At Clinic 51 we offer evidence-based advice and treatment in line with guidance from the British Menopause Society and the UK National Institute of Clinical Excellence.

As a team, we keep up to date through regular meetings where we share learning, current changes in guidance and difficult cases. We ensure we prescribe according to the current majority medical consensus view of best practice for menopause care by attending conferences and liaising regularly with other recognised menopause specialists.

We practice holistically, looking at all the factors that affect wellbeing including psychological, familial and societal factors. Our treatment, where appropriate, will offer hormone therapy but we will also guide you through lifestyle advice, talking therapies and other medical options.

As generalists, we are able to assess your symptoms and advise when symptoms are not in keeping with perimenopause / menopause. In these circumstances, we may suggest that you seek further investigation to exclude other medical problems.

We will review your symptoms, your personal risk factors and your personal preferences to decide on the most appropriate dose, and formulation, of oestrogen and progesterone. We generally start with low doses and will increase the dose according to your symptoms, as necessary.

We will help to guide you to the correct dose for you; the most important indicator of dosing is symptom control. If you feel well, then this is usually the correct dose.

If your symptoms do not improve on maximum licensed doses, we may organise blood tests to help guide our treatment.

If your symptoms do not improve on licensed doses of oestrogen, and the blood tests confirm you are absorbing the treatment well, then we may look for a different cause of your symptoms or suggest an alternative treatment plan, rather than just increasing your HRT.

We are always happy to discuss any side-effects you are experiencing. It is normal to experience some side-effects on first starting HRT though these will often settle with time. These can include bloating, nausea and heartburn, headaches, breast tenderness and swelling, fluid retention, pelvic pain, mood swings and vaginal bleeding.

Vaginal bleeding is common in the first 6 months after starting HRT. If the initial bleeding is getting lighter with time then we will often wait for this to settle and are happy to discuss this at your 3 month review. If you are getting persistent heavy bleeding, your bleeding pattern is getting heavier or you start bleeding after a few months of HRT use, contact us and we will discuss this with you. At review we may increase the dose of your progesterone, change your progesterone, reduce your oestrogen or, sometimes, we will refer you for further investigation.

British Menopause Society guidance states that high dose oestrogen is anything 100mcg and above. This is equivalent to a 100mcg patch, 4 pumps of Oestrogel or 2mg of oral oestrogen (Lenzetto is licensed for 3 sprays, but the dose equivalent of 100mcg is 4 sprays).

However, we also know that women absorb oestrogen through the skin (transdermal) differently, and that for a few, this high dose is not enough to return their oestrogen levels to a normal level. If we have confirmed that blood oestrogen levels are still low, even at a dose of 100mcg, we would consider increasing the dose to an unlicensed level. The General Medical Council recognises that doctors may sometimes prescribe unlicensed doses of medications to meet the specific need of an individual patient.

At this dose we will consider whether it is necessary to increase your progesterone dose. When making this decision we will take into account your underlying risk factors for thickening of your endometrial lining (endometrial hyperplasia).

High dose oestrogen is any dose equivalent to or greater than 100mcg, which is also described as an unlicensed dose, since it is not officially approved for treating your health condition at present. The General Medical Council recognises that doctors may sometimes prescribe unlicensed doses of medications to meet the specific needs of an individual patient.

A 100mcg dose of oestrogen is a licensed dose and we will prescribe this dose if needed to control symptoms.

We will very occasionally prescribe a higher than licensed dose (>100mcg), though we will generally only do this after checking your oestrogen levels to confirm that they are low. We will consider swapping to an alternative preparation prior to increasing to a higher than licensed dose. We will always recheck your blood levels to ensure they remain in the female range.

If we prescribe higher than licensed doses, we will always discuss this with you in advance and explain our rationale for doing this. When we prescribe higher than licensed doses, we will increase the progesterone dose to ensure that the lining of your womb is well protected.

Young women with premature ovarian Insufficiency (POI) or surgical menopause sometimes require higher than licensed doses of HRT. Again we will discuss this with you.

The safety data available to all practitioners only applies to doses of 100mcg or less. As a result, when prescribing at higher doses, there is no reliable safety data to support this.

We know that prescribing high dose oestrogen, or insufficient progesterone, can put you at risk of endometrial thickening and endometrial cancer and will always discuss this with you.

Please also note, however, that use of continuous combined regimes (daily progesterone with oestrogen) at licensed doses is associated with a significantly lower risk of endometrial cancer in women compared with those not taking HRT.

We will ALWAYS discuss this with you.

At doses of high dose oestrogen (100mcg) we may increase the dose of progesterone dependent on your personal risk factors, such as your body mass index (BMI), a history of diabetes or polycystic ovaries, or a family history of colorectal, ovarian and endometrial cancers.

If we are prescribing doses of higher than 100mcg, we will increase your progesterone dose or suggest a Mirena coil. The Mirena coil offers excellent endometrial protection.

If you are sensitive to progesterone, and we are not able to increase this, we will discuss a plan tailored to your specific needs to monitor your endometrial lining, usually with ultrasound scans.

No, vaginal oestrogen preparations do not result in significant absorption so there is no concern about their safety.

We will continue to review your symptoms and your risk factors. We will discuss the current evidence and will agree a management plan taking into account your views. We will support you to reduce your dose, if appropriate, whilst recognising that very high doses of oestrogen can result in a dependence so that reducing the dose can result in marked worsening of your symptoms. We would therefore support you to do this slowly. We will also review your progesterone dose to ensure you have suitable endometrial protection.

We will review your symptoms and ensure that there is no other underlying cause, We will discuss alternative treatment options.

We are delighted that at our new home, The Barn in Duncton, you will soon be able to access some of the supportive management options such as acupuncture, exercise classes and talking therapies.