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Menopause - Management
How should I manage women who have had a hysterectomy with HRT?

  • Offer lifestyle advice.
  • Advise the woman about the risks and benefits of oestrogen-based hormone replacement therapy (HRT) 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) or systemic (oral or transdermal) oestrogen replacement therapy:
      • Low-dose vaginal oestrogen may be preferred if the woman does not wish to take or cannot tolerate systemic oestrogen.
  • Vasomotor symptoms (e.g. hot flushes, night sweats), with or without urogenital symptoms:
    • Offer systemic (oral or transdermal), unopposed oestrogen replacement therapy.
  • Decreased libido:
    • Seek specialist advice if considering testosterone patches or implants.
  • For a full discussion on the choice of HRT preparations, see Type of product to offer.
Clarification / Additional information
  • Urogenital symptoms: long term treatment is often required as symptoms can recur on cessation of therapy.
  • Vasomotor symptoms generally respond to systemic therapy within 4 weeks of starting treatment and have a maximal therapeutic effect at 3 months.
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].
  • Oestrogen therapy:
    • Hysterectomized women should be given oestrogen alone and have no need for progestogen therapy [Rees and Purdie, 2006a]. Progestogens are added to oestrogen therapy to reduce the risk of endometrial hyperplasia and carcinoma which occurs with unopposed oestrogen.
    • 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].
  • Libido:
    • Hormone replacement therapy (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. Specialist advice should be sought because it is not successful in all women and other factors such as marital problems may be involved [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].
  • Hot flushes and night sweats:
    • Good evidence indicates that systemic 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 vaginal atrophy (dryness, burning and itching, and dyspareunia).
  • Recurrent urinary tract infections:
    • There is evidence that oral or 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].
  • 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 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 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 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].

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