Common clinical plans

Following your appointment in the menopause and PMS clinic, an individualised treatment plan will have been agreed in your clinical summary shared with your GP. Common clinical treatment plans with signposts to useful resources are available here.

Note: Additional management plans will be added in the future.

On this page

Investigations

Serum estradiol (E2), luteinising hormone (LH), follicle stimulating hormone (FSH) Blood test for diagnosis and assess treatment
Anti-Müllerian hormone (AMH) Blood test to assess fertility
Genetics testing (in POI) To identify potential cause of POI

Chelsea and Westminster Hospital (CWH) patients only:
  • This blood test has to be done at the CWH
  • You will either be sent a paper request form in the post or asked to collect the form from gynaecology outpatients on the first floor.
  • The form must be handed to the phlebotomist at the time of the test
  • Samples cannot be processed without the request form
  • The samples get sent to an external lab for analysis and the test may take up-to four months to be processed
DEXA bone density scan (BMD) X-ray of spine and hip to assess risk of osteoporosis
Transvaginal ultrasound scan (TVUSS) To assess the womb (uterus), womb lining (endometrium) and ovaries

An antra follicle count (AFC) may be requested if assessing fertility

The AFC is the number of small immature follicles seen within the ovary
Dietary calcium check Online self-assessment

Calcium supplements are not generally recommended if you have a calcium rich diet

Excess calcium intake can lead to deposits around the heart and in breast tissue, potentially increasing long-term health risk

Resources

Premature ovarian insufficiency (POI)

POI is a diagnosis made in women under the age of 40. Due to the loss of estrogen, hormone replacement may be advised for symptom relief as well as long-term heart bone and brain heath. Hormone replacement may be either a combined hormonal contraception or with hormone replacement therapy (HRT). The decision is very personal and guided by your specialist.

If you have been diagnosed with POI you be interested in joining the POISE multicentre trial comparing the benefit of different hormone treatments.

Premenstrual syndromes (PMS)/Premenstrual dysphoric disorder (PMDD)

The treatment for PMS and PMDD at Chelsea and Westminster hospital is based upon the National Association for PMS and Royal College of Gynaecologist guidelines.

Cycle suppression treatment may be recommended using a gonadotropin releasing agonist (GnRHa) which supress FSH and LH, prevents ovulation and lowers estrogen. GnRHa are only licenced for short-term use due to the risk of developing osteoporosis. If GnRHa is being used outside of the licensed use, estrogen ‘add-back’ must be taken to prevent the risk of osteoporosis.

Checklist

When on this treatment you should:

  • Not be planning a family within the next 12–18 months (due to the risk of delayed return of regular spontaneous ovulation or periods
  • Have a baseline estradiol, FSH/LH and AMH
  • Discuss your fertility and future family planning with the specialist
  • Have a baseline DEXA scan, repeated every 18 months, to assess osteoporosis risk
  • Have a serum estradiol at least every 12 months to ensure optimal replacement for bone health
  • Use contraception (eg condoms) as GnRHa are not a licenced contraceptive. Spontaneous ovulations may still occur with the risk of pregnancy

Most GPs will prescribe and administer GnRHa injections. Where this is not possible, the may be prescribed request through the clinic, but the injection given by the GP.

Low libido and testosterone replacement

Testosterone may be recommended for postmenopausal women with hypoactive psychosexual desire disorder (HSDD) or low libido, who are taking hormone replacement therapy (HRT). There are currently no licensed testosterone products for female use  but clinical trials have demonstrated its benefit and safety. Other invalidated benefits of  testosterone may include improved muscle strength, cognition, energy levels and reduced migraines.

