Women's Health · Full case

Menopause & HRT

NICE NG23 CKS 2024

51Average UK menopause age

12 monthsAmenorrhoea to diagnose menopause

FSH >30IU/L if <45 yrs (×2, 6 wks apart)

<60 yrsBenefit window for HRT start

1.8×VTE risk with oral combined HRT

No increaseVTE risk with transdermal HRT

5 yrsStandard HRT treatment duration

1 in 1,000Extra BC cases per yr (combined HRT)

📋 Clinical Stem — Menopause & HRT Consultation

A woman presents with symptoms of menopause — to seek diagnosis, discuss HRT, or review existing treatment.

"A 51-year-old woman attends her GP with a 6-month history of hot flushes occurring 8–10 times per day and disturbing her sleep. Her last menstrual period was 14 months ago. She is otherwise well, with no significant past medical history. She works as a secondary school teacher and reports that the symptoms are significantly affecting her concentration at work and her relationship with her husband."

This stem represents any point on the menopause journey — initial presentation, HRT start, HRT review, or late presentation with osteoporosis or cardiovascular concerns. The symptom burden and the patient's own priorities shape the consultation.

Scenario A — Classic perimenopause Irregular cycles, hot flushes, mood change, sleep disruption; FSH borderline; discuss lifestyle, HRT eligibility and risks.

Scenario B — Requesting HRT after WHI scare Patient reluctant due to historical cancer fears; needs updated NICE-concordant risk communication and shared decision making.

Scenario C — Premature ovarian insufficiency (POI) Woman <40 with amenorrhoea and elevated FSH; different risk-benefit profile; HRT is cardiovascular and bone protective here.

Scenario D — HRT review with complications Established HRT user with new diagnosis (hypertension, breast cancer history, DVT); re-assess risk; consider switching route or stopping.

Scenario E — Non-hormonal options requested Woman who cannot or will not take HRT; explore reasons; discuss SSRIs, clonidine, cognitive behavioural therapy, lifestyle.

Key variables to adapt for Age, time since last period, breast cancer history, VTE history, cardiovascular risk, route preference (oral vs transdermal), type of HRT (sequential vs continuous), and psychosocial impact of symptoms.

Steps:

Step 1

History Taking — Open Question First · Targeted Questions · ICE · Psychosocial Context

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Menopause history is holistic, not hormonal alone. The consultation must capture symptom burden across all domains (vasomotor, urogenital, psychological, musculoskeletal), explore the patient's attributions and fears, and identify contraindications to HRT. The decision to start HRT must be the patient's, informed by an individualised risk-benefit discussion — not directed by the clinician's prior assumptions.

🎓 Consultation opener — use existing information first

"I can see from your notes that you've come in today to talk about the menopause. It would really help me to hear from you directly — what's been going on, and what's been most difficult for you?"

Opening with "when did your periods stop?" before the patient has spoken costs Global Skills and Relating to Others marks. The patient's own description of impact is the most clinically important information in this consultation.

1A — Start with an open question: let the patient lead, then move to targeted questions

Question to ask	Why it matters clinically	Changes what?
🟢 OPEN QUESTION — always start here"Can you tell me what's been happening and what's been most affecting you day to day?"	Allows the patient to prioritise her own symptom burden — vasomotor, psychological, sexual or urogenital. Different priorities require different management decisions.A patient who leads with mood and sleep disruption may have depression or thyroid disease, not menopause.	DDxPsychosocialRx plan
Last menstrual period and cycle changes"When did your periods stop or become irregular? Have they changed over time?"	12 months of amenorrhoea = menopause (in women ≥45). Perimenopause has irregular cycles but menopause diagnosis requires 12 months. Needed to determine if sequential or continuous combined HRT is appropriate.Sequential HRT for perimenopause (<12 months amenorrhoea); continuous combined for ≥12 months amenorrhoea.	RxDDx
Vasomotor symptoms"How often are you getting hot flushes or night sweats? How badly are they affecting your sleep?"	Frequency and severity score (Greene Climacteric Scale) guides treatment need. Mild = lifestyle; moderate-severe = HRT discussion. Night sweats disrupting sleep cause secondary depression, fatigue and cognitive impairment.Aim: <50% reduction in flush frequency at 3 months on HRT indicates dose review needed.	RxReferral
Psychological symptoms"How has your mood been? Have you noticed any anxiety, low mood, brain fog, or memory difficulties?"	Depression, anxiety and cognitive symptoms are common in perimenopause and often unattributed to hormonal change. Differentiating primary depression from perimenopausal mood change affects management (HRT vs antidepressant vs both).NICE NG23: do not diagnose depression without first considering whether symptoms are menopausal in origin.	DDxRx
Genitourinary symptoms"Have you noticed any vaginal dryness, discomfort during sex, or problems with your bladder — like urgency or recurrent urine infections?"	Genitourinary syndrome of menopause (GSM) affects 40–50% of menopausal women and is underreported. Often separate to vasomotor symptoms and often persists after systemic HRT resolves flushes — needs separate vaginal oestrogen treatment.Vaginal oestrogen safe in most women, including those with breast cancer history (low systemic absorption).	RxDDx
Musculoskeletal symptoms"Have you noticed any joint pains, muscle aches, or changes in your hair or skin?"	Joint pains and muscle aches are common in perimenopause and often attributed to ageing or fibromyalgia. Oestrogen deficiency affects connective tissue. Collagen loss accelerates after menopause.Rule out inflammatory arthritis, hypothyroidism and other causes before attributing to menopause.	DDx
Previous or current HRT"Have you ever tried HRT or hormonal treatment for the menopause? What happened?"	Prior HRT experience reveals tolerability issues (breakthrough bleeding on continuous combined, nausea on oral preparations) that guide preparation choice. Discontinuation reason informs this consultation.Women who stopped HRT after WHI (2002) publication often did so unnecessarily — updated evidence (NICE 2015/2019) significantly changes the risk-benefit communication.	Rx
Breast cancer history (personal or family)"Have you or any close family members had breast cancer?"	Personal history of oestrogen-receptor positive breast cancer = systemic HRT UKMEC 4 in most cases (oncology-led decision). ER-negative breast cancer: specialist discussion. Strong family history alone does not preclude HRT but should prompt BRCA testing discussion.Vaginal oestrogen is generally safe even in breast cancer survivors — very low systemic absorption.	RxReferral
VTE history and cardiovascular risk"Have you ever had a blood clot in your leg or lung? Any heart problems or history of stroke?"	Oral HRT (not transdermal) increases VTE risk 1.8-fold. Personal DVT/PE = oral HRT contraindicated; transdermal HRT has no increased VTE risk and is safe.NICE NG23: offer transdermal as first-line route when VTE risk elevated (obesity BMI >30, immobility, strong FH).	RxReferral
Age and time since last period"How old are you now, and how long ago was your last period?"	HRT benefit-risk ratio most favourable if started within 10 years of menopause or before age 60 (the "window of opportunity"). Starting after 60+ in women with no symptoms has less clear benefit and potentially increased cardiovascular risk.Premature ovarian insufficiency (<40 yrs): HRT is strongly recommended until at least age 51 for cardiovascular and bone protection — this overrides most HRT concerns.	RxDDx
Contraceptive need"Are you still having any periods at all? Are you using any contraception?"	Menopausal women still need contraception until 1 year after last period (≥50) or 2 years (<50). HRT is NOT a contraceptive. Mirena IUS (licensed for HRT progestogen component) also provides contraception.Women on sequential HRT who want contraception need a separate progestogen-only method (implant, Cu-IUD, DMPA) or Mirena IUS.	Rx
Current medications"Are you on any other regular medications or supplements?"	Tamoxifen + HRT = contraindicated (competes at oestrogen receptor). Enzyme inducers reduce oral HRT levels. SSRIs and SNRIs may already partially control vasomotor symptoms.Venlafaxine (off-label) and paroxetine (avoid with tamoxifen) reduce flush frequency by ~50% — useful HRT alternatives.	RxDDx

1B — Red flags: must not miss · must ask · must act

🚨

Red Flags — act before continuing history

Red flag	Why dangerous	Action
Postmenopausal bleeding (PMB) — any bleeding >12 months after last period	Endometrial carcinoma must be excluded. PMB is an urgent 2-week wait (2WW) referral until proven otherwise; risk increases with age and unopposed oestrogen.	2WW referral
Unexpected vaginal bleeding on continuous combined HRT (>6 months of use)	Breakthrough bleeding after initial 3–6 months on continuous combined HRT should be investigated to exclude endometrial pathology. Early bleeding is common and expected; late bleeding is not.	Pelvic USS
New unilateral breast lump on HRT	Combined HRT increases breast cancer risk by approximately 1 additional case per 1000 women per year of use. Any new breast lump requires urgent 2WW breast clinic referral regardless of HRT status.	2WW breast
DVT / PE symptoms	Oral HRT increases VTE risk ~1.8-fold. DVT or PE on oral HRT = stop oral HRT; transdermal route may be continued after haematology review.	A&E / DVT clinic
Symptoms of POI in woman under 40 (<45 with amenorrhoea)	Premature ovarian insufficiency (POI) is missed in 50% on first presentation. Untreated POI leads to premature cardiovascular disease, osteoporosis and cognitive decline.	Same day / urgent
Severe hypertension (>160/100) on oral HRT	Oral oestrogen can raise blood pressure via hepatic angiotensinogen. Switch to transdermal route which has no hepatic first-pass effect and does not increase BP.	BP management + switch route

🛡️

Safeguarding Considerations — Consider in Every Consultation

Menopause can amplify vulnerability. Hormonal change, sleep deprivation, mood disruption and sexual dysfunction can destabilise relationships, increase alcohol dependence and reduce capacity for self-protection. GPs must recognise that menopausal women may present with domestic abuse and depression masked by somatic symptoms.

