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Menopause - Management
What advice should I give about the benefits of HRT?

  • Advise the woman that hormone replacement therapy (HRT) is effective for:
    • Treating vasomotor symptoms (e.g. hot flushes and night sweats).
    • Treating urogenital symptoms (e.g. vaginal dryness, dyspareunia as a result of vaginal dryness, recurrent urinary tract infections, and urinary frequency and urgency).
    • Sleep or mood disturbances caused by hot flushes and night sweats.
    • Preventing osteoporosis. HRT is not normally used as a first-line treatment (as the risks outweigh the benefits) except in women with premature ovarian failure.
    • Reducing the risk of colorectal cancer (but hormone replacement therapy is currently not recommended for this use).
Basis for recommendation
  • These recommendations are based on expert opinion from the published literature, as well as systematic reviews and large randomized controlled trials [NZGG, 2004; BMS, 2006a; ICSI, 2006; Rees and Purdie, 2006a; MHRA and CHM, 2007b].
  • Hot flushes and night sweats:
    • Good evidence indicates that oral, or transdermal hormone replacement therapy (HRT), used as oestrogen alone or oestrogens combined with progestogens, is highly effective for reducing the frequency and severity of hot flushes and night sweats caused by the menopause.
  • Vaginal atrophy (dryness and dyspareunia):
    • There is evidence that HRT preparations (combined oral and transdermal oestrogens and progestogens, or intravaginal oestrogens) are effective for treating vaginal atrophy (dryness, burning and itching, and dyspareunia).
  • Recurrent urinary tract infections:
    • There is evidence that oral and intravaginal oestrogen is effective for preventing urinary tract infections. The appropriate dose and duration of therapy have not been established. Long-term treatment may be required because symptoms recur when treatment is stopped [Rees and Purdie, 2006a].
  • Sleep disturbances:
    • By alleviating night sweats, HRT often improves sleep. Women often report an improvement in sleep patterns with HRT even if hot flushes or night sweats are not prominent menopausal symptoms [ICSI, 2006]. There is evidence that combined oral oestrogen and progestogen therapy provides a small statistical but not clinically meaningful improvement in sleep disturbances.
  • Incontinence:
    • The British Menopause Society currently recommends the use of systemic or topical oestrogen for urinary frequency and urgency [BMS, 2006a]. The evidence to support the use of oestrogens is conflicting. A Cochrane systematic review found evidence that oestrogen treatment improved or cured incontinence; this was more likely with urge incontinence [Moehrer et al, 2003]. However, a subsequently published analysis of the Women's Health Initiative trial found that oestrogen therapy alone and combined with progestogen therapy increased the risk of urinary incontinence among continent women and worsened urinary incontinence among symptomatic women after 1 year [Hendrix et al, 2005].
  • Mood disorders:
    • No evidence indicates that HRT has a direct effect on mood, irritability, or anxiety. However, HRT may be helpful if other menopausal symptoms, such as hot flushes and sleep disturbance, are present [ICSI, 2006].
  • Libido:
    • Other than relieving hot flushes and improving sleep, HRT improves urogenital atrophy, thinning, dryness, and loss of elasticity, all of which may cause dyspareunia. While this may improve sexual functioning for many women, HRT has no proven direct benefit on sexuality or libido [ICSI, 2006].
  • Osteoporosis:
  • Colorectal cancer:
    • There is evidence that HRT reduces the risk of colorectal cancer [Writing Group for the Women's Health Initiative Investigators, 2002].
    • The risk of colorectal cancer increases with increasing age. Therefore, HRT produces a greater potential reduction in the number of cases of colorectal cancer in older women than in younger women. However, some of the potential risks of HRT also increase with age. Little is known about colorectal cancer risk when treatment is stopped. No information is available about HRT in high-risk populations, and current evidence does not allow recommendation of HRT to prevent colorectal cancer [BMS, 2006a].
  • Use of HRT may be associated with reduced tooth loss, reduced incidence of age-related macular degeneration and cataracts, improved faecal continence, improved wound healing, and improved balance. However, HRT is not licensed for these indications, and the risks of prescribing HRT for any of these problems are likely to outweigh the benefits.

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