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Menopause - Management
Which regimen should I use?
- Offer oestrogen-only hormone replacement therapy (HRT) for women who do not have a uterus (usually taken continuously).
- Offer combined (oestrogen and progestogen) HRT to women with an intact uterus:
- For perimenopausal women, monthly or 3-monthly cyclical regimens may be used:
- A 3-monthly regimen may be more suitable for women with infrequent periods or who are intolerant of progestogens.
- A monthly regimen produces monthly bleeding and a 3-monthly regimen produces a bleed every three months.
- For postmenopausal women, monthly, 3-monthly cyclical regimens, or continuous combined regimens may be used. Continuous combined regimens may be preferred because they do not produce withdrawal bleeding:
- Continuous combined HRT may produce irregular bleeding or spotting the first 4–6 months of treatment. Bleeding should be investigated if it persists beyond 6 months, if it becomes heavier rather than less, or it if occurs after amenorrhoea.
- Tibolone is an alternative no-bleed regimen for postmenopausal women.
- It is preferable for the oestrogen and progestogen to be in combined form (e.g. in one tablet), because the adverse effects of the progestogen may lead to poor compliance if given separately. If oestrogen and progestogen are given separately, an explanation about the endometrial protective effect of progestogens is important to ensure compliance.
Clarification / Additional information
- Combined hormone replacement therapy regimens:
- Monthly cyclical regimens: oestrogen is taken daily and progestogen given at the end of the cycle for 10–14 days.
- Three-monthly cyclical regimens: oestrogen is taken every day and progestogen is given for 14 days every 13 weeks.
- Continuous combined regimens: oestrogen and progestogen are taken every day.
Basis for recommendation
- These recommendations are based on expert published opinion [Rees and Purdie, 2006a].
- Hysterectomy:
- Women who have a had a hysterectomy do not usually require the addition of progestogen. Progestogens are added to hormone replacement therapy regimens to reduce the increased risk of endometrial hyperplasia and cancer which occurs with unopposed oestrogen.
- Perimenopausal women:
- Continuous regimens are not recommended because they often cause unpredictable bleeding in these women.
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