👴 Domestic abuse during menopause

Mood change, irritability and low libido can increase relationship conflict and abuse risk
Symptoms may mask IPV — ask NICE-recommended enquiry: "Do you feel safe at home?"
Alcohol use may increase in peri-menopausal women with poor sleep and mood symptoms
Refer to MARAC if high risk; document DASH assessment

🧠 Mental health and capacity

Severe perimenopausal depression may impair capacity for treatment decisions
Women who present with cognitive symptoms — exclude depression before dementia
Psychiatric medication interactions with HRT must be reviewed
Women on antipsychotics may have drug-induced amenorrhoea — distinguish from menopause

👤 Older women and carer abuse

Post-menopausal women presenting late may have delayed help-seeking due to carer responsibilities
Financial exploitation by family members may prevent access to private HRT formulations
Loneliness and isolation amplify somatic symptom burden
Ensure patient is seen alone for part of consultation

🕊 POI and reproductive loss

POI causes permanent infertility — significant psychological impact
Refer to specialist fertility counselling before discussing HRT in POI
Young women with POI have elevated risk of depression and anxiety
Psychological support alongside HRT is part of NICE-recommended POI management

If a safeguarding concern is identified: Follow standard GP safeguarding adult protocols. Document clearly. Discuss safety planning with the patient without the presence of any potential perpetrator. Refer to MARAC if high risk. For women with POI and psychological distress, consider same-day urgent mental health referral if there is risk of self-harm.

1C — PMH · FH · Drug history · Social history: management impact

🧬 PMH / FH — changes management

Factor	Why it matters	Management impact
ER+ breast cancer (personal)	Systemic oestrogen may stimulate ER+ cancer recurrence	Systemic HRT generally contraindicated; discuss with oncologist; vaginal oestrogen usually safe
DVT / PE history	Oral HRT increases VTE risk 1.8-fold via hepatic clotting factor synthesis	Oral HRT contraindicated; transdermal has no VTE risk — safe to use
Cardiovascular disease (established)	HRT initiated >10 years after menopause in women with existing CVD carries risk	Avoid starting HRT late; if symptomatic, transdermal preferred; consult cardiologist
Osteoporosis / fragility fracture	Oestrogen deficiency causes 3–5% bone loss per year in first 5 years post-menopause	HRT prevents bone loss; consider DEXA; calcium and vitamin D supplementation alongside
Endometrial cancer (treated)	Progestogen needed to protect endometrium; prior endometrial cancer complicates this	Specialist-only decision; generally avoid systemic HRT; vaginal oestrogen usually safe
Premature ovarian insufficiency (POI)	Different risk-benefit: HRT protective against CV disease and osteoporosis until age 51	HRT strongly recommended; higher dose often needed; continue until at least natural menopause age
Hypothyroidism (family history)	Thyroid disease mimics menopausal symptoms — fatigue, weight gain, mood change, irregular periods	Check TSH before attributing all symptoms to menopause; hypothyroidism must be treated first
Migraine with aura	Oral HRT can worsen migraine with aura via first-pass oestrogen effect on vasomotor tone	Use transdermal HRT — steady oestrogen levels avoid oestrogen fluctuation triggering migraines

💊 Drug history · Social history — clinical impact

Factor	Why it matters	Management impact
Tamoxifen	Tamoxifen and oestrogen compete at ER; combined use reduces tamoxifen efficacy significantly	Systemic HRT absolutely contraindicated with tamoxifen; paroxetine also reduces tamoxifen metabolism — use venlafaxine instead for vasomotor symptoms
Antidepressants (SSRIs/SNRIs)	Venlafaxine and desvenlafaxine reduce hot flush frequency by ~50% independently of antidepressant effect	If HRT declined/contraindicated: venlafaxine 37.5–75mg first-line; avoid paroxetine if on tamoxifen
Smoking	Smoking accelerates oestrogen metabolism; increases CVD and bone loss risk; compounds menopausal cardiovascular risk	Transdermal HRT preferred (avoids hepatic first-pass); smoking cessation referral; discuss bone risk
BMI >30	Obesity is the greatest risk factor for endogenous oestrogen after menopause (peripheral aromatisation); also increases VTE risk with oral HRT	Transdermal HRT preferred to avoid VTE risk from oral route; weight management referral
Heavy alcohol use	Alcohol increases breast cancer risk independently; combined with HRT may further elevate risk; worsens sleep and vasomotor symptoms	Discuss alcohol intake in HRT risk conversation; reduce alcohol to improve symptom control
Sedentary lifestyle	Physical inactivity accelerates bone loss, CVD risk and vasomotor severity after menopause	150 min/week exercise reduces vasomotor symptoms and preserves bone; strengthen counselling before HRT
Work / occupational stress	Vasomotor symptoms significantly impair cognitive function, concentration and workplace performance in up to 1 in 4 menopausal women	Workplace impact score influences treatment intensity; adjust HRT dose/route based on functional impairment
Hypertension on treatment	Oral HRT can further raise BP via hepatic angiotensinogen; transdermal route does not	Well-controlled HTN: transdermal HRT preferred; if BP rises on oral HRT, switch route before stopping

1D — ICE: Ideas · Concerns · Expectations

Millions of women stopped HRT after the 2002 WHI publication due to a fear of breast cancer that was significantly overstated in media coverage. Updated NICE evidence (2015, reviewed 2019) provides a far more nuanced and reassuring picture. Without exploring what the patient believes about HRT, the GP may spend the entire consultation prescribing to a woman who has already decided she will not take it — or may withhold effective treatment from a woman who desperately needs it but is afraid to ask. ICE in menopause can change a woman's life.

💭 Ideas

"What do you already know about the menopause and about HRT? Have you been reading anything about it, or spoken to anyone?"

Reveals whether the patient's understanding is based on current NICE evidence or on outdated WHI data. A woman who believes HRT causes cancer in 1 in 10 needs updated risk communication before any treatment discussion can proceed.

😟 Concerns

"A lot of women have worries about HRT — particularly around breast cancer. Is that something that's been on your mind, or is there something else you're concerned about?"

Naming the most common concern (breast cancer) normalises it and opens the door. Unaddressed, this concern will prevent adherence. Addressed with accurate risk framing (1 in 1000 per year additional risk — similar to drinking 1–2 units alcohol per day), it becomes manageable.

🔇 Expectations

"What are you hoping we can do today? Are you looking to try HRT, or were you wanting to discuss other options, or just understand what's going on?"

Some patients attend expecting to be told HRT is dangerous and walk away with nothing. Some are desperate for immediate treatment. Without asking, the consultation aims at the wrong target. Expectations also reveal practical constraints (cost, administration route preference, partner's opinion).

1E — Psychosocial context: the person behind the symptoms

The biological reality of menopause is the same for every woman — but the lived experience varies enormously based on cultural framing, social support, occupational demands and psychological resilience. Women in high-pressure roles may experience symptoms as catastrophic to their identity and professional competence. Women in cultures where menopause is viewed positively experience fewer reported symptoms. Addressing the psychosocial context is not supplementary — it determines whether treatment is accepted, adhered to and effective.

👶 Occupational impact and identity

Cognitive symptoms (brain fog, memory loss) and vasomotor symptoms (public hot flushes) directly threaten professional confidence. Up to 1 in 4 menopausal women report significant occupational impairment. Some women contemplate early retirement due to untreated symptoms.

"You mentioned work has been affected — can you tell me a bit more about what that looks like day to day? Is it the concentration, the hot flushes, or the sleep that's most disruptive?"

Workplace impact score influences treatment urgency; occupational trigger may motivate treatment initiation and adherence.

💍 Relationship and intimacy

Genitourinary syndrome of menopause (GSM) causes dyspareunia and reduced libido which directly impacts intimate relationships. Partners may misinterpret symptoms as rejection. Relationship distress secondary to menopause is common and rarely volunteered.

"Has this been affecting your relationship or your sex life at all? That's something I ask everyone because it's very common and very treatable."

Vaginal oestrogen addresses GSM specifically; exploring this avoids under-treatment of a significant QoL domain.

⚖️ Cultural framing of menopause

In many Western cultures, menopause is medicalised and associated with loss of femininity and ageing. In some East Asian cultures, it is viewed as liberation. A patient's cultural framing shapes her symptom severity, help-seeking behaviour and treatment preferences.

"How do you feel about this change in your body? Is it something you've been dreading, or does it feel like a natural transition for you?"

Negative cultural framing amplifies symptom burden; positive reframing alongside treatment is a therapeutic intervention in itself.

💉 Alcohol, sleep and mood

Night sweats disrupt sleep architecture, leading to secondary depression, irritability and daytime fatigue. Many women increase alcohol intake to manage sleep. Alcohol worsens night sweats, creating a vicious cycle.

"A lot of women find they use alcohol or other things to help them sleep when the night sweats are bad — has that been an issue for you?"

Alcohol cessation + HRT combined reduces vasomotor symptoms more than HRT alone; brief intervention for alcohol if identified.

💥 Grief and transition

For women who have not completed their family, menopause represents permanent infertility. For women whose identity is closely tied to fertility or youth, it may trigger grief or existential distress disproportionate to physical symptom burden.

"How are you feeling emotionally about this chapter in your life? Is there anything about this transition that feels particularly difficult to come to terms with?"

NICE NG23 recommends CBT (in person or digital: Wellbeing of Women app) for psychological symptoms of menopause as a primary or adjunct treatment.

📚 Health literacy and media influence

The media landscape around menopause has shifted dramatically since 2018 — from undertreatment of debilitating symptoms to occasional overclaiming of HRT benefits. Some patients have unrealistic expectations; others remain unjustifiably terrified. Health literacy shapes both.

"There's a lot of conflicting information about HRT in the press — has any of that affected how you feel about it, positively or negatively?"

Recalibrate media-driven beliefs with NICE NG23 individualised risk framing; written BMS/RCOG patient information offers reliable counters to misinformation.

🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills

Key phrases that score

"Before we get into the details, could you tell me what's been most difficult for you day to day?"

"A lot of women have heard worrying things about HRT — has any of that been on your mind?"

"Has this been affecting your relationship or your sex life? I ask everyone because it's very common and very treatable."

"What would feel like a good outcome from today's appointment for you?"

