Finally cracking the HRT code: NICE on the menopause

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by NICE.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I will go through the NICE guideline on “Menopause: diagnosis and management” or NICE guideline NG23.
I will summarise the guidance from a Primary Care perspective only.
I am not giving medical advice; this video is intended for health care professionals; it is only my interpretation of the guidelines and you must use your clinical judgement.
Tracks:
00:00 - Introduction and welcome
00:51 - Symptoms
01:16 - Diagnosis
02:20 - Advice and contraception
03:15 - Management of menopausal symptoms
05:54 - Review, referral, starting and stopping HRT
06:56 - Long-term risks and benefits of HRT
10:38 - Premature ovarian insufficiency
12:05 - Flowchart including some HRT preparations
15:36 -Thank you and good-bye
There is a podcast version of this and other videos that you can access here:
Primary Care guidelines podcast:
• Redcircle: redcircle.com/...
• Spotify: open.spotify.c...
• Apple podcasts: podcasts.apple...
• TH-cam podcast: • Primary Care Guidelines
The NICE guideline NG23 “Menopause: diagnosis and management” can be found here:
• www.nice.org.u...
The guidance from the Faculty of Sexual & Reproductive Healthcare on contraception for women aged over 40 years can be found here:
• www.fsrh.org/pd...
The MHRA summary of HRT risks and benefits during current use and current use plus post-treatment from age of menopause up to age 69 years, per 1000 women with 5 years or 10 years use of HRT can be found here:
• assets.publish...
The summary flowchart with examples of preparations can be found here:
• 1drv.ms/b/s!Ai...
Thumbnail photo: from Freepik: www.freepik.com/
• Image by LipikStockMedia on Freepik: a href="www.freepik.co..."Image by LipikStockMedia/a on Freepik

[@vivekgoel419]

You are really making so much of efforts to help so many people
I have so much respect for you

[@practicalgp]

Thank you very much. I really appreciate your comment. Hoping that I am doing something worthwhile keeps me going 🙏

[@SheikhMokhtar]

Great summary .Thank you so much for your great efforts, Dr Fernando

[@practicalgp]

Thank you very much for your support. I really appreciate it 🙏

[@rinleeds]

This is brilliant Fenando. Excellent snapshot tutorials. By the way, what do you use to move the presentation around a flowchart. it is very effective. I'm doing a HDR presentation on menorrhagia and would like to use the same tool to move around the flowchart.

[@practicalgp]

Thank you very much for your comment. It really helps.
I use the morph transition in PowerPoint. You have to insert the flowchart as a picture in the first slide and then duplicate it as many times as necessary, zooming into the areas that you want. It can be time consuming but it’s worth it. This video explains it well th-cam.com/video/nzH4KPz_cIs/w-d-xo.htmlsi=8yCcDJlKCDS8A8K2. I hope that it helps. Let me know if I can do anything else to help. Good luck with your presentation. I presume that you have also seen my video on menorrhagia? 🙏

[@holohorn7442]

This is so helpful dear Fernando !
I am just wondering how much of this should I be actually covering in my 10 minute consultation.

[@practicalgp]

Thank you very much for your comment, I really appreciate it. We have to be realistic in what we can do in our limited time. Information leaflets, involving skilled practice nurses and, if necessary, utilising more than one appointment are sometimes the way to avoid burnout 🙏

[@kuldipsingh4049]

Great video. Where is the link for the flowchart? Thanks

[@practicalgp]

Thank you for your comment. I really appreciate it. The link is in the video description, towards the end. The link is this: 1drv.ms/b/s!AiVFJ_Uoigq0mFjbJIiJs842urJB?e=FcfiJl

[@ojushealthcare5402]

Thanks as always, Dr! Are we still switching perimenopausal patients started on sequential HRT to continuous combined HRT after 12 months regardless of menstrual bleeds?

[@practicalgp]

Thank you for your comment. We can switch to continuous combined HRT if the patient is postmenopausal and it has been longer than 12 months from their last period.
Continuous combined HRT is not recommended in the perimenopause because these women continue to have some periods and the period free benefit of continuous combined HRT does not work.
You are generally considered to be postmenopausal at the age of 54 or after 12 months from the last period.
So, there are some options:
You can sometimes develop amenorrhoea on combined cyclical HRT. If that is the case, great, switch to continuous combined HRT after a year. Also, if after a year of cyclical combined HRT, you have turned 54, then also great, you can confidently make that switch too.
The problem occurs when you are on cyclical HRT and still having monthly bleeds. Is this because of the withdrawal effect of the HRT or is it because you still have the capacity for natural periods?
So, it is a clinical judgement call. Most doctors may agree with you and switch to a continuous combined preparation after one year of cyclical combined HRT on the assumption that the woman has become postmenopausal and that the periods would have stopped by then if left to their own devices.
But I would consider staying on the cyclical version for a bit longer (maybe 2 years) if the woman developed the perimenopause at an early age, if she is still relatively young and you are worried that she may continue to have natural periods on the continuous preparation. This would then be considered “postmenopausal bleeding” which would be a worry and trigger investigations etc.
Sorry about the long reply. I hope that this helps. I am not an expert though, so keep your eyes peeled! 👍

[@ojushealthcare5402]

That's very sensible and practical advice, Dr! Thanks very much!