Referral - Menopause (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. Specific Remedy pages based on common advice and guidance queries may provide useful advice.

Indications for referral include:

• HRT treatment resistance - ongoing symptoms despite trialling different preparations and dosages (please list in referral) 
• HRT side effects - leading to cessation such as progestogen sensitivity despite trialling different preparations and ensuring oestrogen optimisation (please list if referring) or unscheduled bleeding with normal investigations which has not responded to measures as outlined in the BMS guideline(1) - (page 29, table 6 in full joint guideline document).
• Premature Ovarian Insufficiency - this can be managed in primary care if there is a GP menopause specialist who can undertake the counselling / investigations for causes and health effects, contraception, fertility aspects and symptom management. Otherwise refer.
• 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 where surgery is proposed in conditions such as BRCA / Lynch. 
• History of breast or oestrogen receptor positive cancer - women with these cancers and with symptoms of menopause can be referred. Please include receptor status, grade, year of diagnosis and any ongoing adjuvant therapy. See further advice of the following Remedy pages: Hormone sensitive cancers and Breast conditions.

Before Referral

Before considering referral, please review individual Remedy pages for advice on management in specific groups:

• 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
• Gynaecology USC

Testosterone Treatment **work between the ICB, primary and secondary care is ongoing regarding testosterone prescribing in primary care to establish clearer guidance for practices. This includes defining a menopause specialist, guidance on management of testosterone initiated by private practice (please see p22 of the Access Policy for general guidance on private referrals BNSSG ICB Elective Care Access Policy August 2024) and a review of the cohorts of women who are eligible for testosterone (outcome expected Dec 24).  We will update Remedy by early 2025**

Please note that there are criteria for consideration of testosterone treatment. If referring outside of these criteria then please manage patient expectation as referrals may not be accepted and may be returned with advice

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

If testosterone therapy is started through a private provider ideally they should continue to provide follow up and monitoring until the patient is seen by an appropriate NHS prescriber. Please note patients who continue to take testosterone require ongoing blood level monitoring every 6 months until stable when it can change to annually. 

Red Flags

Post menopausal Bleeding

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

Referral

Advice and Guidance

UHBW and NBT have Gynaecology Advice & Guidance via eRS if specific advice is required that is not covered in the Menopause sections on Remedy.

UHBW -Complex Menopause and Oncology Menopause Service.

Referrals to the menopause service at UHBW are through a Triage Service 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 which may mean the patient does not need to be seen in clinic. If advice is not felt to be appropriate a clinic appointment can still be offered without requiring a new 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. 

NBT - Gynaecology Clinic

Menopause is seen within General Gynaecology at NBT . Refer via eRS to General Gynaecology.

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 letter specifying concerns. Referrals with just a list of consultations are difficult to triage and do not support effective clinical care.
• If referring for testosterone therapy – please ensure criteria for referral are met and include the baseline testosterone levels in the referral and what has been done to optimise symptoms before referring. 

Resources

(1) Management of unscheduled bleeding on hormone replacement therapy (HRT) - British Menopause Society - links to summary page. Full document can also be accessed via this page.

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.