Deductions (examiner flags)

Starting with LMP before patient's agenda — loses GS marks
Not asking about breast cancer history before prescribing HRT
Not asking about DVT/PE history before prescribing oral HRT
Missing GSM/sexual symptoms — undermanagement of treatable symptom
Ignoring ICE — especially WHI-related concerns about breast cancer
Not discussing PMB as 2WW if mentioned

🔴 Red

LMP before agenda • no VTE/breast cancer screen • no ICE • PMB not escalated • GSM not asked

🟠 Amber

UKMEC mostly checked • ICE superficial • GSM missed • concerns acknowledged but not addressed

🟢 Green

Opens with patient agenda • UKMEC screened • ICE fully explored • GSM asked • WHI concerns addressed with NICE evidence

Step 2

Triage Engine — Emergency · Urgent · Routine

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Most menopause presentations are routine — but several require urgent action. Postmenopausal bleeding, unexpected bleeding on established HRT, new breast lumps and symptoms of POI in a young woman all require urgent investigation or referral before HRT is started or continued.

🔴 Emergency

999 or Same-Day Hospital

Urgent assessment

DVT or PE on HRTStop oral HRT; 999 or urgent anticoagulation pathway; transdermal may be restarted after specialist review
Stroke / TIA on oral HRT999 immediately; stop HRT; hypercoagulable screen; TIA clinic same day
Acute severe chest painExclude MI / PE; oestrogen-related arterial thrombosis is rare but real
Adrenal or pituitary crisis mimicking menopauseSevere hypotension, confusion, severe nausea in young woman with amenorrhoea — exclude Addison's or hypopituitarism

🟠 Urgent

Same-Day / 2-Week Wait

Days to 2 weeks

Postmenopausal bleeding (any)2WW gynaecology referral; USS endometrium; do not start HRT until investigated
Unexpected bleeding >6m on continuous combined HRTPelvic USS; endometrial biopsy if indicated; consider Pipelle biopsy
New breast lump on HRTUrgent 2WW breast clinic; do not delay referral for HRT review
POI in woman <40 (amenorrhoea >4 months)FSH x2 six weeks apart; testosterone; oestradiol; investigate primary cause; start HRT promptly
Severe uncontrolled menopausal symptoms affecting safetySuicidal ideation secondary to severe perimenopausal depression — same-day MH crisis referral

🟢 Routine

GP-managed

Planned appointment

Moderate vasomotor symptoms — new HRT requestFull history, UKMEC, individualised risk discussion, HRT start
HRT annual reviewSymptom control, side effects, bleeding pattern, CVD/breast risk update
Switching HRT preparationsSide effects, route preference, transition planning
Non-hormonal symptom managementCBT, venlafaxine, lifestyle if HRT declined or contraindicated
Long-term bone and CVD risk counsellingDEXA if indicated; calcium/vitamin D; statins; lifestyle optimisation

🎓 SCA Checkpoint — Step 2TasksGlobal Skills

Triage phrases

"Before anything else, I want to check — have you had any bleeding since your periods stopped? Any new breast lumps?"

"With any bleeding after the menopause, I would want to refer you quickly to exclude any serious causes — that's a standard precaution."

Deductions

Starting HRT without asking about PMB
Not flagging PMB as 2WW referral — patient safety failure
Not screening for new breast lump before HRT start

🔴 Red

PMB ignored • HRT started without exclusion of endometrial pathology • no breast lump check

🟢 Green

PMB asked • 2WW referenced if PMB present • new symptoms screened before HRT start

Step 3

Do I Need This Examination?

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Examination in menopause should be targeted, not reflexive. BP must be checked before starting oral HRT. Breast examination is not required as a routine prerequisite to HRT — but must be performed if a new breast symptom is reported. Pelvic examination is required if PMB is reported or if GSM/dyspareunia symptoms are present.

Examination	Why it matters	What finding changes management	Changes?
Blood pressure	Oral HRT increases hepatic angiotensinogen and can raise BP; must be documented before startTransdermal HRT does not raise BP — preferred if BP is borderline	BP ≥160/100 = use transdermal route only; BP >180/110 = control BP before any HRT	YES — route choice
BMI / weight	BMI >30 increases VTE risk with oral HRT; obese women also have more endogenous oestrogen (peripheral aromatisation)Transdermal preferred in BMI >30 to avoid VTE risk	BMI >30 = transdermal HRT preferred; BMI >35 = strongly avoid oral route	YES — route choice
Breast examination	Not a routine prerequisite to HRT — but mandatory if patient reports new lump, nipple discharge or breast changeNICE NG23: routine breast examination not required before HRT start	New breast lump = urgent 2WW breast clinic referral; defer HRT until investigated	Context: new symptoms
Pelvic / vaginal examination	Required for PMB investigation; also useful if GSM symptoms prominent — visualise vaginal atrophy, check vaginal pH, assess uterine size for IUS suitabilityNot required for routine HRT start without specific pelvic symptoms	PMB + palpable pelvic mass = urgent gynaecology; vaginal atrophy = topical oestrogen ± systemic	Context: PMB / GSM
Abdominal examination	If pelvic mass, ascites or distension in context of PMB — raises concern for ovarian or endometrial malignancyNot required for routine HRT consultation	Palpable mass + PMB = urgent CA-125 + gynaecology USS referral	Context: PMB
Skin examination (progestogen patch sites)	At follow-up — check for skin reaction to transdermal patches; local erythema or contact dermatitis requires switching to gelCheck rotation of patch sites at annual review	Contact dermatitis = switch to oestrogen gel; rash elsewhere = investigate drug reaction	Context: HRT review
Thyroid examination	If thyroid disease suspected as cause of or contributor to symptoms — goitre, exophthalmos, tremor, bradycardia suggest thyroid disorder masquerading as menopauseHypothyroidism classically mimics menopause: fatigue, weight gain, mood change, irregular periods	Goitre or thyroid features = TSH + thyroid antibodies before HRT	Context: thyroid symptoms
Cervical screening check	Menopause consultation is an opportunity — check smear status; atrophic changes on smear in menopausal women may cause false abnormality readings; vaginal oestrogen before repeat smear improves cell qualityNot an examination per se, but a clinical check	Atrophic changes causing inadequate smear = vaginal oestrogen 4 weeks then repeat	Opportunistic

🎓 SCA Checkpoint — Step 3TasksGlobal Skills

Examination phrases

"I'd like to check your blood pressure today — it helps us decide which form of HRT is safest for you."

Deductions

No BP check before oral HRT start — prescribing outside NICE guidance
Not arranging pelvic examination / USS for PMB — patient safety failure

🔴 Red

Oral HRT without BP check • PMB without pelvic assessment arranged

🟢 Green

BP documented • transdermal if elevated • pelvic exam / USS arranged for PMB • breast exam if new symptoms

Step 4

Do I Need This Investigation?

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NICE NG23 is clear: do not routinely measure FSH to diagnose menopause in women ≥45 years. The diagnosis is clinical in women ≥45. FSH is only needed if the patient is <45, on the combined pill, or the diagnosis is uncertain. Investigations are targeted to contraindications (lipid profile for VTE risk), monitoring (BP on oral HRT), and excluding differential diagnoses (TSH, coeliac screen, FBC).

Investigation	Clinical question it answers	What result changes management?
FSH (follicle-stimulating hormone)	Is this menopause or another cause of amenorrhoea? Only needed <45 yrs, or on COC, or clinical uncertainty. NOT needed ≥45 with typical symptoms + 12 months amenorrhoea.	FSH >30 IU/L twice (6 weeks apart) in woman <45 = POI; ≥45 = clinical diagnosis only
TSH (thyroid-stimulating hormone)	Is thyroid disease mimicking menopause? Hypothyroidism causes fatigue, weight gain, mood change, irregular periods indistinguishable from perimenopause.	Low TSH = hyperthyroidism (sweats, palpitations, anxiety); High TSH = hypothyroidism; treat thyroid before or alongside HRT
LH, oestradiol, testosterone (POI screen)	Is this primary ovarian insufficiency? In POI: FSH elevated, oestradiol low, LH elevated. Testosterone may be low.	Confirmed POI = HRT strongly recommended; referral to specialist POI clinic; fertility counselling if <40
Pelvic ultrasound (USS)	Is there endometrial thickening or pelvic pathology in PMB? Endometrial thickness ≥4mm on transvaginal USS in postmenopausal woman = further investigation required.	Endometrial thickness ≥4mm = endometrial biopsy (Pipelle); thickness <4mm = reassuring but histology if symptomatic
DEXA bone density scan	Is osteoporosis present? Indicated in POI, early menopause, prolonged glucocorticoid use, strong FH of hip fracture, low BMI (<19), prolonged immobility.	T-score < −2.5 = osteoporosis; T-score −1 to −2.5 = osteopenia; results influence decision to start/continue HRT and need for bisphosphonate
FBC and CRP	Is anaemia explaining fatigue? Is inflammatory condition mimicking joint pain? Perimenopausal women often present with fatigue attributed to menopause that is anaemia.	Low Hb = investigate iron deficiency / haematology; elevated CRP = investigate inflammatory cause
Lipid profile (fasting)	What is the baseline cardiovascular risk before HRT? HRT modestly improves lipid profile. Important for longer-term CVD risk management in peri/post-menopause.	Very high LDL or TG = ensure CVD risk management alongside HRT; statin consideration; does not preclude HRT
Blood glucose / HbA1c	Does metabolic syndrome (common peri-menopausally) or prediabetes explain symptoms? Menopause increases insulin resistance.	HbA1c ≥48 = type 2 diabetes; ≥42 = prediabetes; lifestyle + metformin ± HRT (HRT improves insulin sensitivity)
Coeliac screen (anti-TTG IgA)	Is coeliac disease causing bone loss (malabsorption of calcium/vitamin D) presenting as early osteoporosis in a menopausal woman?	Positive TTG = gastroenterology referral; gluten-free diet; DEXA for bone density assessment

🎓 SCA Checkpoint — Step 4TasksGlobal Skills

Investigation phrases

"Because you're 51 and haven't had a period for over a year, I don't actually need to do a blood test to confirm the menopause — the diagnosis is clinical. I would like to check your thyroid, though, as it can cause very similar symptoms."

