Referral to Menopause Clinic (DRAFT)

Overview

***UPDATE OCTOBER 2024 - The waiting time for a clinic appointment is 6 months – this is in part due to 1/3 of  referrals being for consideration of testosterone therapy. The menopause team kindly ask that referrers check criteria before considering a referral. ***

Most patients with menopause can be managed in primary care. Some patients will require advice from or referral into secondary care services. Please review specific pages for advice. 

Services available in BNSSG include:

• UHBW have a Complex and Oncology Menopause Service, see referral guidance below.
• Referrals to NBT should be made via eRS to Gynaecology or the Reproductive Medicine clinic if fertility is a concern in POI (<40) - is this only for POI/fertility in which case the fertility policy would need to be applied - Infertility
• Gynaecology Advice and Guidance via eRS if specific advice is required and not covered in these pages. 

Please review individual Remedy pages for advice regarding referrals in specific groups. Follow advice on these pages:  

• Cardiovascular conditions and HRT
• VTE and HRT 
• HRT over 60
• Gynaecology Conditions and HRT

Bleeding Problems

If there are bleeding problems, review the relevant pages (Unscheduled bleeding on HRT and Post-menopausal bleeding) and make an appropriate referral

• Post menopausal bleeding - refer on USC pathway + request an USC pelvic ultrasound (Gynaecology - USC (2WW) 
• Unscheduled bleeding on HRT - A direct access pelvic ultrasound (TVUSS) request should be made with appropriate urgency.   
• Urgent Suspicion of Cancer (USC) ultrasound AND a USC pathway referral.  
• Urgent ultrasound request (6weeks) as per unscheduled bleeding on HRT pathway 

Before Referral

Before considering a referral please check advice on Remedy about how patients can be managed and supported in primary care and review the referral criteria below.

If a referral is needed then please ensure the appropriate service is requested.

If criteria are not met or you need further advice then consider using Gynaecology Advice and Guidance

Testosterone Treatment

Please note that there are criteria for referral to consider testosterone treatment. Referrals not meeting these criteria will be returned.

Please see the Testosterone for low libdo (DRAFT) page for details.

Recommended Referral Criteria

• HRT treatment resistance: ongoing symptoms despite trialling different preparations and dosages (please list in referral) 

• Side effects leading to cessation such as progestogen sensitivity (despite trialling different preparations and ensuring oestrogen optimisation – please list) or unscheduled bleeding (with normal investigations which has not responded to measures as outlined in the BMS guideline). 

• Premature Ovarian Insufficiency (this can be managed in primary care if there is a menopause specialist who can undertake the counselling / investigations for causes and health effects, contraception, fertility aspects and symptom management) 

• Medical comorbidities where oestrogen therapy can have deleterious effect such as Lupus, Epilepsy, Porphyria, unprovoked thrombosis, Fibroids, Endometriosis, Unstable liver disease, Connective tissue disorders, Histamine Sensitivity 

• Risk reducing surgery pre-operative menopause counselling such as for BRCA / Lynch. 

• Women with symptoms of menopause and a history of breast or an oestrogen receptor positive cancer (see Hormone sensitive cancers and Breast conditions): please include receptor status, Grade, year of diagnosis and any ongoing adjuvant therapy if taking. 

Red Flags

Post menopausal Bleeding

Please see the Gynaecology - USC (2WW) page for details 

Referral

Menopause Clinic at UHBW

Referrals to the menopause service at UHBW are through a RAS on eRS. 

To offer appointments as quickly and safely as possible, all referrals are triaged; an advice letter may be provided in the first instance instead of a clinic appointment. Following this, if an appointment is still needed, please make a further referral.

Those offered an appointment will be booked into the appropriate clinic (complex or oncology). Appointments cannot be expedited as all women referred are struggling with symptom control and complex conditions. 

Tips on making a referral: 

• If referring for HRT treatment resistance, please summarise their prior and current menopause therapies and ongoing symptoms 
• Make it clear WHY you are referring – which menopause service referral criteria do they meet, or what is the alternative reason requiring specialist input.
• Please include a referral summary letter. Referrals with just a list of consultations are difficult to triage and do not support effective clinical care.
• If referring for testosterone therapy – include the baseline testosterone levels in the referral and what has been done to optimise symptoms before referring. 

**If testosterone therapy is started through a private provider they need to complete the baseline, 3 months and 6-month follow-up before referral to the clinic for potential ongoing assessment will be accepted.  - I'm not sure about this statement as the patients should be able to be referred if they meet NHS criteria whatever their private status or stage of treatment.

Gynaecology Clinic at NBT

The gynaecology service at NBT does not have a specific menopause service. Do you know if they still accept referrals for patients regarding the menopause or would they reject and advice referral to UHBW

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.