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Menopause

Terminology note
What is menopause?
The importance of recognising and treating menopause
Symptoms of menopause
Talking about menopause
Diagnosis
Self-care symptom management
Overview of treatment options
The socioeconomic divide in accessing menopause care
HRT Myths
HRT
When to refer to secondary care
Summary
References
Menopause Quiz

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Hormone Replacement Therapy (HRT) 

HRT involves replacing the hormones that are reduced during menopause. Either oestrogen-only or a mix of oestrogen and progesterone can be prescribed. These can be prescribed in several different forms:

  • Oral tablet
  • Pessary
  • Transdermal gel
  • Transdermal patch
  • Spray

The choice of preparation depends on age, symptoms, co-morbidities, and contraindications. The aim should be to prescribe the lowest dose for the shortest possible duration.

Contraindications for HRT

HRT cannot be prescribed for women with:

  • Current, past, or suspected breast cancer
  • Known or suspected oestrogen-dependent cancer
  • Undiagnosed vaginal bleeding
  • Untreated endometrial hyperplasia
  • Previous or current deep vein thrombosis (unless on anticoagulant treatment)
  • Active liver disease with abnormal liver function tests
  • Pregnancy
  • Thrombophilic disorder (increased risk of blood clots)

The risk/benefit balance of HRT varies for each individual, but HRT should be prescribed for as long as the benefits outweigh the risks. Healthcare professionals should discuss these risks and benefits in detail and signpost patients to high-quality sources of information.

Selecting the Most Appropriate HRT Therapy

The choice of HRT regimen depends on several factors, including whether the woman is perimenopausal or postmenopausal, the preferred route of administration, and her individual needs. See the decision-making chart below for more details:

HRT Decision Chart

Learn more about different HRT preparations on NumarkNet.

Ongoing HRT Treatment

According to NICE guidelines, HRT treatments should be reviewed:

  • 3 months after starting or changing the prescription
  • Annually thereafter (unless there is a clinical indication for earlier review)

Reviews should assess the efficacy, tolerability, and management of adverse effects or persistent symptoms. Adjustments to dose or preparation may be necessary. Women often try several HRT products before finding one that suits them best.

Regimens Based on Menopausal Status

For Perimenopausal Women:

  • Daily oestrogen with cyclical progestogen to mimic the hormone cycle.
  • Monthly regimen: Oestrogen taken daily and progestogen for 10-14 days at the end of each month.
  • Three-monthly regimen: Oestrogen taken daily and progestogen for 14 days every 3 months (suitable for women with infrequent periods).

For Postmenopausal Women:

  • Continuous combined regimen: Oestrogen and progestogen taken daily (preferred as it avoids monthly bleeds).
  • Monthly or three-monthly cyclical regimens (if required).

Duration and Side Effects

HRT can be continued as long as the benefits outweigh the risks. There is no fixed limit for duration of use. If stopping HRT, it can be tapered over 3-6 months or stopped abruptly.

Common side effects include:

  • Fluid retention
  • Breast tenderness
  • Unscheduled vaginal bleeding