Initiating and assessing testosterone replacement

  • Serum testosterone is needed prior to starting testosterone replacement, then repeated yearly or more frequently if side-effects are reported
  • The effectiveness of testosterone replacement is based upon individual self-reported benefit and side-effects
  • Testosterone replacement may increase the risk of side-effects—lowering the dose or frequently of use, can reduce the risk of side-effects
  • Testosterone replacement should be discontinue after three to six months if no benefit or only side-effects occur

Prescription choices and regimens

  • Testogel 40.5mg/2.5g: A small pea sized amount, about a 1/8th packet per day = 5mg (1 box = 6/12 supply)
  • Testim 50mg/5g: A small pea sized amount, about a 1/10th sachet per day = 5mg (1 box = 6/12 supply)
  • Tostran gel 2% (60g): Half or one metered dose, two or three times a week—maximum use 1 metered dose on alternate days = 10mg (1 bottle = 6/12 supply)
  • Testavan gel 2%: Half or one metered dose, two or three times a week—maximum use 1 metered dose on alternate days = 10mg (1 bottle = 6/12 supply)—off label
  • Testogel 16.2mg/g gel: Not recommended for female use
  • Androfeme cream: Formulated for female use but only available privately

Application: Apply to thigh, lower abdomen or wrists and rotate sites regularly to avoid of localised hair growth
Potential side-effects: Hirsutism, alopecia, acne, voice change and weight gain

Genitourinary symptoms of the menopause (GSM)

If you have persistent, severe symptoms or unusual vaginal bleeding see your GP advice.
If you have had a new sexual partner within the last six months or experiencing any of the following symptoms, you should discuss this with you GP and attend a sexual health clinic.

  • Unusual discharge from the vagina
  • Pain or burning when you pass urine (pee)
  • Itches, rashes, lumps or blisters, mainly around the genitals or anus (back passage), but can be on other parts of the body
  • Pain and/or bleeding during sex
  • Bleeding between periods (including those using hormonal contraception)
  • Bleeding after sex
  • Pain in the testicles

GSM, is also known as vulvo-vaginal atrophy (VVA) or dryness. There are many over the counter options of help with GSM and these should be tried before using local vaginal estrogen.

Non-hormonal options for vulvovaginal dryness or painful intercourse

Vaginal moisturisers rehydrate the skin and can be used daily. Lubricants help relieve pain during sex by increasing glide and reducing friction. Soaps and shower gels are not recommended for washing around the labia (vuvla), vagina and anus as this may increase the symptoms associated vulvo-vaginal dryness.

  • Soap free emollients: Dermol 500 lotion, E45 emollient or Oilatum (nhs.uk/conditions/Emollients)
  • Vaginal moisturisers: Hyalofemme, Yes WD/OB, Replens, Vagisil, Balance Activ, Regelle
  • Vaginal lubricant: YES DG/WD/OB, Sylk
  • Natural oil base lubricant: natural Vitamin E liquid capsules, natural coconut oil, natural almond oil, Yes OB (Caution: not to be used with latex condoms or barrier contraceptives)
  • Silicone-based lubricant: for skin sensitivities/allergies, recurrent UTI or yeast infections

Hormonal options for vulvovaginal atrophy

First line

  • Estradiol pessary - now available without prescription as Gina
  • Estriol vaginal cream or gel
  • Referral to Pelvic health physiotherapy

Second line

  • Intrarosa (Prasterone-DHEA): for dyspareunia and atrophy (contraindication breast cancer)
  • Senshio (Ospemifene-SERM): severe symptomatic vulval symptoms and vaginal atrophy (VVA)
  • Referral to dermatology vulval clinic for unresolved vulval symptoms

Hormone implant clinic

Blood tests are required to be done two weeks before every implant appointment. Please refer to your last clinic letter for the indicated tests. Your blood test will have been requested at either Chelsea and Westminster Hospital with the results viewable via Patients Know Best or via your GP and the results on your NHS app.

The serum estradiol should be less than 600pmol/l before the next implant can be inserted. If the serum estradiol is more than 600pmol/l, please call the appointment office and:

  • Re-book your appointment for two months and repeat your blood test-the appointment can only be re-booked once
  • Or ask for you appointment to be changed to a telephone appointment