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 To check if the topic you are viewing is current or out of date, please refer to the topic publication details by clicking on the 'How up-to-date is this topic?'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
Which hormone should I use?
- Choice of systemic oestrogen:
- 'Natural' oestrogens, such as conjugated oestrogen, estradiol, estrone, and estriol, are suitable for use as systemic hormone replacement therapy (HRT).
- Choice of vaginal oestrogen:
- Low dose oestrogens such as estriol (cream or pessary) or estradiol (tablet or ring) preparations are suitable for topical (vaginal) use. Endometrial effects should not be incurred. A progestogen is not needed with such low dose preparations [Rees and Purdie, 2006a].
- Synthetic or conjugated oestrogens should be avoided as they are well absorbed from the vagina and may potentially result in endometrial stimulation.
- Choice of progestogen:
- The progestogens most commonly used in HRT are almost all synthetic and include:
- Dydrogesterone and medroxyprogesterone.
- Norethisterone and levonorgestrel.
- Drospirenone.
- Women vary in their tolerance to progestogens.
- Medroxyprogesterone and dydrogesterone are sometimes better tolerated than norethisterone or levonorgestrel because they are less androgenic.
- Drospirenone is also considered to be less androgenic and has aldosterone antagonistic activities. It is useful for women who complain of fluid retention during the progestogen phase.
- Combined HRT tablets contain medroxyprogesterone, dydrogesterone, or drospirenone (less androgenic); or norethisterone, or levonorgestrel (more androgenic).
- Combined HRT patches only contain norethisterone or levonorgestrel (more androgenic). There are currently no patches containing less androgenic progestogens.
- The levonorgestrel-releasing intrauterine system is an alternative route of delivery of progestogen to protect the endometrium. Since levonorgestrel is delivered locally to the uterus, a much lower daily dose is used, which also results in low systemic levels of levonorgestrel.
- Tibolone is a synthetic steroidal agent with oestrogenic, progestogenic, and androgenic activity. It may be used as an alternative to combined therapy for postmenopausal women who wish to have amenorrhoea.
- Testosterone supplementation (patches and implants) can improve loss of libido, 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].
Clarification / Additional information
- For the purposes of this guideline, 'natural oestrogen' is defined as one that is found in normal physiology, irrespective of whether it has been prepared by chemical synthesis or extraction from a plant or animal source.
Basis for recommendation
- These recommendations are based on published expert opinion [Rees and Purdie, 2006a].
- Synthetic oestrogens, such as mestranol or ethinylestradiol, are generally considered not to be suitable for hormone replacement therapy (except in women with early ovarian failure) because of their greater metabolic impact.
© NHS Institute for Innovation and Improvement