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Early menopause - under 45 (DRAFT)

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Overview

Early menopause is defined as menopause under the age of 45years and is relatively common, predicted to occur in 8-12% of women. Diagnosis of early menopause is often delayed and can cause emotional distress, particularly in individuals hoping to become pregnant.

Women diagnosed with menopause under the age of 40 should be managed as POI

Symptom management and long-term health implications are relevant in this group, including increased risk of cardiovascular disease, osteoporosis and cognitive impairment.

Diagnosis

Under age 45 at time of diagnosis
Oligo/amenorrhoea for >4months duration
Elevated (>25 iu/L) FSH on at least two occasions, measured at least 4-6weeks apart (do not measure FSH whilst a patient is using combined hormonal contraception, estradiol or injectable contraceptives)

NB: FSH measurement is not required in women over 45y old with menopausal symptoms.

In women under 45y, with possible menopausal symptoms and two normal FSH results, other causes for her symptoms should be explored. If no other cause is found, offer a 6-month trial of HRT (there is a high placebo rate in the first 3 months) and if good symptom control is achieved, provide a diagnosis of early perimenopause, instigate investigations for a cause and continue treatment with HRT. For all women, test and manage as appropriate:

Thyroid function
HbA1c
Lipids
Anaemia screen – folate/ferritin/B12
Blood pressure
BMI

Management

Hormone replacement in the form of hormone replacement therapy (HRT) (or combined contraceptive pill) up until the age of 51:

Reduces the long-term risk of cardiovascular disease and osteoporosis, and has a beneficial effect on cognition if started within 5-10 years of symptom onset. 
Provides symptom control   
HRT does not increase the risk of breast cancer in this group up until the natural age of menopause compared to the general population. 
Follow the local HRT guidelines for advice on prescriptions.
The combined oral contraceptive can be used as an alternative to HRT (unless contraindicated) and has the additional benefit of providing contraception. This should be stopped by age 50.
If symptomatic, topical oestrogen can be used to treat genitourinary symptoms in addition to systemic HRT

Lifestyle advice  

Balanced diet, adequate calcium and vitamin D intake (consider replacement), weight bearing exercise, smoking cessation and avoidance of excess alcohol.

Fertility and contraception

Contraception should be discussed and offered as appropriate in line with FSRH guidelines. HRT is not contraceptive. If eligible, the combined oral contraceptive can be used as an alternative to HRT and offers both hormone replacement and contraception.

Women wishing to discuss their fertility options and considering treatment should be informed that unfortunately there is no NHS fertility assessment and treatment provision for those ≥39y (Infertility Assessment and Treatment Policy.docx. Women who fall outside of ICB referral criteria for NHS fertility assessment can be informed that they can seek private fertility consultation and licenced fertility clinics can be found at www.hfea.gov.uk

Early menopause health screening

Women who have experienced an early menopause are at an increased risk of metabolic syndrome, even with prompt HRT.

This should be discussed and considered at their annual review, and they should be offered:

HbA1c
Lipid profile
Blood pressure
BMI
Lifestyle advice

Resources

Patient Resources

15-WHC-FACTSHEET-The-Menopause-NOV2022-B.pdf (womens-health-concern.org)

Early menopause - NHS (www.nhs.uk)

Women's Health Concern | Confidential Advice, Reassurance and Education (womens-health-concern.org)

Resources and Guidelines

Optimising health after early menopause - The Lancet

Diagnosis of menopause and perimenopause | Diagnosis | Menopause | CKS | NICE

BMS-Menopause-Practice-Standards-JULY2022-01D.pdf (thebms.org.uk) – Standard 10

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