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Menopause - Management
What follow up is required?

  • Review the woman 3 months after starting hormone replacement therapy (HRT) and once each year thereafter.
  • At the initial 3-month review:
    • Assess the effectiveness of treatment and adjust to achieve symptom control.
    • Enquire about any adverse effects and manage appropriately.
    • Enquire about bleeding patterns.
    • Check blood pressure and body weight.
  • Once each year:
    • Check effectiveness of treatment and adjust to achieve symptom control.
    • Check for adverse effects and manage appropriately.
    • Consider switching from cyclical HRT to continuous combined HRT, if appropriate.
    • Interrupt treatment with intravaginal oestrogen and consider stopping systemic HRT, to re-assess the need for continued use.
    • Explain that some of the risks (e.g. breast cancer, ovarian cancer) associated with HRT increase with longer duration of hormone replacement therapy (HRT):
      • Breast cancer: combined HRT increases this risk by about 1.6 times after 5 years of use and 2.3 times after 10 years of use. Risk decreases within a few years of stopping HRT.
      • Ovarian cancer: long-term use of oestrogen-only HRT and combined HRT may slightly increase the risk. Risk decreases after stopping HRT.
    • Perform a breast examination if indicated by personal or family history.
    • Encourage breast awareness and participation in the national breast screening programme as appropriate for their age.
    • Pelvic examination is required only if clinically indicated (e.g. if there is unscheduled bleeding, especially if heavy, prolonged, or recurrent).
    • Check blood pressure.
  • Oestrogen levels are rarely indicated.
Clarification / Additional information
  • Measurement of estradiol is rarely indicated but may be of use if the clinical response (i.e. symptomatic relief) to HRT is poor [Smellie et al, 2006]:
    • To establish whether absorption of transdermal HRT is adequate in women in whom poor absorption is suspected. If poor absorption is confirmed, prescribe oral HRT.
    • To ensure that oestrogen levels have fallen before implant replacement in women, to avoid supraphysiological concentrations and possible tachyphylaxis.
    • Rarely, in women with persisting symptoms where poor compliance is suspected.
Basis for recommendation
  • These recommendations are based on published expert opinion [Working Group on Breast and Pelvic Examination, 2001; RCPE, 2003; AACE Menopause Guidelines Revision Task Force, 2006; Rees and Purdie, 2006a; MHRA and CHM, 2007b; Roberts, 2007].
  • An initial review is recommended at 3 months, as most menopausal symptoms respond by then:
    • Vasomotor symptoms: improvement is usually noted within 4 weeks. Usually, hormone replacement therapy (HRT) is used for less than 5 years [BMS, 2006a].
    • Urogenital symptoms: topical oestrogens should be used in the lowest effective amount to minimize systemic absorption [CSM, 2003b]. However long term treatment is often required as symptoms can recur on cessation of therapy [BMS, 2006a]. Treatment should be interrupted as least annually to re-assess the need for continued treatment. If breakthrough bleeding or spotting appears at any time on therapy, the reason should be investigated and may include endometrial biopsy to exclude endometrial malignancy [CSM, 2003b].
  • An annual review is recommended because the risks and benefits of HRT for each woman change over time and need to be discussed regularly.
  • Blood pressure measurement is not routinely needed, but opportunistic screening is useful.
  • Measurement of follicle-stimulating hormone:
  • Measurement of oestrogen:
    • This recommendations is based on Best Practice in primary care pathology [Smellie et al, 2006].

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