Menopause Information and Questionnaire

This questionnaire is designed to make the consultation with your doctor for menopausal symptoms an easier and more efficient experience

This questionnaire is designed to make the process of diagnosing menopause easier for you and those that are seeing you for your symptoms.

It will help to make the first consultation with your doctor or clinician an easier and more relaxed experience.

We recognise that the menopause is a significant event in a woman’s life, and it is important to give yourself time and space to work through the changes that occur during this challenging time.

People are often juggling busy schedules and so understanding what is going on and receiving help during this time will make a big difference to how this natural process plays out.

What is the Menopause?

· The menopause refers to the period in a woman’s life when periods (menstruation) cease.

· This typically occurs between the ages of 45 and 50.

· This occurs because it is the time when the ovaries stop producing hormones and menstrual periods stop.

· The hormones that are low are called oestrogen and progesterone and are released by the ovaries as mentioned above.

· Different people experience the menopause in different ways and so symptoms vary between individuals.

· The menopause can feel like a big change physically and mentally for many women and can last for extended periods of time.

What is the Perimenopause?

Sometimes people experience symptoms like that of the menopause before periods have stopped completely and this is called the perimenopause. This is due to a reduction in hormones produced by the ovaries in the years leading up to the menopause.

What is early menopause?

Sometimes people can experience symptoms of the menopause before the age of 40 and this is called early or premature menopause. This affects around 5% of women.

Diagnosing the menopause

The diagnosis of the menopause is based on symptoms and age and so investigations such as blood tests are usually not required. However, sometimes a blood test is required, and this is called an FSH. This is used when there is uncertainty about a diagnosis or when the symptoms develop earlier than usual.

*If you do need to have a blood test this will take place before you meet with your doctor as this information will help in decision making with regard to whether HRT is necessary.

Conditions that can mimic The Menopause

There are many medical conditions that can present in a similar way to the menopause and so it is important to rule these out. Here are a few of these:

· Conditions that cause fatigue

· Depression

· Thyroid disorders

· Vitamin deficiencies

Following your econsult you may need to have blood test to look for alternative causes of your symptoms. This may include the following:

· Full blood count – to look for anaemia

· Urea and electrolytes – to look at kidney function and the concentration of salts in the blood stream

· Liver function tests – to look at the function of the liver

· Bone profile – to look at calcium levels

· Vitamin levels (Vitamin D, Folic acid, Vitamin B12 and Iron levels)

· Thyroid function – to look for Hypothyroidism and Hyperthyroidism

Please tell us what symptoms you are experiencing?

Menopause and perimenopause can cause a variety of symptoms and some of these are listed below.

Are you experiencing any of the following Menopausal symptoms. Please tick the boxes below:

Symptoms experienced Yes No

Have your periods

become more

irregular or stopped

Hot flushes and night


Sleep disturbance

A change in your

mood or


Brain fog

Vaginal discomfort or


during intercourse

Loss of libido (reduced

desire to engage in

sexual intercourse)

Recurrent lower

urinary tract


Muscle and joint


If your periods have not stopped, please can you tell us where in your cycle you are currently. What day of your cycle are you on?

If you are experiencing other symptoms that are not listed above, please write these below:

Other symptoms:

Please can you also give your height and weight:




*This can be checked in surgery (Automatic in reception at Emsworth surgery) or on a home monitor

Please can you tell us when your last cervical smear was:

Medical treatment for Menopausal Symptoms

The aim of treatment for perimenopause and menopause is to relieve the symptoms you are experiencing. The primary goal is to relieve hot flushes. People also report improvements in other symptoms such as sleep disturbance, mood and joint aches and pain.

Menopause and Hormone Replacement therapy (HRT)

What is HRT?

· This is a treatment used to relieve the symptoms of the menopause. HRT replaces the female hormones (Oestrogen and Progesterone) that are reduced when you experience the menopause.

· These hormones have played an important role in a woman’s body up until now and so replacing these when the body stops producing them will help to regulate things and control the symptoms of the menopause.

· Oestrogen and progesterone are therefore the hormones that are replaced in HRT.

· There are different ways of taking the hormones that constitute HRT medication and the discussing the options available with your GP or Doctor will form part of your menopause consultation should you need them.

· You may not need treatment with HRT when going through the menopause as

HRT Risk Assessment:

There are risks associated with taking HRT medication and these are listed below. Please can you answer the following questions to help us determine whether you are suitable for HRT:

Risks Yes No


Suspected Endometrial Cancer

Untreated Endometrial Hyperplasia

Undiagnosed vaginal Bleeding

Active or PMHx of VTE

Thrombophilic/clotting Disorder

Active or recent CVA/IHD

Active Liver disease or abnormal LFTS

Acute porphyrias


Please can you answer the following questions to help us determine whether you are suitable for HRT:

Cautions yes No

FHX of Breast Cancer

PMHx of Endometrial cancer

Risk Factors for VTE

Uncontrolled CVD Risks

Migraine/Migraine like headaches

Porphyria Cutanea tarda

What are the different types of HRT?

Tablets – which are taken by mouth

Patch – that you stick on your skin

Gel – Oestrogen gel which is applied to the skin

An Implant – Under the skin under local anaesthetic

What you need to do

· Complete an Econsult with your doctor to ask for a telephone consultation and state that you are experiencing menopausal symptoms.



· Please fill in the questionnaire above and then send this to our reception team who will forward this to your doctor.

· Your doctor will then read through the questionnaire prior to your consultation and will have a better idea of what you are experiencing and your background.