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M enopause: diagnosis and ! !&8NICE guideline .%",!OS78S(

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Y our responsibility The r ecommendations in this guideline represent the view of NICE, arrived at after careful (',"+-"('S(S- !S0"'S0"%%NS!'S2+","' S-!"+S#. &'-MS)+(,,"('%,S'S)+-"-"('+,S+ S2)-S-(S-$S-!",S ."%"'S.%%3S"'-(S(.'-MS%(' ,"S-!S"'"0".%S',MS)+ +',S'S0%.,S(S-!"+S)-"'-,S(+S-!S)()%S.,"' S-!"+S,+0"NS-S",S'(-S&'- (+3S-(S))%3S-!S+(&&'-"(',MS'S-!S ."%"'S(,S'(-S(0++"S-!S+ !S-!&S'S-!"+S&"%",S'S++,S(+S .+"'NS%%S)+ (.+S,!(.%SS+)(+-S-(S-!S ""',S'S%-!+S)+(.-,S .%-(+3S '3S.,"' S- !S %%(1S+S!&NS (%S(&&",,"('+,S'S)+ (0"+,S(S!%-!+S!0SS+,)(',""%"-3S-(S'%S-!S ."%"'S- (SS))%"S1!'S"'"0".%S)+(,,"('%,S'S)()%S.,"' S,+0",S1",!S-(S.,S"-NS!

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Con tents Ov

erview NNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNN:S

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or? NNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNN:S

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ecommendations NNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNN;S

1

.1 Individualised care NNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNN;S

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N8S" '(,",S(S)+"&'().,S'S&'().,SNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNN;S

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7 N;S(' I-+&S'"-,S'S+",$,S(S!(+&('S+)%&'-S-!+)3SNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNN78S 7

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Implementation: getting star

ted NNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNN87S

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opping the use of follicle-stimulating hormone tests to diagnose menopause "'S1

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!S!%%' OS(&&.'"-"' S- !S%(' I-+&S'"-,S'S+",$,S(S!(+&('S+)%&'-S- !S!%%' OS)+ (0""' S'(. !S,)"%",-S,+0",SNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNN8 :SS&(+ Cont

ext NNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNN8=S

1 W

omen with breast cancer NNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNN8?S

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Finding mor

e information and resources NNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNN98S

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This guideline is t

he basis of QS143. Ov erview This guideline co vers the diagnosis and management of menopause, including in women 1!(S!

0S)+&-.+S(0+"'S"',.""'3NS!S ."%"'S"&,S-(S"&)+(0S-!S(',",-'3S(S,.))(+

-S'S"'(+&-"('S)+(0"S-(S1(&'S"'S&'().,NSW ho is it for? • %- (&'S"'S&'().,MS'S-!"+S&"%",S'S++,NS '().,OS" '(,",S'S&' &'-SB89C

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R ecommendations P eople have the right to be involved in discussions and make informed decisions (.-S- !"+S+MS,S,+"S"'SL,S"' (+&-"('S('S&$"' S","(',S(.-S3(.+S+ NS $"' S","(',S.,"' SS ."%"',S

2)%"',S!(1S1S.,S1(+,S-(S,!(1S-!S,-+

' -!SB(+S+-"'-3CS(S(.+S+(&&'-"(',MS'S!,S"'(+&-"('S(.-S)+ ,+""' S&""',SB"'%."' S(I%%S.,CMS)+(,,"('%S ."%"',MS,-'+,S'S%1,SB"'%."' S('S(','-S'S&'-%S)"-3CMS'S, .+"' NS1.1 I ndividualised care 1 .1.1 Adopt an individualised appr oach at all stages of diagnosis, investigation 'S&' &'-S(S)+"&'().,S'S&'().,NS (%%(1S+ (&&'-"(',S"'S-!SS ."%"'S('S)-"'-S

2)+"'S"'S.%-SS,+

0",NS 1.2 D iagnosis of perimenopause and menopause 1 .2.1 Diagnose t he following without laboratory tests in otherwise healthy 1 (&'S S(0+S:;S3+,S1"-!S&'().,%S,3&)-(&,OSKS)+"&'().,S,S('S0 ,(&(-(+S,3&)-(&,S'S"++ .%+S)+"(,SKS&'().,S"'S1 (&'S1!(S!0S'(-S!SS)+"(S(+S-S%,-S78S&('- !,S'S+S'(-S.,"' S!(+&('%S('-+)-"('S

KS&'().,S,S('S,3&)-

(&,S"'S1(&'S1"-!(.-SS.-+.,NS1 .2.2 T ake into account that it can be difficult to diagnose menopause in 1 (&'S1!(S+S-$"' S!(+&('%S-+-&'-,MS(+S2&)%S(+S-!S-+ -&'-S(S!03S)+"(,NS1 .2.3 Do not use t he following laboratory and imaging tests to diagnose '().,OS" '(,",S'S&' &'-SB89C

