Download Menopause Referral Form

Menopause Referral Form
GSTT gynaecology clinic
details
KCH gynaecology clinic details
Gynaecology Out patients
McNair Centre, Guy’s
Hospital SE1 9RT
Gynaecology outpatients, Suite 8,
3rd floor, Golden Jubilee Wing,
KCH, Denmark Hill
London, SE5 9RS
020 7188 2000
0203 299 3246 (option 1)
Fax
020 7188 3674
0203 299 3471
Email
n/a
n/a
Address
Contact details:
Phone
Referral date
System Date
Referring doctor: Referring Doctor
Address:
Practice Address
Stacked
Referral urgency
Patient
name:
DOB:
Address:
(include postcode)
Practice Main Telephone
Phone:
Other
Phone:
NHS number:
Title Forenames
Surname
DOB
Patient Address List
Home Telephone
Mobile Telephone
NHS Number
Hospital Number:
A GP should be able to assess symptoms, and prescribe and discuss the risks and benefits of
Hormone Replacement Therapy (HRT) with patients over 45 years old.
Yes / No
1 Have you assessed the woman’s symptoms, diet and lifestyle (and given
advice), past and family history, cardiovascular risk and considered thyroid
Yes
No
1
disease?
2 Have you done or considered a vaginal examination to exclude:
a)other gynaecological problems
Yes
No
b)urogenital atrophy2
3 Is the patient up to date with their cervical smear and mammogram if indicated?
Yes
No
(If not please arrange.) 1
4 Have you assessed the risk factors for osteoporosis? 1
Yes
No
5 Have you discussed hormonal2, 3 and non-hormonal3 interventions4?
Yes
No
5
6 Have you discussed the risks/benefits of HRT?
Yes
No
7 Have you tried systemic HRT in those with vasomotor symptoms and no
complicating factors? Or
Yes
No
Have you tried topical treatments for those with urogenital symptoms only?
8 Has the patient got one of the following:
a)After logical therapy changes:
persistent side effects (from HRT)
Yes
No
poor symptom control after trial of three or more treatments
bleeding problems after 4-6 months of therapy6
b) Complex medical history? e.g. leukaemia, renal failure, history of venous
840979930
Review date: December 2013
thromboembolic (VTE) disease (or family history of VTE)
c)Past history of hormone dependent cancer or any cancer
d)menopause and contraceptive problems
e)early menopause (confirm with FSH if <45 years) and fertility problems
9 Reason for referring if answering ‘No’ to any of above:-
Yes
No
1 This is an opportunity for health promotion, and also to assess risks if systemic HRT is considered
2 With the recommended dose regimens for topical treatment, no adverse endometrial effects should be incurred
and a progestogen need not be added for endometrial protection
3 The following hormonal and non-hormonal treatments have been tried: oestrogens, progestogens, clonidine,
Selective serotonin reuptake inhibitors (unlicensed use)
4 There is little or poor evidence from randomised trials that alternative and complementary therapies improve
menopausal symptoms or have the same benefits as HRT, and there is little control over the quality of alternative
products, but many women may have tried them
5 “NHS choices” or “Menopausematters.co.uk” are good websites to recommend to patients to consider risks and
benefits (including the lack of evidence base for alternative and complementary therapies and the risks of hormonal
based HRT)
6 If bleeding is new and continues after 6 weeks of HRT cessation, a referral should be made on the two-week wait
pathway, for other bleeding problems on HRT refer to the menopause clinic
References: www.cks.nhs.uk/menopause
With thanks to the British Menopause Society “Management of the Menopause”
Information required for referral
Medical history &
examination
Problem Table
Allergies
Allergy Table
Medications
Medication Table
GP comments (including any other relevant information)
840979930
Review date: December 2013