• The risks and benefits of hormone replacement therapy or tibolone if appropriate.
• 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. Regular attempts (at least annually) to stop treatment are usually made. Symptoms may recur once treatment has stopped.
• Any possible adverse effects such as breast tenderness or enlargement, nausea, headaches, or bleeding.

• 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:
• Breast cancer: oestrogens may slightly increase the risk of having breast cancer diagnosed. Combined (oestrogen and progestogen) HRT increases this risk by about 1.6 times after 5 years of use and 2.3 times after 10 years of use. Risk decreases within a few years of stopping HRT.
• Endometrial cancer: increased risk only with unopposed oestrogen. There is no increased risk with combined (oestrogen and progestogen) HRT.
• Ovarian cancer: long-term use of oestrogen-only HRT and combined 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.
• Coronary heart disease: the increased risk is for women who have started combined HRT more than 10 years after the menopause.
• Stroke and dementia: found mainly in women over the age of 65 years.

In depth

• Tibolone is effective for treating vasomotor symptoms and reduces the risk of spine fractures. It may also improve sexual functioning.
• Tibolone is associated with a small increased risk of stroke.
• Most studies have shown a small increased risk of having endometrial cancer diagnosed with tibolone use.
• Limited data suggest that tibolone may be associated with a small increased risk of breast cancer, and that tibolone does increase the risk of breast cancer recurrence in women with a history of breast cancer.
• In younger women, the risk profile of tibolone is broadly similar to that for conventional combined hormone replacement therapy.
• For women more than about 60 years of age, the risks associated with tibolone start to outweigh the benefits because of the increased risk of stroke.

In depth