CKS is no longer commissioned by the National Institute for Health and Clinical Excellence (NICE). NICE remains committed to providing a replacement service for CKS and is currently reviewing its options. In the meantime, although CKS content is now not being maintained, it still remains relevant and will continue to be made available. CKS content was generated under a programme of topic creation and update. To check if the topic you are viewing is current or out of date, please refer to the topic publication details by clicking on the 'How up-to-date is this topic?' link in the left hand menu on individual topic pages.
Menopause - Management
How should I manage post-menopausal women with HRT (intact uterus)?
- Offer lifestyle advice.
- Advise the woman about the risks and benefits of oestrogen-based hormone replacement therapy (HRT) or tibolone as appropriate and record this in her notes.
- Urogenital symptoms alone (e.g. vaginal dryness, dyspareunia, recurrent urinary tract infections, or urinary frequency and urgency):
- Offer treatment with low-dose vaginal oestrogen (cream, pessary, tablet or ring) therapy or systemic (oral or transdermal) continuous combined HRT:
- Low-dose vaginal oestrogen may be preferred if the woman does not wish to take systemic HRT or cannot tolerate systemic HRT.
- Vasomotor symptoms (e.g. hot flushes, night sweats), with or without urogenital symptoms:
- Offer systemic (oral or transdermal) continuous combined HRT or tibolone.
- If the woman requires treatment for decreased libido, consider offering tibolone (licensed use).
- For a full discussion on the choice of HRT preparations, see Type of product to offer.
- Give advice regarding contraception:
- A suitable method of contraception should be used for 1 year after the last menstrual period if the woman is more than 50 years of age, or for 2 years after the last menstrual period if the woman is younger than 50 years of age.
- See the CKS topic on Contraception for a detailed discussion on the most appropriate method of contraception in menopausal women and for how long it should be continued.
Clarification / Additional information
- Prescribe hormone replacement therapy at the lowest effective dose for the shortest duration possible.
- Maximal benefit of systemic hormone replacement therapy is usually seen within 3 months, and treatment is generally continued for up to 5 years.
- Urogenital symptoms: topical oestrogens should be used in the lowest effective amount to minimize systemic absorption. 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. Long-term treatment is often required as symptoms can recur on cessation of therapy.
Basis for recommendation
- These recommendations are based on published expert opinion and evidence from systematic reviews and large randomized controlled trials [NZGG, 2004; ICSI, 2006; Rees and Purdie, 2006a; MHRA and CHM, 2007b].
- Vaginal oestrogens:
- Low-dose oestrogen therapy is preferred because it incurs no adverse endometrial effects and a progestogen is not required for endometrial protection [Rees and Purdie, 2006a]. Vaginal oestrogen therapy may be required long-term, as symptoms recur when treatment is stopped. However the endometrial safety of long term or repeated use of topical vaginal oestrogens is uncertain [CSM, 2003b].
- Continuous combined hormone replacement therapy (HRT):
- Cyclical HRT preparations may be used in postmenopausal women; however, continuous combined preparations are generally preferred because they do not induce bleeding.
- Treatment for vasomotor symptoms should be continued for at least 1 year; otherwise, symptoms recur. Menopausal symptoms usually resolve within 2–5 years, but some women experience symptoms for many years, even into their seventies and eighties [Rees and Purdie, 2006a].
- Tibolone:
- There is evidence that tibolone is effective for treating vasomotor symptoms and improving sexual functioning.
- Hot flushes and night sweats:
- Good evidence indicates that systemic (oral and transdermal) HRT with 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 (combined oral oestrogens and progestogens or intravaginal oestrogens) is effective for treating symptoms of vaginal atrophy (dryness, burning and itching, and dyspareunia).
- 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.
- Mood disturbances:
- 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 disturbances, are present [ICSI, 2006].
- Libido:
- 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].
- There is evidence that loss of libido can be improved by testosterone supplementation, particularly after surgical menopause. Treatment is not always successful, other factors such as marital problems may be involved, and testosterone may cause potentially serious adverse effects [Rees and Purdie, 2006a].
- Testosterone patches are licensed for women with surgically induced menopause (in women receiving concomitant oestrogen therapy), but they are not recommended for women naturally menopausal or those taking conjugated oestrogens. Safety and efficacy of testosterone patches have not been established beyond 1 year of treatment [BNF 54, 2007].
- 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, and long-term treatment is required because symptoms recur when treatment is stopped [Rees and Purdie, 2006a].
- Incontinence:
- The British Menopause Society currently recommend the use of oral 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 alone or combined with progestogen increased the risk of urinary incontinence among continent women and worsened urinary incontinence among symptomatic women after 1 year [Hendrix et al, 2005].
© NHS Institute for Innovation and Improvement