• 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

• 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