Deductions

Routinely ordering FSH in woman ≥45 with typical symptoms — NICE says this is unnecessary
Missing TSH before attributing all symptoms to menopause — misdiagnosis
Not arranging pelvic USS for PMB

🔴 Red

Routine FSH in ≥45 • No TSH • No pelvic USS for PMB

🟢 Green

Clinical diagnosis ≥45 • TSH ordered • FSH only if <45 • USS for PMB • DEXA if indicated

Step 5

Reaching a Diagnosis & DDx — Explained in Plain Language

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The diagnosis of menopause is clinical in women ≥45 — but the art lies in explaining the physiology in plain language and addressing the WHI legacy fears about HRT. Differential diagnoses must be considered and excluded before attributing all symptoms to menopause.

🗣️ Explaining menopause in plain language — say something like this

"What's happening is that your ovaries are producing less oestrogen — that's the hormone that used to regulate your cycle and protect you from things like hot flushes and bone thinning. As oestrogen levels drop, your brain keeps sending signals asking for more, and that back-and-forth is what causes the flushes and night sweats. The good news is that we have very effective treatments — and the latest evidence shows that for most women, the benefits of HRT far outweigh the risks when it's started at the right time."

💬 Addressing patient's own beliefs — particularly WHI fears

"I read that HRT causes breast cancer — isn't it really dangerous?"
"I completely understand that concern — there was a lot of alarming coverage about a study in 2002. But that study looked at a specific type of HRT taken by older women for a long time, and the results have since been reinterpreted. For most women in your age group, the current evidence shows the risk of breast cancer from HRT is smaller than the risk from drinking a couple of glasses of wine a day — and the benefits, especially for your bones and heart if started now, are real."

"I thought I just had to put up with it — isn't it just natural?"
"It's natural in the sense that it happens to every woman, but that doesn't mean you have to suffer through it. These symptoms are caused by a hormone change that we can help with — the menopause isn't something to endure, it's something we can manage together."

A — Clinical diagnosis / GP-managed

GP can diagnose

Menopause (≥45, 12 months amenorrhoea)

Clinical diagnosis; no FSH required. Vasomotor, mood, sleep, GSM symptoms. Confirm no red flags. Start HRT discussion.

Perimenopause (irregular cycles, symptoms)

Variable oestrogen levels — diagnosis clinical. Sequential HRT appropriate; contraception still needed.

GSM (genitourinary syndrome)

Vaginal dryness, dyspareunia, urinary urgency — treat with topical vaginal oestrogen; may not need systemic HRT

B — Investigate / specialist input

Further investigation needed

Premature ovarian insufficiency (POI, <40)

FSH >30 IU/L x2 six weeks apart; refer to POI specialist; fertility implications; HRT until 51

Early menopause (40–44)

FSH to confirm; DEXA; higher long-term bone and CV risk than natural menopause; NICE: offer HRT

Hypothyroidism / Hyperthyroidism

TSH confirms; treat thyroid condition first or alongside. Hypothyroidism mimics menopause exactly.

C — Urgent exclusion needed

Diagnose & act now

Endometrial carcinoma (PMB)

Any PMB = 2WW referral; do not start HRT; pelvic USS; endometrial biopsy if thickness ≥4mm

Ovarian cancer

CA-125 + USS if persistent bloating, pelvic pain, altered bowel habit in menopausal woman; urgent gynaecology

📊 Menopause Staging & HRT Choice Framework

Stage	Definition	HRT type	Key consideration
Perimenopause	Irregular cycles + symptoms; FSH variable	Sequential combined (21 days oestrogen + 10–14 days progestogen) or Mirena IUS + oestrogen	Provides regular withdrawal bleed; contraceptive cover needed separately
Menopause (≥12m amenorrhoea, ≥45)	Clinical diagnosis; no FSH needed	Sequential (if <1 year post-menopause) or continuous combined after 1 year	Continuous combined causes no planned withdrawal bleed
Early menopause (40–44)	FSH to confirm; DEXA recommended	Standard-dose continuous combined HRT	Higher bone and CV risk; NICE recommends HRT until at least age 51
POI (<40)	FSH >30 x2; specialist referral	HRT or COC (if contraception also needed); higher doses often needed	Protects against CVD and osteoporosis; continue until natural menopause age
Post-menopause >10 yrs / >60 yrs	Late start; poor evidence window	If symptomatic: transdermal preferred; lower doses; reassess annually	Starting HRT after 60+ in asymptomatic women: no clear net benefit; risk-benefit less favourable

🎓 SCA Checkpoint — Step 5TasksRelating to OthersGlobal Skills

Explanation phrases

"Based on your symptoms and the fact your periods stopped 14 months ago, I'm confident this is the menopause — I don't need a blood test to confirm that."

"The risk of breast cancer from HRT is real but much smaller than most people think — it's similar to the risk from drinking one glass of wine per day."

Deductions

Dismissing breast cancer concern without addressing it with evidence
Not explaining WHI context when patient raises breast cancer fear
Ordering FSH in woman ≥45 with typical symptoms — NICE says not needed

🔴 Red

PMB dismissed • breast cancer concern not addressed • wrong HRT type for stage

🟢 Green

Clinical diagnosis explained • WHI fear addressed with evidence • correct HRT type for stage • DDx considered

Step 6

If Referral Is Needed — What the GP Does Before & During

▲collapse

Most menopause management should be in primary care. The GP's role is to identify the minority requiring secondary care (PMB, new breast symptoms, POI, complex medical history) while managing the majority confidently. Do not routinely refer all women for menopause specialist review — NICE NG23 places primary care at the centre of this pathway.

Condition	Urgency	What GP does before referral	What GP must NOT do
Postmenopausal bleeding	2WW	Arrange urgent transvaginal USS; do not start or continue systemic HRT until investigated; document bleeding history precisely; check current medications (HRT, tamoxifen)	Start HRT before excluding endometrial pathology; delay 2WW referral; reassure without investigating
New breast lump or nipple discharge on HRT	2WW	Examine breast; document findings precisely; advise patient to continue HRT until reviewed (brief continuation is not harmful) or stop if she prefers; urgent breast clinic	Reassure without examination; delay referral; stop HRT abruptly without discussion
POI (FSH >30, age <40)	4–6 weeks	Start HRT promptly (do not wait for specialist appointment); arrange DEXA; fertility counselling referral; autoimmune POI screen (thyroid, anti-adrenal, anti-21-hydroxylase antibodies); karyotype if <30	Delay HRT pending specialist appointment — every month without oestrogen in POI causes preventable bone loss
Complex HRT management (breast cancer history, multiple CIs)	Routine	Contact oncologist if breast cancer treated; arrange menopause specialist input; document risk-benefit discussion and patient preference; prescribe vaginal oestrogen (usually safe)	Prescribe systemic HRT in ER+ breast cancer without oncology input; withhold vaginal oestrogen without clinical reason
Suspected ovarian cancer (CA-125 raised, pelvic mass, ascites)	2WW	CA-125 + transvaginal USS; stop HRT; urgency communication to gynaecology 2WW pathway; safety-net for worsening symptoms	Attribute symptoms to menopause without USS; delay referral
Severe perimenopausal depression with suicidal ideation	Same day MH	Same-day mental health crisis referral; safety plan; do not dismiss as "just hormonal"; start HRT + SSRI concurrently as appropriate; involve CMHT	Dismiss suicidal ideation as menopausal; start HRT without addressing immediate safety; delay referral

🎓 SCA Checkpoint — Step 6TasksRelating to Others

Referral phrases

"With any bleeding after the menopause, I always want to refer you quickly to check the lining of the womb — it's almost certainly nothing serious but it's the right thing to do."

"I'd like to refer you to a specialist who focuses specifically on early menopause — but in the meantime I'm going to start treatment because every month without oestrogen at your age matters for your bones."

Deductions

Delaying PMB referral — 2WW is mandatory
Delaying HRT in POI while waiting for specialist
Missing ovarian cancer in menopausal woman with new abdominal symptoms

🔴 Red

PMB without 2WW • HRT in ER+ breast cancer without oncology • delaying POI treatment

🟢 Green

PMB = 2WW stated • POI treatment started promptly • complex cases escalated appropriately

Step 7

Management — Expectation · Goals · Lifestyle · Prescribing Guide · Drug Cards · Psychosocial Impact · Follow-Up · Safety-Netting

▲collapse

7A — Address the patient's expectation first: validate → explain → negotiate

🤝

Never dismiss the expectation — acknowledge it, share your reasoning, then agree a shared plan

Validate — name their expectation

Whether the patient wants HRT urgently or is afraid of it, name where she stands before offering your clinical view.

"It sounds like these symptoms have been really significantly affecting your life — you've had months of disrupted sleep and it's affecting your work. That's exactly the kind of situation where HRT can make a real difference."

Explain — share your clinical reasoning

Address the breast cancer concern with current NICE evidence. Share the risk as an absolute number, not a relative risk.

"You mentioned you're worried about the breast cancer risk — the current evidence shows it's around 1 in 1000 women per year of using combined HRT. To put that in context, it's similar to the risk from drinking one glass of wine daily."

Negotiate — offer something today

Always leave with a plan, even if HRT decision is deferred. Lifestyle and non-hormonal options can begin today.

"Whatever you decide about HRT, I'd like to start you on some things today that will definitely help — and we can revisit the HRT decision once you've had time to think about what we've discussed."

Key principle: NICE NG23 explicitly states that women should be given individualised information about the benefits and risks of HRT and supported to make an informed decision. The clinician's role is to facilitate an informed choice, not to advocate for or against HRT.

7B — Why treatment matters: goals tailored to this patient

Treatment goals

✓ Control vasomotor symptoms✓ Restore sleep quality ● Prevent bone loss (3–5%/yr without HRT)● Reduce CVD risk (window of opportunity) ● Treat GSM / dyspareunia● Improve mood, cognition and concentration Annual HRT review and breast screeningLifestyle optimisation alongside HRT

Motivational language — tailored to the patient

"Starting HRT now, before the bone loss accelerates, reduces your risk of a hip fracture by around 30% — that's a very meaningful benefit on top of the symptom control."

"You mentioned that the concentration issues are affecting your work as a teacher — improving your sleep quality with HRT often has the biggest impact there. Many women feel like a different person within 3 months."

