• Scenario: Perimenopausal with uterus (HRT): covers the management of menopausal symptoms with hormone replacement therapy (HRT) in perimenopausal women who have an intact uterus. A woman is considered to be perimenopausal from the time the clinical features of the menopause start to 12 months after the last menstrual period.
• Scenario: Postmenopausal with uterus (HRT): covers the management of menopausal symptoms with hormone replacement therapy (HRT) in postmenopausal women who have an intact uterus. A woman with a uterus is considered to be postmenopausal when she has not had a period for 12 months.
• Scenario: Menopausal symptoms after a hysterectomy (HRT): covers the management of menopausal symptoms with hormone replacement therapy (HRT) in women who have had a hysterectomy.
• Scenario: Premature menopause: covers the management of women who have a menopause below the age of 45 years.
• Scenario: Poor symptom control on HRT: covers management strategies for women who experience poor symptom control while taking HRT.
• Scenario: Managing adverse effects of HRT: covers the management of adverse effects (e.g. bleeding) of HRT.
• Scenario: Stopping HRT: covers the withdrawal of HRT.
• Scenario: Managing the menopause without HRT: covers the treatment options available for women who cannot, or do not wish to take HRT.

• The risks and benefits of hormone replacement therapy.
• 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

• 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

• 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

• The risks and benefits of hormone replacement therapy.
• 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 as symptoms recur once treatment has stopped.
• Any possible adverse effects such as breast tenderness or enlargement, nausea, headaches.

• 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:
• Ovarian cancer: long-term use of oestrogen-only Hormone replacement therapy (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.
• Stroke and dementia: this is mainly found in women over the age of 65 years.

• Offer lifestyle advice.
• Advise the woman about the risks and benefits of oestrogen-based hormone replacement therapy (HRT) 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) oestrogen replacement therapy:
• Vaginal oestrogen may be preferred if the woman does not wish to take, or cannot tolerate systemic oestrogen.
• For vasomotor symptoms (e.g. hot flushes, night sweats), with or without urogenital symptoms, offer systemic (oral, or transdermal) unopposed oestrogen replacement therapy.
• Decreased libido: seek specialist advice if considering testosterone patches or implants.

In depth

• A remnant of endometrial tissue may be present in women who have had a subtotal hysterectomy (in which the main part of the uterus is removed but the cervix is retained).
• To test for the presence of endometrial tissue, prescribe a 3-month course of cyclical hormone replacement therapy (HRT):
• If withdrawal bleeding occurs, endometrial tissue is present, and combined HRT should be started.
• If the woman does not have withdrawal bleeding, endometrial tissue is unlikely to be present, and oestrogen-only HRT may be started.

In depth

• 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.
• Re-assess the need for continuing HRT.
• 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.

In depth

• Refer to secondary care if there is multiple treatment failure (e.g. three or more regimens have been tried).

In depth

• 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

• Review the woman:
• Check that the hormone replacement therapy (HRT) has been used as recommended for at least 3 months to ensure full effect.
• Check that patches are adherent.
• Review the woman's expectations. HRT can help symptoms due to oestrogen deficiency but is not an answer to all problems.
• Consider an alternative diagnosis. See Other causes of the symptoms.
• Treatment options include:
• Increasing the oestrogen dose.
• Adding vaginal oestrogen if urogenital symptoms are not controlled.
• Switching from oral to a non-oral route (e.g. if absorption is poor owing to a bowel disorder or if a drug interaction is present).
• Switching delivery system if patch adhesion is poor.

In depth

• Oestrogen-related adverse effects (e.g. fluid retention, bloating, breast tenderness or enlargement, nausea, headaches, leg cramps, and dyspepsia) may occur continuously or randomly throughout the cycle.
• Advise to persist with treatment for 3 months (as adverse effects may resolve):
• Leg cramps: lifestyle changes (e.g. exercise and stretching of the calf muscles) may be helpful.
• Nausea/gastric upset: adjust the timing of the oestrogen dosage or take with food.
• Breast tenderness: low-fat, high-carbohydrate diet may be helpful.
• Migraine: transdermal therapy as this produces more stable oestrogen levels.
• For persistent adverse effects, consider:
• Reducing the dosage or
• Changing the oestrogen type (i.e. swap between the two main forms of oestrogen, that is, estradiol and conjugated oestrogens) or
• Changing the route of delivery (e.g. tablets may cause nausea, but patches and gels generally do not).

