The video version of this podcast can be found here: · https://youtu.be/JktVjws4xQ4 This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country. My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review a section of the NICE guideline on Hypertension in adults, always focusing on what is relevant in Primary Care only. I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement. Disclaimer: The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido. Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] Music provided by Audio Library Plus Watch: https://youtu.be/aBGk6aJM3IU Free Download / Stream: https://alplus.io/halfway-through There is a podcast version of this and other videos that you can access here: Primary Care guidelines podcast: · Redcircle: https://redcircle.com/shows/primary-care-guidelines · Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK · Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148 There is a YouTube version of this and other videos that you can access here: The Practical GP YouTube Channel: https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The NICE clinical guideline on Menopause: identification and management [NG23] can be found here: · https://www.nice.org.uk/guidance/NG23 The FSRH Guideline: Contraception for Women Aged Over 40 Years can be found here: · https://www.cosrh.org/Common/Uploaded%20files/documents/fsrh-guideline-contraception-for-women-aged-over-40-years.pdf Transcript If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the episode description. Hello and welcome, I’m Fernando, a GP in the UK. Today we are reviewing the NICE guideline on the menopause, always focusing on what is relevant in Primary Care only. Today we will focus on patient information, diagnosis, and treatment choices. In future episodes we will cover the other sections of the guideline. Right, let’s jump into it. Let’s start by saying that the NICE menopause guideline applies to women, trans men, and non-binary people registered female at birth who have menopause-associated symptoms now, or who may experience them in the future. It does not apply to people having gender-affirming hormone therapy. Let’s now look at what information should be given to patients. When we assess and manage menopause, we should use shared decision making when discussing symptom management, including the benefits and risks of different options. We should explain that menopause usually happens in mid-life, but that it can also happen earlier because of surgery, medical treatment, an inherited condition, or an unknown cause. Menopause symptoms may be mild or severe, and they may last for a short time or a long time. Symptoms may include changes in the menstrual cycle, hot flushes, vaginal dryness, mood symptoms, joint or muscle pain, and sexual difficulties, such as low sexual desire. NICE says we should discuss contraception with people who have menopause-associated symptoms because menopause symptoms do not necessarily mean that ovulation has stopped. Although fertility declines with age, contraception may still be needed if pregnancy is not wanted. For people using non-hormonal contraception, the Faculty of Sexual and Reproductive Healthcare advises that contraception can usually be stopped after 2 years of amenorrhoea between the ages of 40 and 50, or after 1 year of amenorrhoea after the age of 50. However, most women using hormonal contraception during the perimenopause will have altered bleeding patterns or amenorrhoea. As a result, it can be difficult to give accurate advice, so we should check the specific recommendations for each type of hormonal contraceptive in the Faculty of Sexual and Reproductive Healthcare guidance. In general, it advises that contraception can be stopped at age 55, because spontaneous pregnancy after this age is exceptionally rare. Bone health should be discussed too, explaining the importance of maintaining muscle mass and strength through physical activity. For people experiencing early menopause, between the ages of 40 and 44, we should offer psychological support if they are distressed by it. Let’s now look at the diagnosis. In otherwise healthy people aged 45 or over, with menopause-associated symptoms, NICE says we can usually identify perimenopause and menopause without laboratory tests. Perimenopause can be identified if vasomotor symptoms have recently started, and there are changes in the menstrual cycle. Menopause can be identified if the person has not had a period for at least 12 months, and they are not using hormonal contraception. In people who have had a hysterectomy, menopause is identified based on the type and combination of symptoms, for example vasomotor symptoms. NICE also says that menopause can be harder to identify in people taking hormonal treatments, because, as we mentioned earlier, hormonal contraception can alter bleeding patterns, making it difficult to know the underlying menopausal status. NICE says we should not use FSH to identify menopause in people using combined oestrogen and progestogen contraception, or high-dose progestogen and The Faculty of Sexual and Reproductive Healthcare explains why: combined hormonal contraception suppresses oestradiol, FSH, and LH, and depot medroxyprogesterone acetate can suppress FSH to some extent, meaning someone could be menopausal but not show the expected rise in FSH. NICE also says that people from some ethnic minority backgrounds, and people with some lifelong conditions, may experience menopause at a younger age. NICE does not give a list of specific ethnicities, but in its rationale, it gives Down’s syndrome as an example of a lifelong condition. So, the practical point is to think about menopause earlier in these groups. NICE says that FSH should only be considered in specific situations. This includes people aged 40 to 45 with menopause-associated symptoms, including a change in their menstrual cycle. It also includes people under 40 in whom menopause is suspected, where we also need to think about premature ovarian insufficiency. When discussing management options with people aged 40 or over, we should discuss the benefits and risks of the various treatment options. Additionally, when discussing HRT, we should discuss combined HRT compared with oestrogen-only HRT, and explain which type the person would be offered and why. We should also discuss transdermal HRT compared with oral HRT, the different types of oestrogen and progestogen, and when to give sequential versus continuous combined HRT, and why. If the person chooses to take HRT, we should discuss the possible duration of treatment from the start and revisit, at every review, the benefits and risks of continuing it. We should also explain that symptoms may return when HRT is stopped, and discuss the option of restarting treatment if needed. Cognitive behavioural therapy can also be discussed as a possible management option, including menopause-specific CBT, which may include face-to-face or remote sessions, individual or group sessions, and self-help options, depending on the person’s preferences. For complementary therapies, we should explain that the safety, quality, and purity of unregulated preparations may be unknown. There is some evidence that isoflavones or black cohosh may relieve vasomotor symptoms, but NICE says we should also explain that their safety is uncertain, preparations may vary, and interactions with other medicines have been reported. For people with a personal history of breast cancer, or at high risk of breast cancer, we should explain that, although St John’s wort may help relieve vasomotor symptoms, there is uncertainty about the correct dose, how long the effect lasts, and the variation in strength and content between preparations. We should also warn about potential serious interactions with other medicines, including tamoxifen, anticoagulants, and anticonvulsants. So that is it, a review of a section of the NICE guideline on the menopause. We have come to the end of