7C — Non-medication management: mechanism + evidence + tailored advice

Never give generic lifestyle advice. Each recommendation should be specific, quantified and linked to the mechanism by which it reduces menopausal symptom burden.

🏃

Aerobic Exercise

150 min/week moderate intensity

Mechanism

Raises endorphins and serotonin; reduces thermoregulatory dysfunction; preserves bone density and muscle mass; reduces cardiovascular risk post-menopause.

Practical

Brisk walking 30 mins 5 days/week; swimming; cycling. Weight-bearing exercise additionally protects bone density more than non-impact exercise.

Reduces flush frequency by ~25%; preserves bone density

🥰

CBT for Menopause

6–8 sessions; app-based available

Mechanism

Reframes catastrophic thinking about flushes; reduces arousal response to vasomotor events; directly addresses perimenopausal anxiety and mood change.

Practical

NICE NG23-recommended: menopause CBT with trained therapist or Mindfulness app (Wellbeing of Women app). Available on NHS in some areas.

Reduces psychological symptoms by up to 50%; NICE-recommended

🧔

Alcohol Reduction

<14 units/week; none before bed

Mechanism

Alcohol is a vasodilator and triggers hot flushes. It disrupts sleep architecture and worsens night sweats. It independently increases breast cancer risk.

Practical

Advise alcohol-free evenings, particularly 3 hours before bedtime. Even modest reduction (2 nights/week off) reduces flush frequency measurably.

Reduces flushes; reduces breast cancer risk alongside HRT

🌼

Phytoestrogens & Diet

Soy isoflavones: limited evidence

Mechanism

Phytoestrogens (soy, red clover) weakly bind oestrogen receptors. Evidence for symptom reduction is inconsistent and modest. Mediterranean diet reduces cardiovascular risk post-menopause.

Practical

Soy foods (tofu, edamame) 2–3 servings/day. Mediterranean diet — oily fish, vegetables, whole grains. Calcium-rich foods 700mg/day.

Some women find symptom relief; no evidence of harm; bone protection

🌛

Sleep Hygiene

7–9 hrs; cool bedroom <18°C

Mechanism

Night sweats fragment sleep by waking the patient in sympathetically aroused state. Poor sleep amplifies mood change, cognitive symptoms and cardiovascular risk.

Practical

Cool cotton night clothes and bedding; fan or open window; consistent sleep schedule; avoid caffeine after 2pm; layer bedding for easy adjustment.

Reduces secondary sleep deprivation effects; improves mood

🥬

Calcium & Vitamin D

700mg calcium; 800–1000 IU vit D/day

Mechanism

Oestrogen deficiency causes rapid bone resorption; calcium and vitamin D are essential co-factors for mineralisation. Deficiency accelerates menopause-related bone loss.

Practical

Dairy products, leafy greens, fortified foods. Vitamin D supplement in UK autumn/winter; test 25-OH vitamin D if suspected deficiency; supplement at 800–2000 IU if low.

Reduces fracture risk; essential alongside HRT for bone health

7D — Prescribing guide: what to start, in what order, and why

The NICE NG23 HRT prescribing algorithm has four key decisions: (1) Does the patient have a uterus? (2) What route? (3) What type? (4) Sequential or continuous combined? Each decision tree branch follows NICE guidance and individualised risk assessment.

Decision 1 — Does she have a uterus?

Uterus intact: must add progestogen to protect endometrium.

Combined HRT (oestrogen + progestogen): sequential if <12 months amenorrhoea; continuous combined if ≥12 months
Mirena IUS can provide the progestogen component alongside systemic oestrogen (patch/gel)
Unopposed oestrogen = endometrial hyperplasia risk — prescribing error with intact uterus

Post-hysterectomy: oestrogen-only HRT is safe and appropriate

Decision 2 — Which route?

Transdermal (patch/gel) preferred in:

VTE risk factors (obesity BMI >30, prior DVT/PE, immobility, thrombophilia)
Hypertension (oral HRT can raise BP; transdermal does not)
Migraine with aura (avoids oestrogen fluctuation of oral route)
Liver disease (avoids hepatic first-pass)

Transdermal has no increased VTE risk — NICE NG23

Decision 3 — Sequential or continuous?

Sequential combined: for perimenopause or <12 months amenorrhoea.

21 days oestrogen + 12–14 days progestogen; produces regular withdrawal bleed
Irregular bleeding in first 3 months is expected and normal
Late cycle irregular bleeding (days 1–9) after 6 months: investigate endometrium

Continuous combined: for ≥12 months amenorrhoea.

Daily oestrogen + daily progestogen; aim: no withdrawal bleed
Irregular bleeding in first 3–6 months is common; review if persists >6 months

Do not start continuous combined in perimenopausal women — irregular bleeding & endometrial risk

Non-hormonal alternatives when HRT declined or contraindicated

Venlafaxine 37.5–75mg OD — SNRI; reduces flush frequency ~50%; useful when HRT CI; avoid with tamoxifen (paroxetine) — venlafaxine is safe
Clonidine 50–75mcg BD — alpha-2 agonist; modest effect on flushes; useful if venlafaxine not tolerated; hypotensive side effects
Gabapentin 100–300mg nocte — reduces nocturnal flushes; useful for sleep disruption; off-label; caution in renal impairment
CBT — NICE NG23 first-line for psychological symptoms; reduces anxiety, low mood, cognitive symptoms

Genitourinary syndrome — local oestrogen

Vaginal oestrogen (Vagifem pessaries / Ovestin cream / Estring ring) — minimal systemic absorption; safe in most women including breast cancer survivors (check with oncologist if ER+ cancer); no endometrial protection needed
DHEA (prasterone, Intrarosa) — vaginal insert; converted locally to oestrogen and testosterone; useful when systemic HRT not tolerated; licensed in UK
Ospemifene — oral SERM for GSM; useful when vaginal application difficult; avoid in breast cancer history; licensed in UK
Vaginal moisturisers (Replens) and lubricants: non-hormonal first-line for mild GSM

⚙ Interactive Medication Chooser — tick the patient profile, options re-tier live against NICE / BNF

A live, topic-scoped version of the standalone Medication Chooser. The static selector and reference cards below are unchanged.

7E — HRT medication selector

Select patient characteristics — refer to 7D prescribing guide for recommended HRT type

Uterus intact (needs progestogen) DVT / PE history (use transdermal) Migraine with aura (transdermal) BMI >30 (transdermal preferred) Hypertension (transdermal preferred) Post-hysterectomy (oestrogen-only) <12 months amenorrhoea (sequential) ≥12 months amenorrhoea (continuous combined) GSM only (vaginal oestrogen)

Guidance

Select patient characteristics above and refer to the 7D prescribing guide. Transdermal oestrogen is preferred in most women with risk factors. Always add progestogen if uterus intact.

7F — Drug reference cards: HRT preparations

Oral Oestrogen — Unopposed

Premarin (CEE); Zumenon; Elleste Solo (oestradiol); Progynova

✓ Recommended

Post-hysterectomyOestradiol 1–2mg OD

✓ Prefer when

Post-hysterectomy only — no uterus, no endometrial risk

Oral route acceptable, no VTE risk factors, no hypertension

✗ Avoid if

Uterus intact — unopposed oestrogen causes endometrial hyperplasia/cancer (UKMEC 4 equivalent)

VTE risk factors (obesity, prior DVT) — use transdermal instead

⚠ Side effects

Nausea (take with food); breast tenderness; bloating

BP elevation possible — check at 3 months; switch to transdermal if raised

🔬 Monitor

BP at 3 months; annually; breast screening up to date; symptom review

💬 Counselling

"This is the oestrogen-only version — because you've had your womb removed, you don't need the second hormone. Take it at the same time each day."

SCA pearl: Never prescribe unopposed oestrogen if the uterus is intact — this is one of the most consequential prescribing errors in HRT and must be checked explicitly.

Transdermal Oestrogen (Patch/Gel)

Estradot / Evorel (patches); Oestrogel / Sandrena (gel); Lenzetto (spray)

✓ Recommended

First-line25–100mcg/24h patch; 1–2 pumps gel

✓ Prefer when

VTE risk (obesity, prior DVT/PE, thrombophilia) — no hepatic first-pass; no VTE risk increase

Hypertension, migraine with aura, liver disease, smoker — transdermal avoids all oral HRT hepatic effects

Patient preference: no daily pill; steady hormone levels (avoid peaks/troughs of oral)

✗ Avoid if

ER+ breast cancer (systemic oestrogen) — specialist decision

Skin conditions / eczema at application site — switch to gel or spray

⚠ Side effects

Local skin reaction at patch site — rotate site; switch to gel if persistent

Breast tenderness, bloating — usually resolves in 3 months

🔬 Monitor

BP at 3 months; annually; check patch site rotation

Symptom review at 3 months — dose may need titrating

💬 Counselling

"Apply the patch to clean, dry, hairless skin on the buttock or lower tummy — rotate the site each time. The gel is rubbed in to the inner arm or thigh; let it dry before getting dressed."

SCA pearl: Transdermal HRT has NO increased VTE risk — this is the key clinical difference from oral HRT. If a patient has risk factors for VTE, transdermal is the correct route. Stating this distinction in the SCA consultation scores a Tasks mark.

Sequential Combined HRT

Evorel Sequi (patch); Femoston 1/10; Elleste Duet; Climagest

✓ Recommended

Perimenopause21d oestrogen + 12–14d progestogen

✓ Prefer when

Perimenopausal (<12 months amenorrhoea or irregular cycles)

Produces predictable monthly withdrawal bleed — reassuring for patient; monitors for PMB

Can be used within 5 years of last period in women switching to no-bleed prep

✗ Avoid if

Post-menopausal (>12 months amenorrhoea) wanting no bleed — use continuous combined

History of progestogen intolerance — consider micronised progesterone (Utrogestan)

⚠ Side effects

Progestogen phase symptoms: low mood, bloating, breast tenderness (days 12–21)

Irregular breakthrough bleeding in first 3 months — normal and expected

Late cycle bleeding (days 1–9) after 6 months — investigate endometrium

🔬 Monitor

Bleeding diary for 3 months; report late-cycle bleeding to GP; annual review

💬 Counselling

"You'll have a regular monthly bleed with this type — that's expected and reassuring. If you get any bleeding at other times, especially in the first half of your cycle, please let us know."

