• The risks and benefits of hormone replacement therapy (HRT).
• The expected duration of treatment:
• Women with premature menopause usually take HRT up to the age of the natural menopause (50 years); at that time, treatment is usually reassessed.
• 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

• Offer lifestyle advice.
• Refer women who are younger than 40 years of age to a gynaecologist.
• Offer systemic hormone replacement therapy (HRT) or the combined oral contraceptive pill (COC):
• HRT: the HRT regimens used will depend on whether or not the woman has undergone a hysterectomy, still has some ovarian activity and still has periods.
• For women who are still having periods offer oral or transdermal, combined cyclical HRT (a 3-monthly regimen may be preferred).
• For women who have had a hysterectomy offer oral or transdermal oestrogen replacement therapy.
• COC: whether or not the woman can be prescribed the COC will depend upon the woman's age and associated risk factors (e.g. smoking).
• Decreased libido: testosterone implants and patches may be considered (especially in oophorectomized women); however, seek specialist advice before prescribing.
• Advise the woman that she may still become pregnant if contraception is not used.
• See the CKS topic on Contraception for a detailed discussion on the use of contraception in perimenopausal women.

In depth

• Women with premature menopause usually take hormone replacement therapy up to the age of the natural menopause (50 years); at that time, treatment is usually reassessed.

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.
• Interrupt treatment with intravaginal oestrogen to re-assess the need for continued use.
• 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.
• Pelvic examination is required only if clinically indicated (e.g. if there is unscheduled bleeding, especially if heavy, prolonged, or recurrent).

In depth

• For women taking cyclical hormone replacement therapy (HRT) refer if:
• There is a change in pattern of withdrawal bleeds or breakthrough bleeding.
• For women taking continuous combined HRT or long cycle regimens refer if:
• Breakthrough bleeding persists for more than 4–6 months after starting therapy.
• A bleed occurs after amenorrhoea.
• Refer if 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