A milestone in managing complex menopause

Since the opening of the complex menopause clinic in Cork University Maternity Hospital (CUMH) last year, there is now a complex menopause service in every hospital group in Ireland. As in all the regional clinics, the service at CUMH is funded by the National Women and Infants Health Programme (NWIHP) as a result of the Women’s Health Action Plan 2022-2023, which acknowledged that there was a need for a change in approach to menopause care in Ireland, with increased public supports for women before, during and after menopause.¹

The CUMH complex menopause clinic saw its first patients through the door last September. This clinic is run on a weekly basis with two 0.1 equivalent doctor sessions, one full time clinical nurse manager (CNM2) and a 0.5 part-time administrator. The clinic has eligibility criteria in order to make the best use of resources as the majority of women are able to receive menopause care within primary care without the need for additional input in a complex clinic setting. The criteria in CUMH are in line with the benchmark set by the National Maternity Hospital as the first established clinic, and includes patients with a previous or current history of conditions such as: 

• Established ischaemic heart disease, structural heart disease and arrhythmias
• Cerebrovascular disease and transient ischaemic attack (TIA)
• Venous thromboembolism and conditions leading to an increased risk of VTE
• Active liver disease
• Immunological disease
• Breast or hormone sensitive cancers
• Premature ovarian insufficiency (POI), ie. menopause before the age of 40 years.

In short, patients are usually those with an actual, perceived or historical contraindication to the use of hormone replacement therapy (HRT), or those with POI or an early menopause.

By virtue of catering for complex cases, the clinic usually requires access to relevant specialty letters stating the medical condition and treatment, investigations and histology, so as to have all relevant clinical information in advance of the first consultation so that a fully informed clinical opinion and discussion can take place. Otherwise, the consultation could result in delayed decision making. This can be a frustrating bureaucratic layer, especially for referring GPs, as currently most of this information cannot be sent as attachments via Healthlink, and usually must be sent separately via post or secure email. In time, we are hoping to have a standardised national referral template on Healthlink for all complex menopause clinics which will standardise the referral process.

As with most clinical services, there was a lead-in period and operational overview before the clinical aspect of the service started. This involved a significant amount of content creation such as: the design of pre-clinic patient questionnaires, defining the eligibility criteria and referral process; setting up templates; learning to work on a new patient software (Cerner); the creation of comprehensive patient information leaflets; and creating educational template replies for certain conditions and themes, which can usually be managed in primary care initially, such as family history of breast cancer, starting HRT in the late menopausal stage and progesterone sensitivity.

Initial consultation

Every patient who comes through the clinic fills out the clinic questionnaire which consists of a symptom checker (a modified version of the Greene Climacteric Scale) and pertinent clinical questions.² The symptom checker is useful as it can then be referred to over subsequent consultations when assessing response to treatment options. The clinic puts a lot of value on the first question in the questionnaire: “What is bothering you the most?”, as this ultimately leads the consultation and can be surprisingly different to what was anticipated based on information from the referral letter and symptom checker. 

The clinic also gathers information on factors affecting bone health, breast cancer risk and gynaecological history, as these are relevant to the overall benefit/risk to the patient of potentially starting HRT if this is an option for them. We ask for a contraceptive history and whether there is any use of contraception at present, as most women require contraception until the age of 55. Although fertility rates sharply decline in the perimenopause, pregnancy can still occur, and HRT is not a contraceptive unless the levonorgestrel 52mg IUD is being used as the progesterone component.³

We try to give all patients adequate time and space to feel listened to, and to discuss and implement a management plan. There is much to cover within a menopause consultation, irrespective of having a history, that can make this more challenging. Our aim is to provide individualised care while often balancing the paucity, or complete absence, of evidence pertaining to HRT in particular, for many of these conditions. Navigating uncertainty can be difficult and challenging for both the healthcare professionals and the patient, and this is an area in which we frequently find ourselves. Good communication is an essential component of good menopause care, and no more so than in a complex menopause setting. Acknowledging this uncertainty during the consultation is part of the process, which then usually leads to shared decision making.