SCA pearl: Sequential = perimenopause. Continuous combined = post-menopause (>12 months amenorrhoea). Mixing them up = wrong preparation for patient's stage — a scored Tasks failure.

Continuous Combined HRT

Evorel Conti (patch); Femoston-Conti; Kliofem; Kliovance; Angeliq

✓ Recommended

Post-menopauseDaily oestrogen + daily progestogen

✓ Prefer when

Post-menopausal (≥12 months amenorrhoea) who wants no monthly bleed

Most convenient preparation for women established in menopause

Mirena IUS + systemic oestrogen (patch/gel) is equivalent: IUS provides progestogen + contraception

✗ Avoid if

Perimenopause (<12 months amenorrhoea) — high risk of irregular breakthrough bleeding, endometrial risk

Progestogen intolerance — micronised progesterone (Utrogestan) 100mg OD continuous is better tolerated

⚠ Side effects

Irregular spotting for 3–6 months — normal; review if persists >6 months

Breast tenderness; bloating; mood change — usually resolves in first 3 months

🔬 Monitor

Bleeding diary; investigate late onset or heavy breakthrough bleeding; annual review

💬 Counselling

"This type aims for no monthly bleed. There may be some irregular spotting for the first few months — that's normal. If you get heavier or more regular bleeding after the first 6 months, please let us know."

SCA pearl: The most common reason for investigation during HRT review is unexpected late-cycle bleeding. Know when it's expected (first 6 months, continuous combined) vs when it needs investigation (after 6 months, or new onset in established user).

Progestogen — Endometrial Protection

Utrogestan (micronised progesterone 100/200mg); dydrogesterone (in Femoston); norethisterone; Mirena 52mg IUS

✓ Recommended

Uterus intact100mg OD cont · 200mg 12–14d/month seq

✓ Prefer when

Uterus intact on a separate oestrogen (gel/patch/spray) — a progestogen is mandatory for endometrial protection

Micronised progesterone (Utrogestan) is body-identical, best tolerated, and carries the lowest breast-cancer signal — first-line progestogen

Mirena 52mg IUS is an excellent alternative — gives endometrial protection + contraception, licensed 5 years for the HRT progestogen role

✗ Avoid if

Oestrogen-only prescribing with an intact uterus — unopposed oestrogen risks endometrial hyperplasia/cancer

Severe peanut/soya allergy — Utrogestan capsules contain soya lecithin; use dydrogesterone or Mirena instead

⚠ Side effects

Utrogestan: drowsiness (take at night); can be given vaginally if oral progestogenic side effects

Progestogenic effects: bloating, breast tenderness, low mood — commonest reason for HRT intolerance; Utrogestan usually best tolerated

🔬 Monitor

Bleeding pattern; continuous regimen aims for no bleed (review unscheduled bleeding >6 months); sequential gives a predictable monthly bleed

💬 Counselling

"This second hormone protects the lining of your womb. Take it at night as it can make you a little sleepy. If you've had your womb removed you don't need it at all."

SCA pearl: With transdermal oestrogen (gel/patch/spray) you must add a progestogen if the uterus is intact — Utrogestan 100mg daily (continuous) or 200mg for 12–14 days/month (sequential), or a Mirena IUS. Naming the regimen scores a Tasks mark.

Tibolone (single-agent)

Livial 2.5mg OD

✓ Recommended

Post-menopause2.5mg OD continuous

✓ Prefer when

Post-menopausal (≥12 months amenorrhoea) wanting a single no-bleed tablet with built-in progestogenic activity

Low libido a prominent symptom — tibolone has weak androgenic activity that may help

✗ Avoid if

Personal history of breast cancer or hormone-dependent cancer

Perimenopause / <12 months amenorrhoea — causes irregular bleeding; women >60 (increased stroke risk)

⚠ Side effects

Unscheduled bleeding if started too soon after menopause; small increased breast-cancer and stroke risk (as with combined HRT)

🔬 Monitor

BP and symptom review at 3 months; investigate any unscheduled bleeding >6 months; annual review

💬 Counselling

"This is a single daily tablet that acts like a combined HRT — it shouldn't give you a monthly bleed. It's only suitable once your periods have stopped for a year."

SCA pearl: Tibolone is for established post-menopausal women only — offering it perimenopausally (irregular bleeding) is a scored Tasks error. Its mild androgenic effect makes it a reasonable choice where low libido is the dominant complaint.

Vaginal Oestrogen (Local)

Vagifem / Vagirux pessaries; Ovestin cream; Estring ring; Gynatrof gel

✓ Recommended

GSMTopical; minimal systemic absorption

✓ Prefer when

GSM symptoms (dryness, dyspareunia, urgency) with or without systemic HRT

HRT contraindicated (breast cancer) — vaginal oestrogen is generally safe even post-breast cancer; discuss with oncologist for ER+ cancer

Can be used long-term indefinitely — no systemic risks at low topical doses

✗ Avoid if

Unexplained vaginal bleeding — investigate first

ER+ breast cancer on aromatase inhibitors — consult oncologist; systemic absorption may be higher than expected

⚠ Side effects

Minimal systemic side effects; local mild irritation initially (resolves)

No endometrial protection needed at standard topical doses — no systemic progestogen required

🔬 Monitor

Symptom review at 3 months; no specific blood tests required

Cervical smear: atrophic changes may improve with 4–6 weeks of vaginal oestrogen before repeat

💬 Counselling

"This is a very low dose of oestrogen applied directly to the vaginal area — it stays local and doesn't significantly raise the oestrogen in your blood. You can use it long-term and there's no need to stop it after 5 years like systemic HRT."

SCA pearl: GSM is massively under-treated. Always ask about vaginal symptoms specifically — patients rarely volunteer them. Vaginal oestrogen is safe in most women including many with breast cancer. Mentioning this scores RO and Tasks marks.

Non-Hormonal Vasomotor Treatment

Venlafaxine 37.5–75mg; Clonidine 50–75mcg BD; Gabapentin 100–300mg nocte

✓ Recommended

HRT alternativesVarious — see card

✓ Prefer when

HRT contraindicated (ER+ breast cancer on aromatase inhibitors, active VTE)

HRT declined on personal grounds; patient on tamoxifen (use venlafaxine, NOT paroxetine)

Concurrent depression/anxiety — venlafaxine addresses both symptoms

✗ Avoid if

Paroxetine with tamoxifen — inhibits CYP2D6 reducing tamoxifen to active metabolite; use venlafaxine

Clonidine in patients with hypotension or on antihypertensives

⚠ Side effects

Venlafaxine: nausea, headache, BP elevation — take with food; start low dose

Clonidine: dry mouth, sedation, hypotension; wean off slowly to avoid rebound hypertension

Gabapentin: sedation, dizziness; avoid in renal impairment; caution driving

🔬 Monitor

Venlafaxine: BP at 3 months; QTc if cardiac history; annual review

💬 Counselling

"This isn't a hormone, but it works on the brain signals that cause hot flushes — around half of women find their flushes reduce by about 50% on this. It can take 2–4 weeks to take effect."

SCA pearl: Always check: is the patient on tamoxifen? If yes, venlafaxine is safe; paroxetine is contraindicated. This is a very common SCA catch — a scored Tasks item for drug interaction awareness.

7G — Psychosocial impact: driving, work, relationships & daily life

🤝

Menopause affects more than the body — proactively address the domains below

Menopausal symptoms are under-reported and under-treated because women feel they should cope. GPs who proactively open conversations about occupational impact, sexual function and mental health dramatically improve quality of life for their patients — and NICE explicitly states this is part of the GP role in NG23.

👶

Occupational impact

Brain fog, concentration difficulties and hot flushes affect 1 in 4 menopausal women at work. Symptom burden reduces performance, increases absenteeism and may prompt early retirement.

HRT consistently improves cognitive symptoms and concentration within 3 months. Advise workplace menopause support policies (available from RCOG patient information).

Reasonable adjustments under Equality Act 2010 may include flexible hours, cooler workspace, reduced uniform requirements during peak symptoms.

"You mentioned work has been affected — after treatment most women find their concentration significantly improves within 3 months."

💓

Libido & sexual function

GSM causes dyspareunia and avoidance of sex — exacerbated by relationship tension if partner is not informed. Testosterone deficiency also contributes to low libido post-menopause.

Vaginal oestrogen addresses GSM effectively. Testosterone supplementation (off-label in UK for hypoactive sexual desire disorder) may be considered after menopause specialist input.

ISSVD and BMS guidelines recommend proactive sexual health discussion in every menopause consultation.

"Has this been affecting your sex life at all? That's very common and very treatable — I'd like to help with that specifically."

🧠

Mood & mental health

Perimenopausal depression is a distinct entity — often responds to HRT alone or in combination with antidepressants. CBT is NICE-recommended for psychological symptoms.

Suicidal ideation in peri-menopause is an under-recognised risk; women in mid-life have a rising suicide rate that is underappreciated by clinicians.

Do not dismiss mood symptoms as "just hormonal" — screen using PHQ-9 and refer if appropriate.

"How has your mood been? I want to make sure we're not missing any depression alongside the menopausal symptoms."

💡

Driving & safety

Cognitive symptoms and severe sleep deprivation may affect driving safety. Night shift workers with severe night sweats and sleep disruption should be counselled on driving risk.

DVLA: there is no specific menopause notification requirement, but severe cognitive impairment may require disclosure. Encourage sleep treatment (HRT, sleep hygiene) before advising on driving limitation.

Gabapentin and clonidine can cause sedation — counsel explicitly on driving when prescribing these.

"While your sleep is this disrupted, I'd encourage you to be mindful of how you feel before driving long distances."

💥

Long-term health implications

Untreated early menopause or POI significantly increases risk of cardiovascular disease, osteoporosis and possibly dementia. These are not trivial long-term consequences of oestrogen deficiency.

HRT started within the window of opportunity (within 10 years / before 60) reduces CVD risk and may reduce dementia risk. NICE explicitly states these benefits in NG23.

