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)

Secondary care referrals may be accepted from within our ICB catchment area.. 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. 

Prior to referral

If PMS/PMDD is associated with self-harm, suicidal risk or ideation, a mental health risk assessment must be completed and safety net in-place with the your GP. Antidepressants are a recommended first line treatment along with talking therapies. We are not an acute psychiatric service and unable to provide crisis support.

Checklist if GnRHa recommended

  • You should be planning a family within the next 12–18 months (due to the risk of delayed return of regular spontaneous ovulation or periods
  • You must discuss your fertility and future family planning with the specialist
  • You will need a baseline DEXA scan, repeated every 18 months, to assess osteoporosis risk
  • You should use a reliable contraceptive (eg condoms) as GnRHa are not a licenced for this purpose. Spontaneous ovulations may still occur with the risk of pregnancy

Most GPs will prescribe and administer GnRHa injections. Where this is not possible, these may be requested here, but the injection should still be given by the GP.

Mental health support

If you are having suicidal thoughts or just finding it difficult to cope, please speak to a friend or family member, your GP, call NHS 111 or attend A&E. Mental health support for the first time 
Call 116 123 to talk to the Samaritans, or email: jp@smaritans.org  for a reply within 24 hours
Text ’SHOUT’ to 85258 to contact the Shout Crisis text Line, or text ‘YM’ if you are under 19
Self-referral talking therapies:  Mental health talking therapies

Low libido and testosterone replacement

The NICE menopause guideline recommends testosterone for low libido and therefore should be prescribed by your GP or local secondary care provider.

  • If your GP is within SWL, they may initiate testosterone without needing to refer you to a specialist: South West London Formulary 
  • If your GP is within NW London, they may need to refer your local specialist, but then may continue prescribing.
  • If your GP is not within in the NWL integrated care board referral region for Chelsea and Westminster Hospital, we can only give advice about prescribing testosterone, but we cannot accept referrals to initiate treatment.

Initiating and assessing testosterone replacement

  • A 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 frequency of use this 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. The appointment can only be re-booked once
  • Or ask for you appointment to be changed to a telephone appointment  and we will call at the appointed date and time

Vaginal progesterone regimens in combined HRT

Alternative sequential progestogen options

1. Micronised progesterone 100mg capsule: 2x 100mg orally for 12 consecutive nights each month
2. Micronised progesterone (generic): 2x100mg oral capsule inserted vaginally for 12 consecutive nights each month (off label in HRT use)
3. Crinone 8% gel: One applications inserted vaginally on alternate nights for six applications per month (off label in HRT use)
4. Cyclogest 400mg pessary: one inserted vaginally for 12 consecutive nights each month (Licensed for premenstrual syndrome and postnatal depression, off label in HRT use)
5. Utrogestan 200mg pessary: one inserted vaginally at night for 12 consecutive nights each month (off label in HRT use)
6. Levonorgestrel 52 mg intrauterine system (any brand)
7. Norethisterone (NETA): 10mg orally for 12 consecutive days each month
8. Provera (MPA): 10mg orally for 12 consecutive days each month

Alternative continuous progestogen options in combined HRT 

1. Progesterone 100mg capsule (generic): One capsule taken orally every night
2. Progesterone 100mg capusle (generic): One capsule inserted into the vagina every night (off label)
2. Lutigest 100mg pessary: one pessary inserted into the vagina every night (off label in HRT use, condom safe)
3. Crinone 8% gel: x1 application inserted into the vagina two or three times a week (off label in HRT use)
4. Cyclogest pessary: 400mg inserted into the vagina (or 1/2 dose - 200mg) every night. (Licensed for premenstrual syndrome and postnatal depression, off label in HRT use)
5. Norethisterone (NETA) 5mg: Taken orally every day
6. Provera (MPA): 5mg taken orally every day
7. Levonorgestrel 52 mg intrauterine system (any brand)