Menopause < 45 years old Menopause <45 CLINICIAN WARNING – FSH LEVELSPatient is taking COCP or depot contraception which can suppress FSH. Consider diagnosing based on symptoms alone, advise stopping or Complete this form to tell us about symptoms you think may be due to the peri-menopause. The form follows the British Menopause Society Guidelines (BMS) and will be reviewed by a clinician to consider the diagnosis. As you are under 45 years old you will require two blood tests one month apart to confirm the diagnosis. “Diagnosis of early menopause should be based on a combination of menopausal symptoms and or oligomenorrhoea/ amenorrhoea of more than 3 months’ duration associated with elevated gonadotropins (FSH >30IU/l) on at least two occasions measured four to six weeks apart in women aged under 45.” Patient Details Patient Name * Date of Birth * Mobile number to contact you * Symptoms The hallmark of peri-menopause is irregular periods. Other symptoms may include: Hot flushes (A sudden feeling of heat in the upper body. Usually for 2–4 minutes. Can be associated with sweating, palpitations, or anxiety) Night Sweats Mood swings Sleep disturbance Memory issues Concentration problems Joint aches First let’s make sure you have no bleeding between periods. This is not a menopause symptom. If you have this, please do not proceed and phone the practice instead. * I do not have any bleeding between periods How are your Periods? * My periods are normal or have only been irregular for less than 3 months My periods are have been abnormal (irregular) for more than 3 months I do not have periods because I have a coil, I take hormonal contraception or I don’t have a womb (hysterectomy) Unlikely menopause Irregular periods for over 3 months is a hallmark of the peri-menopause. Without a change in your periods, your symptoms are very unlikely to be due to peri-menopause. Please describe the symptoms you are experiencing and we will be in touch. * In what way have your periods been abnormal (irregular)? * Longer Shorter Heavier Lighter They have stopped completely What other symptoms of the peri-menopause do you have? * Hot flushes Night Sweats Mood Swings Memory issues Concentration problems None of these symptoms Sleep disturbance Joint aches Any other symptoms you think may be related to peri-menopause? What form of contraception are you taking? * None Condoms The progesterone only pill (eg desogestrel) The combined pill (eg Rigevidon) The coil the Injection the Implant You have reached the end of the form. On submission a clinician will review your answers and be in touch with the next steps which may include blood tests or an appointment. This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our privacy policy to discover how we protect and manage your submitted data. Consent * I agree to the privacy policy © 2024 Kristian Turnbull CAPTCHA Submit If you are human, leave this field blank.
