• Offer lifestyle advice.
• Advise about the risks and benefits of hormone replacement therapy (HRT) and record in the notes.
• For urogenital symptoms (e.g. vaginal dryness, dyspareunia) offer treatment with low-dose vaginal oestrogen (cream, pessary, tablet, or ring) or combined, systemic (oral or transdermal), cyclical HRT:
• Low-dose vaginal oestrogen may be preferred if the woman does not wish to take systemic HRT or cannot tolerate systemic HRT.
• For women with infrequent periods or who cannot tolerate progestogens, a systemic 3-monthly regimen may be preferred.
• For vasomotor symptoms (e.g. hot flushes, night sweats), with or without urogenital symptoms offer systemic (oral or transdermal) cyclical combined HRT:
• For women with infrequent periods or who cannot tolerate progestogens, a 3-monthly regimen may be preferred.
• Advise the woman that she may still get pregnant if contraception is not used:
• A suitable method of contraception should be used for 1 year after the last menstrual period if the woman is more than 50 years of age, or for 2 years after the last menstrual period if the woman is less than 50 years of age.
• See the CKS topic on Contraception for more information on contraception in perimenopausal women.

In depth

• Review the woman 3 months after starting hormone replacement therapy (HRT) and once each year thereafter.
• At 3-months:
• Enquire about bleeding patterns, check blood pressure, and body weight.
• Assess the effectiveness of treatment and adjust to achieve symptom control.
• Enquire about 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.
• Consider switching from cyclical HRT to continuous combined HRT, if appropriate.
• Interrupt treatment with intravaginal oestrogen and consider stopping systemic HRT, to re-assess the need for continued use.
• Discuss the risks and benefits of HRT. Explain that some of the risks (e.g. breast cancer, ovarian cancer) associated with HRT increase with longer duration of 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.
• Pelvic examination is required only if clinically indicated (e.g. if there is unscheduled bleeding, especially if heavy, prolonged, or recurrent).

In depth

• Refer women who are taking cyclical hormone replacement therapy if:
• There is a change in pattern of withdrawal bleeds or break through bleeding.
• There is multiple treatment failure e.g. three or more regimens have been tried.
• Refer to a team specializing in the management of gynaecological cancer (depending on local arrangements) any persistent or unexplained bleeding after cessation of hormone therapy for 6 weeks.

In depth

• Consider switching from cyclical to continuous combined HRT when the woman is considered to be postmenopausal. This may be difficult to judge. Women are generally considered to be postmenopausal if:
• They are more than 54 years of age (approximately 80% of women are postmenopausal by this age).
• They have had previous amenorrhoea or increased levels of follicle-stimulating hormone (FSH). Women who experienced 6 months of amenorrhoea or had increased FSH levels in their mid-40s are likely to be postmenopausal after taking several years of cyclical HRT.

In depth