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perimenopause or menopause in w omen aged over 45 years: KS'-"I /%%+"'S!(+&('S

KS"'!""'SS

KS"'!""'SS

KS(,-+"(%S

KS'-+%S

(%%"%S(.'-SKS(

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.2.4 Do not use a serum f ollicle-stimulating hormone (FSH) test to diagnose &'().,S"'S1 (&'S.,"' S(&"'S(,-+( 'S'S)+( ,-( 'S('-+)-"('S(+S!" !I(,S)+ ( ,-( 'NS1 .2.5 Consider using a FSH t est to diagnose menopause only: KS"'S1 (&'S S:6S-(S:;S3+,S1"-!S&'().,%S,3&)-(&,MS"'%."' SS!' S"'S- !"+S&',-+.%S3%SKS"'S1 (&'S S.'+S:6S3+,S"'S1!(&S&'().,S",S,.,)-SB,S%,(S+ (&&'-"(',S('S" '(,"' S'S&' "' S)+&-.+S(0+"'S"',.""'3CNS 1.3 I nformation and advice 1 .3.1 G ive information to menopausal women and their family members or + +,SB,S))+()+"-CS-!-S"'%.,OSKS'S

2)%'-"('S(S-!S,- ,S(S&'().,SKS(&&('S,3&)-

(&,SB,S+(&&'-"('S7N9N8CS'S" '(,",SKS%" ,-3%S!' ,S'S"'-+0'-"(',S-!-S(.%S!%)S '+%S!%-!S'S1 %%"' SKS'"- ,S'S+",$,S(S-+-&'-,S(+S&'().,%S,3&)-(&,S '().,OS" '(,",S'S&' &'-SB89C

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• %(' I- +&S!%-!S"&)%"-"(',S(S&'().,NS1 .3.2 Explain t o women that as well as a change in their menstrual cycle they &

3S2)+"'SS0+"-3S(S,3&)-(&,S,,("-S1"-!S&'().,MS"'%."' OS

KS0 -,S('S&((SB(+S2&)%MS%(1S&((CSKS.+ ( '"-%S,3&)-(&,SB(+S2&)%MS0 "'%S+3',,CSKS,

2.%S"".%-",SB(+S2&)%MS%(1S,2.%S,"+CNS1

.3.3 G ive information to menopausal women and their family members or + +,SB,S))+()+"-CS(.-S-!S(%%(1"' S-3),S(S-+-&'-S(+S&'().,%S,3&)- (&,OSKS!(+&('%MS (+S2&)%S%('""'SKS'('I)!+&.-"%MS (+S2&)%S( '"-"0S!0"(.+%S-!+)3SBCNS1 .3.4 G ive information on menopause in different ways to help encourage 1 (&'S-(S",.,,S-!"+S,3&)-(&,S'S',NS1 .3.5 G ive information about contraception to women who are in the )+"&'().,%S'S)(,-&'().,%S)!,NSS ."'S+ (&S-!S.%-3S(S

2.%S@S)+(.-"0S%-!+S('S('-+)-"('S(+S1(&'S S(

0+S:6S3+,NS

1 .3.6 Off er women who are likely to go through menopause as a result of &"%S(+S,.+ "%S-+-&'-SB"'%."' S1(&'S1"-!S'+MS-S!" !S+",$S(S!(+&('I,',"-"0

S'+S(+S!0"' S 3'(%( "%S,.+ +3CS,.))(+-S'OS

KS"' '().,OS" '(,",S'S&' &'-SB89C

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1.4 M anaging short-term menopausal symptoms The r ecommendations in this section are not intended for women with premature ovarian "',.""'3SB,S+ (&&'-"(',S('S-!S&' &'-S(S)+&-.+S(0+"'S"',.""'3CNS 1 .4.1 Adapt a w oman's treatment as needed, based on her changing ,3&)- (&,NSV asomotor symptoms 1 .4.2 Off er women HRT for vasomotor symptoms after discussing with them - !S,!(+-I-+&SB.)S-(S;S3+,CS'S%(' +I-+&S'"-,S'S+",$,NS+SS!("S(S)+ )+-"(',S,S(%%(1,OSKS(,-+ ( 'S'S)+( ,-( 'S-(S1(&'S1"-!SS.-+.,SKS(,-+ ( 'S%('S-(S1(&'S1"-!(.-SS.-+.,NS1 .4.3 Do not r outinely offer selective serotonin reuptake inhibitors (SSRIs), ,+

