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Menopause - Management
Which route should I use?

  • Oral or transdermal preparations may be used to treat urogenital symptoms or vasomotor symptoms (e.g. flushes or sweats) with or without urogenital symptoms.
    • Transdermal preparations may be appropriate if:
      • The woman prefers this route.
      • Symptom control is poor with oral treatment.
      • Oral treatment causes adverse effects (e.g. nausea).
      • History of or risk of venous thromboembolism (in this situation, consider hormone replacement therapy [HRT] only after full discussion and appropriate investigation).
      • The woman is taking a hepatic enzyme–inducing drug (e.g. anticonvulsant therapy).
      • The woman has a bowel disorder which may affect absorption of oral therapy.
      • The woman has a history of migraine (when steadier hormone levels may be beneficial).
      • The woman has lactose sensitivity (most HRT tablets contain lactose).
  • Low-dose vaginal oestrogen (tablet, cream, pessary, or vaginal ring) may be used for urogenital symptoms alone.
  • Offer the levonorgestrel-releasing intrauterine system (Mirena®) when:
    • The woman is experiencing persistent progestogenic adverse effects from systemic HRT despite changes in type and route of progestogen.
    • Contraception is required along with HRT in the perimenopause.
    • Withdrawal bleeds on sequential HRT are heavy, after investigation if indicated.
  • Estradiol implants are usually offered as a last resort in women post-hysterectomy when symptoms are not controlled by other means. Implants release estradiol over many months (replaced every 6 months) so that the woman does not have to remember to take medication. However, they can scar the skin and cannot be easily removed.
Basis for recommendation
  • These recommendations are based on pragmatic advice and published expert opinion [Rees and Purdie, 2006a].
  • Oral oestrogens are more likely to cause nausea than other forms of oestrogen.
  • Vaginal oestrogen:
    • Systemic absorption of low-dose vaginal oestrogen is very low and does not relieve other menopausal symptoms, such as hot flushes.
  • Patches:
    • Hormone levels delivered by patch are more constant than if given orally; oestrogen is absorbed directly through the skin into the systemic circulation, bypassing the liver.
    • Some patches come in four strengths of oestrogen, allowing titration to the optimal dose.
  • Mirena®:
    • Mirena® provides adequate endometrial protection. The oestrogen dose and route can be tailored to meet individual needs.
    • Progestogenic systemic absorption is minimal, reducing systemic progestogenic side effects. The endometrial effect of Mirena® can significantly reduce bleeding when used as part of a hormone replacement therapy regimen: 30–60% of women become amenorrhoeic. Although Mirena used for contraception is licensed for 5 years, the license for use for the progestogen part of hormone replacement therapy is currently 4 years.
  • Estradiol implants:
    • Recurrence of vasomotor symptoms at supraphysiological plasma concentrations may occur. Moreover, there is evidence of prolonged endometrial stimulation after discontinuation (calling for continuous cyclical progestogen) [BNF 54, 2007].

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