We discuss health promotion with all patients and suggest lifestyle modification when indicated. This is because regardless of HRT usage, establishing good lifestyle and behavioural habits at this point is integral to long-term health. The advent of perimenopause and menopause for some women can lead to:

• Loss of bone mineral density and muscle loss which can be a risk factor for the development of osteoporosis and sarcopenia
• Increased risk of cardiovascular disease, type 2 diabetes and metabolic syndrome due to a potential adverse effect on lipid profile, a small increase in blood pressure, a negative effect on coronary artery intimal thickness, an increase in abdominal adiposity and an increase in insulin resistance
• A risk factor for the development of cognitive decline in a small cohort of women with a likely genetic susceptibility.⁴

Positive lifestyle changes that can improve menopausal symptoms and potentially reduce the risk of developing some of the aforementioned conditions include a Mediterranean style diet, regular exercise and movement encompassing weightbearing and strengthening exercises, reducing alcohol intake, stopping smoking, healthy sleeping habits, and incorporating cognitive behavioural therapy (CBT) and mindfulness principles into practice.^4,5

For optimising brain health, we discuss the recommendations from the International Menopause Society’s 2022 White Paper on brain fog and memory difficulties in menopause, which encompasses many of the aforementioned lifestyle habits as well as advising to minimise stress, stay socially connected and continue to engage the brain by keeping it active.⁶

Delivering a large volume of information can be overwhelming, therefore this is gauged to each patient, summarising and writing down key points so that they can look at it again later. We usually provide a copy of the Let’s Talk About Menopause booklet, produced by Cork-Kerry Community Healthcare, which is an evidence-based resource which describes many of the behavioural and lifestyle interventions in an easy to navigate fashion.⁷ One of the key skills of good menopause care is condensing large volumes of information, simplifying it and tailoring it to the person in front of us. 

Assessing for and asking about symptoms of genitourinary syndrome of menopause (GSM) is an important aspect of the consultation as it is often not volunteered, yet can negatively impact quality of life. We discuss the importance of vaginal moisturisers and lubricants and determine whether a referral for pelvic physiotherapy would be useful. We will often initiate a course of vaginal oestrogen as this is an effective treatment option for GSM and can often be used in those with a contraindication to systemic HRT or when systemic HRT is not desired.⁸

We then assess whether additional treatments are desired or required such as HRT or prescribed non-hormonal options for vasomotor and other symptoms. For most women, including those who start HRT, a multimodal model is used whereby different treatment options are recommended to maximise impact. This can include pelvic physiotherapy, vaginal moisturisers and lubricants, vaginal oestrogen, psychosexual therapy, yoga and pilates, prescribed non-hormonal options and HRT, in addition to the lifestyle and behavioural factors and interventions previously mentioned.

Other than an active or previous history of a sex-hormone receptor sensitive cancer, most people with complex histories can have a trial of HRT using low to standard doses of transdermal oestrogen as first-line options, with counselling of the paucity of evidence in certain cases.⁹

We usually end the consultation by providing a written management plan, information leaflets and signposting to other resources and supports when required such as Arc House for those with a history of cancer, and The Daisy Network UK for those with a history of POI.^10,11 The therapeutic value of listening and conveying that every woman has treatment options even if hormonal therapy is not recommended, cannot be underestimated.

Review consultation

For most who attend the clinic, there will be a scheduled review consultation to assess how treatment is faring, although for some, several reviews might be required. The majority of patients will eventually be discharged back to their GP so that others can get an appointment in the clinic. The most common referrals to date have been those with either a history of VTE or breast cancer, and we will explore the counselling and treatment options for these patients in follow up articles over the next two issues.

References

1. https://www.gov.ie/en/publication/232af-womens-health-action-plan-2022-2023/
2. Greene J. Methods for assessing climacteric symptoms. Br Menopause Soc J 1999; 5(4):173-176. doi:10.1177/136218079900500414
3. https://www.fsrh.org/documents/fsrh-guidance-contraception-for-women-aged-over-40-years-2017/
4. IMS Recommendations on women’s midlife health and menopause hormone therapy. Climacteric 2016 Apr; 19(2):109-150. 
5. Woyka J. Consensus statement for non-hormonal-based treatments for menopausal symptoms. Post Reprod Health 2017 Jun; 23(2):71-75. doi: 10.1177/2053369117711646. PMID: 28643614.
6. Maki PM, Jaff NG. Brain fog in menopause: a health-care professional’s guide for decision-making and counseling on cognition, Climacteric 2022 Dec; 25(6):570-8; DOI: 10.1080/13697137.2022.2122792
7. thewellbeingnetwork.ie/wp-content/uploads/2023/10/Lets-talk-about-menopause-resource-FINAL.pdf
8. The NAMS 2020 GSM Position Statement Editorial Panel. The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. Menopause 2020 Sep; 27(9):976-992. doi: 10.1097/GME.0000000000001609.
9. Hamoda H, Panay N, Pedder H, Arya R, Savvas M. The British Menopause Society & Women’s Health Concern 2020 recommendations on hormone replacement therapy in menopausal women. Post Reprod Health 2020 Dec; 26(4):181-209. doi: 10.1177/2053369120957514
10. https://www.arccancersupport.ie/
11. https://www.daisynetwork.org/