders
- has the patient had a fracture already, and if so how did it happen and where was it?
e] Other
- migraines, not just headaches
- what medicines are being taken including herbal remedies and vitamin supplements
- risk of pregnancy?
3. What does the patient want?
- does she want to take HRT or not?
- if yes, what preparation would she prefer
- if not what are her most important treatment endpoints
Examination
Physical examination should include BMI and BP. In March 2001, The Committee on Safety of Medicines (CSM) advised that clinical examination of the breasts and pelvic examination is not routinely necessary in all women taking HRT, but should be performed if clinically indicated. These recommendations are in line for women taking the oral contraceptive pill.
Women should also be encouraged to participate in the national cervical screening programme (cervical smear testing), which invites women aged 25-64 in England and age 20-60 in Scotland. The national mammography screening programme and breast awareness must be discussed. In the UK all women aged 50-70 years are invited to have a mammogram every 3 years. This screening is also offered to older women but currently there is no automatic invitation. In the UK, the National Institute for Clinical Excellence has produced clinical guidance for the classification and care of women at risk of familial breast cancer in primary, secondary and tertiary care.
The words "clinically indicated" for pelvic examination should relate to past or current disease, symptoms or family history. It is important not to miss a pelvic mass, or a pregnancy.
It is a woman's evidence based patient choice to take or not to take HRT, and her decision must be recorded in the notes.
Sally Hope
Margaret Rees
March 2005
Revised January 2008.
Whilst great care has been taken to ensure the accuracy of information contained
in the fact sheets, the authors and the BMS cannot accept any responsibility
for any errors omissions, mis-statements or mistakes or for any loss or damage
arising from actions or decisions based on information contained in this publication.
Ultimate responsibility for the treatment of patients and interpretation of
published material lies with the medical practitioner. The opinions expressed
are those of the authors, not necessarily those of the BMS. The inclusion in
the publication of material relating to a particular product, method or technique
does not amount to an endorsement of its value or quality, or of claims made
by its manufacturer.
Margaret Rees and Sally Hope January 2008
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