Standard operating procedure

Menopause Assessment & Diagnosis SOP

The step-by-step method for assessing a new patient and reaching a diagnosis, so that every clinician does it the same way and every record supports the decision made

For Women's Health & Menopause ClinicRef BS-WOM-SOP-001See a sample (PDF) →
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  • Editable Microsoft Word (.docx)
  • Mapped to the CQC standards
  • Optional 3-monthly updates

What's inside

This standard operating procedure is fully drafted and structured, ready to brand and complete for your service. It covers:

  • 1. Purpose
  • 2. Scope
  • 3. Definitions and abbreviations
  • 4. Responsibilities
  • 5. Equipment, systems and information required
  • 6. Before the consultation
  • 7. Opening the consultation: identity, location, privacy and communication
  • 8. Clinical history, measurements and screening
  • 9. Reaching a diagnosis
  • 10. Bleeding, red flags and emergencies
  • 11. Capacity, consent and when a remote assessment is not adequate
  • 12. After the consultation
  • 13. Safety netting and patient information
  • 14. Records
  • 15. Training and competence
  • 16. Monitoring and audit
  • 17. Related documents
  • 18. Review and version control
  • 19. Appendix A - Menopause Pre-Consultation Questionnaire
  • 20. Disclaimer

CQC fundamental standard

Regulation 9 (Person-centred care)
This document is written to evidence that standard. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Legislation & standards it maps to

  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in particular Regulation 9 (Person-centred care), Regulation 10 (Dignity and respect), Regulation 11 (Need for consent), Regulation 12 (Safe care and treatment), Regulation 13 (Safeguarding service users from abuse and improper treatment), Regulation 17 (Good governance) and Regulation 20 (Duty of candour).
  • Mental Capacity Act 2005 and the Mental Capacity Act 2005 Code of Practice.
  • Equality Act 2010.
  • UK General Data Protection Regulation and Data Protection Act 2018; Records Management Code of Practice (2023).
  • National Institute for Health and Care Excellence (NICE) guideline NG23, Menopause: identification and management (as last updated).
  • NICE guideline NG12, Suspected cancer: recognition and referral (as last updated), and NICE guideline NG136, Hypertension in adults: diagnosis and management (as last updated).
  • British Menopause Society, Royal College of Obstetricians and Gynaecologists and partner organisations, joint guideline on management of unscheduled bleeding on hormone replacement therapy (2024).
  • European Society of Human Reproduction and Embryology (ESHRE), Evidence-based guideline: premature ovarian insufficiency (2024).
  • British Menopause Society consensus statements and Tools for Clinicians.
  • General Medical Council (GMC), Good practice in proposing, prescribing, providing and managing medicines and devices, including the sections on remote prescribing and on medicines requiring additional safeguards.
  • GMC, Remote consultations guidance, and the High level principles for good practice in remote consultations and prescribing shared by the UK healthcare regulators.
  • Accessible Information Standard (adopted as good practice; legally required for publicly funded care).
  • Care Quality Commission (CQC) assessment framework: the five key questions (safe, effective, caring, responsive and well-led) and the quality statements of the single assessment framework, and the sector-specific framework for primary care and community services when it replaces them.

Who it applies to

All clinical and administrative staff, including self-employed and locum clinicians

Glossary

Plain-English explanations of the technical terms and legislation used in this document.

111 (mental health option)
The free urgent health telephone line; the mental health option connects to trained mental health staff at any time.
Accessible Information Standard
A national standard, legally required for publicly funded care, on identifying and meeting communication needs linked to disability.
Amenorrhoea
Absence of periods.
Anti-Müllerian hormone (AMH)
A hormone reflecting egg reserve; not used to diagnose menopause over 45.
Best interests
The legal basis for a decision made for a person who lacks capacity to make it (Mental Capacity Act 2005).
Body mass index (BMI)
Weight in kilograms divided by the square of height in metres.
BRCA
Genes (BRCA1 and BRCA2) that, when altered, greatly increase the risk of breast and ovarian cancer.
British Menopause Society (BMS)
The UK specialist society for health professionals in menopause care.
Care Quality Commission (CQC)
The independent regulator of health and adult social care in England.
Combined hormonal contraception
Contraception containing an oestrogen and a progestogen, such as the combined pill, patch or ring.
Data Protection Act 2018
The UK law that, with the UK GDPR, governs the use of personal information.
Duty of candour
The legal duty (Regulation 20) to be open and honest with patients when things go wrong.
Enzyme-inducing medicine
A medicine that speeds up the breakdown of hormones and can make them less effective.
Equality Act 2010
The law protecting people from discrimination and requiring reasonable adjustments for disabled people.
European Society of Human Reproduction and Embryology (ESHRE)
A European professional society that published a guideline on POI in 2024.
Failsafe
A tracking step confirming that a result, referral or follow-up has actually happened.
Follicle-stimulating hormone (FSH)
A hormone that rises as ovarian function declines, measured by blood test.
Generalised Anxiety Disorder-7 (GAD-7)
A 7-question tool measuring the severity of anxiety.
General Medical Council (GMC)
The UK regulator of doctors.
General Pharmaceutical Council (GPhC)
The regulator of pharmacists and pharmacy technicians in Great Britain.
General practitioner (GP)
The patient's family doctor.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The regulations setting the fundamental standards CQC-registered providers must meet.
Hormone replacement therapy (HRT)
Oestrogen, usually with a progestogen if the patient has a uterus, used to relieve menopausal symptoms.
IU/L
International units per litre, the unit for FSH results.
Lasting power of attorney (LPA)
A legal document appointing someone to make decisions if a person loses capacity; a health and welfare LPA covers medical decisions.
Mental Capacity Act 2005
The law on assessing capacity and making decisions for people who lack it.
National Institute for Health and Care Excellence (NICE)
The body publishing national evidence-based health and care guidelines for England.
NICE NG12, NG23 and NG136
NICE guidelines on suspected cancer referral, menopause, and high blood pressure in adults.
Nursing and Midwifery Council (NMC)
The UK regulator of nurses, midwives and nursing associates.
Oestradiol
The main oestrogen made by the ovaries and used in most HRT.
Patient Health Questionnaire-9 (PHQ-9)
A 9-question tool measuring the severity of depression.
Premature ovarian insufficiency (POI)
Loss of normal ovarian function before the age of 40.
Records Management Code of Practice (2023)
National guidance on how long health records are kept and how they are managed.
Standard Operating Procedure (SOP)
A document setting out the agreed step-by-step way to carry out a task.
Subtotal hysterectomy
Removal of the womb leaving the cervix, where some womb lining may remain.
Suspected cancer pathway referral
An urgent referral for tests to confirm or rule out cancer quickly.
Transient ischaemic attack (TIA)
A temporary loss of blood supply to part of the brain (mini-stroke) needing emergency assessment.
UK General Data Protection Regulation (UK GDPR)
The UK law setting the rules for processing personal data, including health information.
Vasomotor symptoms
Hot flushes and night sweats.
Venous thromboembolism (VTE)
A blood clot in a vein, such as in the leg or lung.

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