• The risks and benefits of hormone replacement therapy.
• The expected duration of treatment:
• For vasomotor symptoms, most women require 2–3 years of treatment, but some women may need longer. This judgement should be made on a case-by-case basis with regular attempts to discontinue. Symptoms may recur for a short time after stopping HRT.
• Topical (vaginal) oestrogen may be required long term as symptoms recur once treatment has stopped.
• Any possible adverse effects such as breast tenderness or enlargement, nausea, headaches.

• Hormone replacement therapy (HRT) is effective for:
• Treating vasomotor symptoms (e.g. hot flushes and night sweats).
• Treating urogenital symptoms (e.g. vaginal dryness, dyspareunia as a result of vaginal dryness, recurrent urinary tract infections, and urinary frequency and urgency).
• Sleep or mood disturbances caused by hot flushes and night sweats.
• Preventing osteoporosis. HRT is not normally used as a first-line treatment (as the risks outweigh the benefits) except in women with premature ovarian failure.
• Reducing the risk of colorectal cancer (but HRT is currently not recommended for this use).

In depth

• There is a small increase in risk for:
• Ovarian cancer: long-term use of oestrogen-only Hormone replacement therapy (HRT) may slightly increase the risk. Risk decreases after stopping HRT.
• Venous thromboembolism (deep vein thrombosis or pulmonary embolism): the absolute risk is small and may be lower with transdermal than oral oestrogen.
• Stroke and dementia: this is mainly found in women over the age of 65 years.

• Offer lifestyle advice.
• Advise the woman about the risks and benefits of oestrogen-based hormone replacement therapy (HRT) and record in the notes.
• For urogenital symptoms (e.g. vaginal dryness, dyspareunia) offer low-dose vaginal oestrogen (cream, pessary, tablet, or ring) or systemic (oral or transdermal) oestrogen replacement therapy:
• Vaginal oestrogen may be preferred if the woman does not wish to take, or cannot tolerate systemic oestrogen.
• For 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.

In depth

• A remnant of endometrial tissue may be present in women who have had a subtotal hysterectomy (in which the main part of the uterus is removed but the cervix is retained).
• To test for the presence of endometrial tissue, prescribe a 3-month course of cyclical hormone replacement therapy (HRT):
• If withdrawal bleeding occurs, endometrial tissue is present, and combined HRT should be started.
• If the woman does not have withdrawal bleeding, endometrial tissue is unlikely to be present, and oestrogen-only HRT may be started.

In depth

• Review 3 months after starting hormone replacement therapy (HRT) and once each year thereafter.
• At 3-months:
• Check blood pressure, body weight, and assess the effectiveness of treatment; adjust HRT to achieve symptom control.
• Enquire about any adverse effects and manage appropriately.
• Once each year:
• Check blood pressure, effectiveness of treatment and adjust to achieve symptom control.
• Enquire about adverse effects and manage appropriately.
• Re-assess the need for continuing HRT.
• Discuss the risks and benefits of HRT. Explain that some of the risks (e.g. ovarian cancer) associated with oestrogen-only HRT increase with longer duration of HRT. The risk decreases after stopping HRT.
• Perform a breast examination if indicated by personal or family history.
• Encourage breast awareness and participation in the national breast screening programme as appropriate for their age.

In depth

• Refer to secondary care if there is multiple treatment failure (e.g. three or more regimens have been tried).

In depth