Lifestyle modifications (exercise, diet, calcium, vitamin D, no smoking) amplify the protective effects of HRT on bone and cardiovascular system.

"Starting treatment now, while you're in the right window of opportunity, will protect your heart and bones for the long term."

🕊

Relationships & support

Partners and family members may not understand the physiological basis of mood change, irritability and low libido. Relationship strain from unexplained symptoms is common and rarely volunteered.

Signpost to menopause support organisations: Menopause Support UK, British Menopause Society patient information, Menopause Matters website.

Encourage patient to involve partner in HRT discussion where appropriate; couples who understand the biology together report better treatment adherence and relationship outcomes.

"There's a lot of really good information for partners and family members too — it can really help if the people around you understand what's happening."

7H — Follow-up schedule

3 months (initial HRT review)

Assess symptom response (vasomotor, mood, sleep, GSM); check BP (oral HRT); review side effects (breast tenderness, irregular bleeding, nausea); dose titration if needed; discuss any concerns about breast cancer risk.

BP checkSymptom responseSide effect review

6–12 months (consolidation)

Switch from sequential to continuous combined if now >12 months amenorrhoea; review progestogen type if intolerance evident; bleeding diary review; cervical smear if due; discuss duration of HRT (NICE: no arbitrary limit).

HRT type reviewSmear status

Annual review (ongoing)

Symptom control; bleeding pattern; BP; BMI; breast screening (mammography up-to-date); cardiovascular risk factors; bone health if indicated; ongoing discussion of continuation vs stopping; update on safety evidence.

BP & BMIMammogramCardiovascular risk

5-year review (HRT duration discussion)

NICE NG23: no mandatory stopping point for HRT — discuss continuation vs stopping based on ongoing symptoms and updated risk profile. For some women (POI, early menopause) HRT is appropriate until at least age 51. Breast cancer risk increases with duration but must be weighed against bone and cardiovascular benefits.

Duration reviewUpdated risk discussion

Stopping HRT (when decided)

Gradual dose reduction preferred over abrupt cessation to reduce symptom rebound. Vaginal oestrogen may continue indefinitely regardless of systemic HRT decision. DEXA if not recently done; optimise bone health; CVD lifestyle; continue calcium/vitamin D.

Bone healthWean plan

7I — Monitoring: BP-BMI-Bleeding triad + breast surveillance

Memory rule

For oral HRT: BP at 3 months then annually. For all HRT: bleeding diary for first 3 months; investigate late-cycle or heavy bleeding after 6 months. Annual breast screening reminder. No routine blood oestrogen levels needed. DEXA if POI, early menopause, or bone risk factors.

Preparation	What to check	Timing	Action threshold
Oral HRT	Blood pressure	Before start; 3m; annually	BP >160/100 on oral = switch to transdermal
Sequential combined	Bleeding diary	First 3 months; ongoing	Late cycle bleeding (days 1–9) after 6m = pelvic USS + endometrial biopsy
Continuous combined	Bleeding pattern	First 6 months; ongoing	Breakthrough bleeding >6 months = pelvic USS; PMB any time = 2WW referral
All HRT	BMI; mammogram status	Annually	Mammogram overdue = refer NHS breast screening; BMI >30 = switch oral to transdermal
POI / early menopause	DEXA bone density	At diagnosis; every 2–5 yrs	T-score < −2.5 = osteoporosis — add bisphosphonate; ensure calcium/vit D

Scenario	Expected finding	Action if outside expected
Continuous combined: first 6m	Irregular spotting common	Reassure; no action needed in first 6 months unless heavy
Continuous combined: >6 months	Amenorrhoea (no bleeding)	Any bleeding after 6 months = pelvic USS; endometrial biopsy if thickness ≥4mm
Sequential combined: days 10–21	Withdrawal bleed expected	Normal; reassure
Sequential combined: days 1–9	No bleed expected	Late-cycle bleeding after 6 months = investigate endometrium
BP on oral HRT at 3m	Within 10mmHg of baseline	BP raised >160/100 = switch to transdermal; do not add antihypertensive to compensate for HRT effect without route switch
Symptom control at 3m	≥50% reduction in flush frequency	<50% response = increase oestrogen dose (e.g. 25mcg → 50mcg patch); review progestogen

7J — Safety-netting: exact phrases + medico-legal rationale

⚠ Three scenario-specific phrases — use these verbatim

Why safety-netting matters beyond clinical care

PMB not referred urgently is a leading cause of delayed endometrial cancer diagnosis — medicolegally indefensible if not documented

Starting HRT without discussing breast cancer risk is a GMC consent issue; document risk communication verbatim in notes

Unopposed oestrogen in a woman with intact uterus causing endometrial cancer = prescribing error; always document uterus status

VTE on oral HRT: if VTE risk factors were not assessed and transdermal not offered, this is a prescribing deficiency — document UKMEC equivalent reasoning

Failure to refer breast lump for 2WW = delayed diagnosis complaint; always examine and refer without delay

POI: failure to start HRT promptly and counsel on bone/CVD risk = preventable harm; document that HRT was offered and reason if declined

3 monthsBP check (oral HRT); symptom response; side effect review; dose titration

AnnualMammogram status; BP; BMI; bleeding pattern; DEXA if indicated

ImmediatelyPMB any amount; new breast lump; VTE symptoms; new heavy breakthrough bleeding

🎓 SCA Checkpoint — Step 7 (Final)TasksRelating to OthersGlobal Skills

Closing phrases

"To summarise: we've agreed to start [HRT type] — watch out for [specific symptoms]. See you back in 3 months. Is there anything else?"

"The risk of breast cancer is real but smaller than many people think — around 1 per 1,000 per year, similar to 1 glass of wine daily."

"If you get any bleeding after the menopause, please contact us the same day."

"I'd like to continue this as long as it's helping — there's no reason to stop HRT after 5 years just because it's been 5 years."

"The most important thing is that this decision is yours — I want to make sure you have all the information you need."

Deductions — closing

Prescribing unopposed oestrogen with intact uterus — patient safety failure
No PMB safety-net — mandatory
Not discussing breast cancer risk numerically — loses Tasks mark
Continuous combined in perimenopause — wrong preparation
No follow-up arranged (3 months mandatory for HRT start)
Dismissing breast cancer concern without evidence-based response

Tasks domain — full criteria

Correct HRT type for stage (sequential/continuous combined/oestrogen-only)
Correct route for risk profile (transdermal if VTE/HTN/obesity)
Uterus status documented and progestogen added if intact
Breast cancer risk communicated as absolute number
PMB safety-netting stated explicitly

Relating to Others — full criteria

WHI breast cancer fear addressed with empathy and updated evidence
Patient's own goals (work, sleep, relationship) referenced in plan
Shared decision making — patient chose HRT not clinician
Non-hormonal options mentioned even if patient choosing HRT
Long-term health benefit framed in terms patient values
Closing question asked: "Is there anything else?"

🔴 Red

Unopposed oestrogen with uterus • no PMB safety-net • no breast cancer risk discussed • wrong HRT type for stage • no follow-up

🟠 Amber

Correct HRT type • breast cancer risk mentioned but not quantified • PMB safety-net generic • ICE referenced but not in plan

🟢 Green

Correct HRT type and route • progestogen confirmed • PMB explicit • breast cancer risk as absolute number • patient-led decision • ICE in plan • follow-up 3 months

"I've been having these terrible hot flushes for about 6 months — they're waking me up three or four times a night. I'm exhausted and I'm struggling at work. I want to try HRT but I'm terrified about the breast cancer risk."

Who you are

Sarah, 52 years old, secondary school deputy head teacher. Your last period was 15 months ago. Hot flushes 8–10 times/day, including 3–4 times at night. Significant sleep disruption. Your concentration and memory have deteriorated and your performance reviews have been affected. BMI 28. Mild hypertension (136/82) on amlodipine 5mg. Non-smoker.

Hidden agenda

Your mother had breast cancer at 62 and died from it. You are convinced HRT will give you breast cancer. You have read extensively online and mostly found negative information. You have also been having pain during sex for the past 6 months but are too embarrassed to mention it unless specifically asked. You are also worried your concentration problems could be early dementia.

Symptoms if asked directly

No postmenopausal bleeding — periods stopped 15 months ago completely
No new breast lumps; mammogram 2 years ago was clear
Vaginal dryness and pain during sex (dyspareunia) — will only disclose if specifically asked
Low mood and anxiety; PHQ-9 score would be around 10 (moderate)
No DVT/PE history; no migraine; no liver disease
No family history of VTE

Lifestyle + bonus details

Drinks 8–10 units/week (stress-related); has increased since menopause started
Walks 20 minutes/day but not formally exercising
Has not been to breast screening for 2 years (avoidance due to cancer fear)
Mother's breast cancer was ER+ — this is a specific concern if asked

"But my mum died from breast cancer — surely the risk for me is much higher? Am I not just inviting cancer by taking this?"

Resolution: Accept the plan if the doctor: (1) Addresses the breast cancer fear with empathy and current NICE evidence (absolute number, not relative risk); (2) Asks about and addresses the dyspareunia (vaginal oestrogen); (3) Recommends transdermal HRT rather than oral (due to hypertension); (4) Checks for PMB; (5) Arranges breast screening; (6) Offers a follow-up appointment at 3 months.

