• Offer lifestyle advice.
• Advise the woman about the risks and benefits of oestrogen-based hormone replacement therapy (HRT) or tibolone as appropriate 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) continuous combined HRT:
• Low-dose vaginal oestrogen may be preferred if the woman does not wish to take systemic HRT or cannot tolerate systemic HRT.
• For vasomotor symptoms (e.g. hot flushes, night sweats), with or without urogenital symptoms, offer systemic (oral or transdermal) continuous combined HRT or tibolone.
• Decreased libido: consider offering tibolone (licensed use).
• Offer advice regarding contraception: 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 menopausal 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 if:
• Breakthrough bleeding persists for more than 4–6 months after starting HRT or tibolone.
• A bleed occurs after amenorrhoea.
• 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