I%"'S-+-&'-S(+S0,(&(-(+S,3&)-(&,S%('NS1

.4.4 Explain t o women that there is some evidence that isoflavones or black (!(,!S& )+-"(',S+S0"%%S'S-!"+S,-3S",S.'+-"'SKS" +'-S)+)+-"(',S&3S0+3SKS"'- +-"(',S1"-!S(-!+S&""',S!0S'S+)(+-NSP sychological symptoms 1 .4.5 Consider HRT t o alleviate low mood that arises as a result of the &'().,NS 1 .4.6 Consider CBT t o alleviate low mood or anxiety that arise as a result of - !S&'().,NS '().,OS" '(,",S'S&' &'-SB89C

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1 .4.7 Ensur e that menopausal women and healthcare professionals involved in - (S,S%(1S&((S"'S&'().,%S1(&'S1!(S!0S'(-S'S" '(,S1"- !S)+,,"('SB,S-!SS ."%"'S('S)+ ,,"('S"'S.%-,CNS Al tered sexual function 1 .4.8 Consider t estosterone supplementation for menopausal women with low ,

2.%S,"+S"SS%('S",S'(-S-"0NS'S(

0&+S867;MS-!",S1,S'S(I%%S.,NSSL,S"'

(+&-"('S('S)+ ,+""' S&""',SU rogenital atrophy 1 .4.9 Off er vaginal oestrogen to women with urogenital atrophy (including - !(,S('S,3,-&"SCS'S('-"'.S-+-&'-S(+S,S%(' S,S'S-(S+ %"0S,3&)-(&,NS1 .4.10 Consider v aginal oestrogen for women with urogenital atrophy in whom ,3,- &"SS",S('-+"'"-MS-+S,$"' S0"S+(&SS!%-!+S)+ (,,"('%S1"-!S2)+-",S"'S&'().,NS1 .4.11 If v aginal oestrogen does not relieve symptoms of urogenital atrophy, (',"+S"'+ ,"' S-!S(,S-+S,$"' S0"S+(&SS!%-!+S)+ (,,"('%S1"-!S2)+-",S"'S&'().,NS1 .4.12 Explain t o women with urogenital atrophy that: KS,3&)- (&,S(-'S(&S$S1!'S-+-&'-S",S,-())SKS0 +,S-,S+(&S0 "'%S(,-+( 'S+S0+3S++SKS- !3S,!(.%S+)(+-S.',!.%S0 "'%S%"' S-(S-!"+SNS1 .4.13 Advise w omen with vaginal dryness that moisturisers and lubricants can S.,S%('S(+S"'S"-"('S- (S0 "'%S(,-+( 'NS1 .4.14 Do not off er routine monitoring of endometrial thickness during '().,OS" '(,",S'S&' &'-SB89C

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tr eatment for urogenital atrophy. Com plementary therapies and unregulated preparations 1 .4.15 Explain t o women that the efficacy and safety of unregulated (&)(.'S"("'-"%S!(+&(',S+

S.'$'(1'NS1

.4.16 Explain t o women who wish to try complementary therapies that the *.%"-3 .4.17 Advise w omen with a history of, or at high risk of, breast cancer that, %- !(. !S-!+S",S,(&S0"'S-!-S-S (!'L,S1(+-S&3SS(S'"-S"'S- ()+"-S(,,SKS)+,",- 'S(S-SKS0 '-"%S,+"(.,S"'-+-"(',S1"-!S(-!+S+. ,SB"'%."' S-&(2"'MS'-"( .%'- ,S'S'-"('0.%,'-,CNSR eview and referral 1 .4.18 Discuss wit h women the importance of keeping up to date with nationally + (&&'S!%-!S,+'"' NS1 .4.19 R eview each treatment for short-term menopausal symptoms: KS-S9S&('- !,S-(S,,,,S"3S'S-(%+"%"-3SKS''.%%3S- -&'-S"'-"0',,MS,"S-,S(+S0+,S0'-,CNS1 .4.20 R efer women to a healthcare professional with expertise in menopause if -+ -&'-,S(S'(-S"&)+(0S-!"+S&'().,%S,3&)-(&,S(+S-!3S!0S(' ("' S-+ (.%,(&S,"S-,NS1 .4.21 Consider r eferring women to a healthcare professional with expertise in '().,OS" '(,",S'S&' &'-SB89C