🏥

Clinic Quick Reference

Menopause & HRT — Clinical Decision Framework

NICE NG23 (2019) · NICE CKS Menopause 2023 · BMS Guidelines

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🚦 1 — Triage System

Patient presents re: menopause → First: screen for PMB, new breast lump, VTE symptoms, POI in young woman

↓

🔴 Emergency (999 / A&E)

DVT / PE on HRT (leg pain, breathlessness)
Stroke / TIA on oral HRT
Suicidal ideation secondary to severe perimenopausal depression

999 / Same-day MH

🟠 Urgent (2WW / same day)

Postmenopausal bleeding (PMB) → 2WW gynaecology
New breast lump on HRT → 2WW breast clinic
Unexpected bleeding >6m on continuous combined → pelvic USS
POI in woman <40 → FSH x2 + specialist

2WW / same-week assessment

🟢 Routine GP

New HRT request (no red flags)
Annual HRT review
HRT preparation change
Non-hormonal options

Planned GP appointment

📊 2 — Key Numbers

Average UK menopause age

12 months

Amenorrhoea to diagnose menopause

FSH >30

IU/L x2 confirms POI (<45 only)

<60 yrs

HRT benefit window

1.8×

VTE risk with oral HRT

No increase

VTE risk with transdermal

1/1,000/yr

Extra BC cases (combined HRT)

5 yrs

Standard review point (not stop point)

4mm

Endometrial thickness threshold (USS)

3–5%

Annual bone loss without HRT

<40 yrs

POI definition (amenorrhoea + FSH)

6 weeks

Vaginal oestrogen before repeat smear

💊 3 — HRT Prescribing Rules

🔴 Absolute rules

Never: Unopposed oestrogen if uterus intact • HRT without PMB exclusion • Continuous combined in perimenopause • Delay POI treatment pending specialist
Always: Add progestogen if uterus intact • Use transdermal if VTE risk / HTN / obesity • Refer PMB as 2WW • Start POI HRT promptly

🟢 Route selection guide

Oral: No VTE risk factors, normal BP, post-hysterectomy (oestrogen-only)
Transdermal: VTE risk, hypertension, obesity (BMI>30), migraine with aura, liver disease, smoker
Vaginal: GSM only or as adjunct to systemic HRT

⚠ 4 — Safety Netting & Follow-Up

Follow-up timeline

3 months: BP (oral), symptom response, side effects, dose titration

6–12m: Bleeding diary review; switch sequential→continuous if >12m amenorrhoea

Annual: BP, BMI, mammogram, CVD risk, DEXA if indicated

5 years: Duration review — NICE: no mandatory stop point

📌 No routine oestrogen blood levels needed; clinical symptom review sufficient

🔬 5 — Monitoring

HRT type	What to check	Timing	Action if abnormal
Oral HRT	Blood pressure	Before start; 3m; annually	BP >160/100 = switch to transdermal
Sequential combined	Bleeding diary	First 3m; ongoing	Late cycle days 1–9 bleeding after 6m = pelvic USS + endometrial biopsy
Continuous combined	Bleeding pattern	First 6m; ongoing	Breakthrough >6m or any PMB = pelvic USS; 2WW if PMB
All HRT	BMI; mammogram	Annually	BMI >30 = switch oral to transdermal; mammogram overdue = refer screening
POI / early menopause	DEXA bone density	At diagnosis; every 2–5 yrs	T-score < −2.5 = osteoporosis; consider bisphosphonate; calcium/vit D

🔴 Red flags: PMB (any) • new breast lump • DVT/PE on HRT • late continuous combined breakthrough bleeding • pelvic mass

🛡️ Safeguarding: Domestic abuse exacerbated by mood symptoms • POI grief/mental health • perimenopausal suicidality • carer abuse in older women

🎓

SCA Exam Quick Reference

SCA Consultation Blueprint

Tasks · Relating to Others · Global Skills · RAG guide

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🕐 12-Minute Consultation Flow

0–2 min

Open & Agenda

"Before we go through anything, tell me what's been most affecting you day to day."

Don't start with LMP. Let patient lead. Validate symptom burden first.

ROGS

✗ "When did your periods stop?" first • ✗ Clipboard questioning

2–5 min

Safety Screen

"Have you had any bleeding since your periods stopped? Any new lumps in your breast?"

PMB = 2WW before HRT. New breast lump = 2WW. Check VTE/DVT history. Breast cancer hx.

TasksGS

✗ Starting HRT without PMB screen • ✗ No breast cancer hx check

5–7 min

ICE + WHI Fear

"Have you been worried about the breast cancer risk? That's really common — let me share what the latest evidence actually says."

Name the fear, validate it, then address with absolute numbers. Ask about dyspareunia.

ROGS

✗ Dismissing cancer concern • ✗ Not asking about GSM/dyspareunia

7–10 min

Individualised HRT Plan

"Based on your blood pressure and your history, I'd recommend the patch rather than the tablet — it's safer for your circulation."

Correct type (sequential/continuous/oestrogen-only). Correct route (transdermal if risk factors). Add progestogen if uterus intact.

TasksRO

✗ Oral HRT if HTN • ✗ Unopposed oestrogen with uterus • ✗ Wrong type for stage

10–12 min

Safety-Net & Close

"If you get any bleeding from below, contact us the same day. Some irregular spotting in the first few months is normal — heavy or ongoing bleeding needs to be checked."

PMB warning. VTE warning (oral HRT). 3-month follow-up. Closing question.

TasksROGS

✗ No PMB safety-net • ✗ No follow-up • ✗ No closing question

🔴🟠🟢 RAG Scoring

Tasks Domain

🟢

Correct HRT type + route • progestogen confirmed • PMB safety-net • absolute BC risk given • 3m follow-up

🟠

Correct HRT type but route not tailored • BC risk mentioned not quantified • PMB generic safety-net

🔴

Unopposed oestrogen with uterus • PMB not escalated • oral HRT in high VTE risk • no follow-up

Relating to Others

🟢

ICE all 3 • WHI fear named + addressed • GSM asked • shared decision • closing question

🟠

ICE partial • BC concern acknowledged not addressed with evidence • GSM missed

🔴

No ICE • BC fear dismissed • HRT imposed • no closing question • no GSM

Global Skills

🟢

Opens with agenda • jargon-free • timed • cues noticed • clear summary

🟠

LMP before agenda • some jargon • summary incomplete

🔴

Clipboard style • no patient agenda • jargon throughout • no summary

💬 Key Phrases

Ideas

"What do you already know about HRT? Have you been reading about it?"

BC Fear

"The breast cancer risk is around 1 per 1,000 women per year — similar to drinking one glass of wine daily."

Expectations

"What would a good outcome from today look like for you?"

GSM

"Has this been affecting your sex life or intimacy at all? I ask everyone — it's very common and very treatable."

Transdermal

"With your blood pressure, I'd recommend the patch — it doesn't go through your liver and has no increased clotting risk."

"To summarise: we've agreed on [HRT type]. Any bleeding from below → same day. Back in 3 months. Anything else?"

🚫 9 Danger Zones

✗

LMP before patient agenda
→ Open with "what's been most affecting you?" — always

✗

Unopposed oestrogen with intact uterus
→ Always add progestogen or use Mirena IUS if uterus present

✗

HRT without PMB exclusion
→ Ask PMB before any HRT; 2WW if present; do not start HRT

✗

Oral HRT in high-risk patient (HTN / VTE / obesity)
→ Transdermal has no VTE risk — always use with risk factors

✗

BC fear dismissed without evidence
→ Absolute risk: ~1/1,000/yr combined HRT; validate before correcting

✗

Continuous combined in perimenopause
→ Sequential for <12m amenorrhoea; continuous for ≥12m

✗

GSM not asked about
→ Always ask dyspareunia; vaginal oestrogen addresses GSM specifically

✗

Delaying HRT in POI pending specialist
→ Start HRT immediately; every month without oestrogen = bone loss

✗

Imposing arbitrary 5-year stopping rule
→ NICE NG23: no mandatory stop at 5 years; decision based on symptoms + risk

💊 HRT Quick-Pick

Post-hysterectomy

→

Oestrogen only

No progestogen needed

Perimenopause, uterus intact

→

Sequential combined

<12m amenorrhoea

Post-menopause, uterus intact

→

Continuous combined

≥12m amenorrhoea

VTE / HTN / obesity

→

Transdermal route

No VTE risk increase

GSM only or adjunct

→

Vaginal oestrogen

Safe long-term

HRT contraindicated

→

Venlafaxine / CBT

Not paroxetine + tamoxifen

⛔ Never: Unopposed oestrogen if uterus intact • HRT before PMB excluded • Oral HRT with DVT/PE history • Continuous combined in perimenopause

Menopause & HRT · GP Clinical Reasoning Framework v2 · NICE NG23 Menopause: diagnosis and management (2015, updated 2019) · NICE CKS Menopause (2023) · British Menopause Society (BMS) Guidelines · MHRA HRT safety update (2019)

v2: Clinical stem · Open Q first · ICE in all modes · Psychosocial (1E + 7G) · Lay language DDx (Step 5) · Safeguarding (Step 1) · Expectation management (7A) · SCA RAG checkpoints after every step · SCA Scorecard as standalone section · Dual tailored summaries (Clinic + SCA)

Teaching clinicians why each step matters — not just what to do · Always consult current BNF/NICE CKS/BMS guidelines · Clinical judgement takes precedence over any framework

Menopause & HRT

Red Flags — act before continuing history

Safeguarding Considerations — Consider in Every Consultation

👴 Domestic abuse during menopause

🧠 Mental health and capacity

👤 Older women and carer abuse

🕊 POI and reproductive loss

👶 Occupational impact and identity

💍 Relationship and intimacy

⚖️ Cultural framing of menopause

💉 Alcohol, sleep and mood

💥 Grief and transition

📚 Health literacy and media influence

999 or Same-Day Hospital

Same-Day / 2-Week Wait

GP-managed

Menopause (≥45, 12 months amenorrhoea)

Perimenopause (irregular cycles, symptoms)

GSM (genitourinary syndrome)

Premature ovarian insufficiency (POI, <40)

Early menopause (40–44)

Hypothyroidism / Hyperthyroidism

Endometrial carcinoma (PMB)

Ovarian cancer

Validate — name their expectation

Explain — share your clinical reasoning

Negotiate — offer something today

Select patient characteristics — refer to 7D prescribing guide for recommended HRT type

Occupational impact

Libido & sexual function

Mood & mental health

Driving & safety

Long-term health implications

Relationships & support

3 months (initial HRT review)

6–12 months (consolidation)

Annual review (ongoing)

5-year review (HRT duration discussion)

Stopping HRT (when decided)

Memory rule

⚠ Three scenario-specific phrases — use these verbatim

Why safety-netting matters beyond clinical care

🎭 Patient actor brief — click to practise

Who you are

Hidden agenda

Symptoms if asked directly

Lifestyle + bonus details