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menopause if: KS- (&,NSS tarting and stopping HRT 1 .4.22 Explain t o women with a uterus that unscheduled vaginal bleeding is a (&&('S,"S +S-!S"+,-S9S&('-!,SB,S+ (&&'-"(',S('S'(&-+"%S'+S"'S- !SS ."%"'S('S,.,)-S'+CNS 1 .4.23 Off er women who are stopping HRT a choice of gradually reducing or "&&"- %3S,-())"' S-+-&'-NS1 .4.24 Explain t o women that: KS +.%%3S+ ."' SS&3S%"&"-S+.++'S(S,3&)-(&,S"'S-!S,!(+-S-+&SKS +.%%3S+ ."' S(+S"&&"-%3S,-())"' SS&$,S'(S"+'S-(S-!"+S,3&)- (&,S"'S-!S%(' +S-+&NSW omen with, or at high risk of, breast cancer 1 .4.25 F or advice on the treatment of menopausal symptoms in women with + ,-S'+S(+S-S!" !S+",$S(S+,-S'+MS,S+ (&&'-"(',S('S(&)%"-"(',S(S%(%S-+ -&'-S'S&'().,%S,3&)-(&,S"'S-!SS ."%"'S('S+%3S'S%(%%3S0 'S+,-S'+S'S (&&'-"(',S('S+",$S+.-"('S'S-+-&'-S,-+- ",S"'S-!SS ."%"'S('S &"%"%S+,-S'+NS 1 .4.26 Off er menopausal women with, or at high risk of, breast cancer: KS"' (+&-"('S('S%%S0"%%S-+-&'-S()-"(',S '().,OS" '(,",S'S&' &'-SB89C

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(&'S1"-!S+,-S'+S1!(S+S-$"' S-&(2"'SKS+ ++%S-(SS!%-!+S)+(,,"('%S1"-!S2)+-",S"'S&'().,NS1.5 Long-term beneifi ts and risks of hormone $ # !&8&$#+8V enous thromboembolism 1 .5.1 Explain t o women that: KS- !S,%"'S)().%-"('S+",$SKS- !S+",$S(SS,,("-S1"-!SS",S +-+S(+S(+%S-!'S-+',+&%S)+ )+-"(',SKS- !S+",$S,,("-S1"-!S-+',+&%SS "0'S-S,-'+S-!+).-"S(,,S",S'(S + -+S-!'S,%"'S)().%-"('S+",$NS1 .5.2 Consider transdermal rat her than oral HRT for menopausal women who +

S-S"'+,S+",$S(SMS"'%."' S-!(,S1"-!SS

S(0+S96S$ G&2.

1 .5.3 Consider r eferring menopausal women at high risk of VTE (for example, - !(,S1"-!SS,-+(' S&"%3S!",-(+3S(SS(+SS!+"-+3S-!+(&()!"%"CS- (SS!&-(%( ",-S(+S,,,,&'-S(+S(',"+"' SNSCar diovascular disease 1 .5.4 Ensur e that menopausal women and healthcare professionals involved in - !"+S+S.'+,-'S-!-SOSKS(,S'(-S"'+ ,S+"(0,.%+S",,S+",$S1!'S,-+-S"'S1(&'S S.'+S<6S3 +,SKS(,S'(-S -S-!S+",$S(S3"' S+(&S+"(0,.%+S",,NS1 .5.5 Be awar e that the presence of cardiovascular risk factors is not a '().,OS" '(,",S'S&' &'-SB89C

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contraindication t o HRT as long as they are optimally managed. 1 .5.6 Using tables 1 and 2, e xplain to women that: KS- !S,%"'S+",$S(S(+('+3S!+-S",,S'S,-+($S(+S1(&'S+(.'S&'().,%S S0 +",S+(&S('S1(&'S-(S'(-!+S(+"' S-(S-!S)+,'S(S+ "(0,.%+S+",$S-(+,SKSS1"- !S(,-+( 'S%('S",S,,("-S1"-!S'(MS(+S+.MS+",$S(S(+('+3S!+ -S",,SKSS1"- !S(,-+( 'S'S)+( ,-( 'S",S,,("-S1"-!S%"--%S(+S'(S"'+,S"'S- !S+",$S(S(+('+3S!+-S",,NS1 .5.7 Explain t o women that taking oral (but not transdermal) oestrogen is ,,("- !S,%"'S)().%-"('S+",$S(S,-+($S"'S1(&'S S.'+S<6S3+,S",S0 +3S%(1SB,S-%S8CNST

able 1 Absolute rates of coronary heart disease for menopausal women on different types of hormone replacement t

erence in coronary heart disease incidence per 1,000 menopausal women over 7.5 y earsmv9:smconfidencemintervalwmT ypemofmHRTmCurr entmHRTm usersmT reatmentmdur ationm<:my earsmT reatmentmdur ationm:Ð54my earsm>:my earsmsincemst oppingmtr eatmentmW omen on oestrogen alone BS,-"&- CS1+SBP76S-

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