In depth

• Progestogen-related adverse effects (e.g. fluid retention, breast tenderness, headaches/migraine, mood swings, depression, acne, lower abdominal pain, and backache) tend to occur in a cyclical pattern during the progestogen phase of cyclical HRT.
• Advise the woman to persist with therapy for 3 months (adverse effects may resolve).
• For persistent symptoms, consider:
• Changing froma a more androgenic progestogen (e.g. norethisterone and norgestrel) to a less androgenic progestogen (e.g. medroxyprogesterone or dydrogesterone).
• Changing from oral to transdermal, vaginal, or intrauterine progestogen.
• Reducing the duration of progestogen administration: swap from a 14 day to a 12 day product.
• Changing to a product with a lower dose of progestogen (dosages are preparation dependent).
• Switching to a long-cycle regimen, where progestogen is given for 14 days every 3 months (only suitable for women without natural regular periods).
• Changing to continuous combined therapy or tibolone (only suitable if postmenopausal).
• Many of these strategies are the opposite of what may be needed to give better bleeding control.

In depth

• Before changing treatment, visualize the cervix, check smears are up to date, and refer for transvaginal ultrasound to exclude pelvic abnormalities.
• Check compliance, drug interactions (e.g. anticonvulsants), or gastrointestinal upset.
• Altering the progestogen part of the regimen may improve bleeding problems:
• Heavy or prolonged bleeding: increase the duration or dosage of the progestogen, or change the type of progestogen. Idiopathic menorrhagia may be helped by using the levonorgestrel-releasing intrauterine system combined with an oestrogen delivered orally or transdermally.
• Bleeding early in the progestogen phase: increase dosage or change the type of progestogen.
• Irregular bleeding: change regimen or increase the dosage of progestogen.
• No bleeding whilst taking a cyclical regimen reflects an atrophic endometrium and occurs in 5% of women. Pregnancy needs to be excluded in perimenopausal women. Check compliance if the progestogen component is taken separately.

In depth

• Irregular breakthrough bleeding or spotting is common in the first 3–6 months.
• Bleeding beyond 6 months or after a spell of amenorrhoea requires further investigation or referral.

In depth

• Reassure the woman that HRT does not cause significant weight gain.

In depth

• If systemic Hormone replacement therapy (HRT) is being used for symptom control consider a trial withdrawal (if a woman is symptom-free) after 1–2 years.
• Advise the woman that symptoms may recur for a short time once HRT is stopped.
• Counsel the woman about the possible risks of HRT if she wishes to continue treatment, particularly if treatment is being used for longer than 5 years.
• Topical (vaginal) oestrogen may be required long term as symptoms can recur once treatment has stopped.
• Stop treatment at least annually to re-assess the need for continued treatment.
• Women with premature menopause usually take hormone replacement therapy up to the age of the natural menopause (50 years); at that time, therapy is reassessed. Some women will still be symptomatic.

In depth

• Some women do not notice any symptoms even with abrupt cessation of hormone replacement therapy (HRT), while others may experience a recurrence of hot flushes and sweats.
• Some experts suggest that HRT should be gradually reduced rather than stopped abruptly. Suggested strategies are:
• Oestrogen-only tablets: reduce from a 2 mg to a 1 mg tablet for 1–2 months, then use 1 mg on alternate days for a further 1–2 months.
• Oestrogen-only patches: reduce the dose gradually to 25 micrograms daily (e.g. step the dose down a patch strength each month). Half a matrix-type patch (12.5 micrograms daily) can be used for a further 1–2 months.
• Cyclical combined HRT tablets: reduce to a cyclical HRT pack containing 1 mg estradiol for 1–2 months. Cut the tablet in half for the next 1–2 months; this will ensure that the woman still receives oestrogen combined with a progestogen.
• Cyclical combined HRT patches: reduce the dose as for oestrogen-only patches, but ensure that the woman still uses the oestrogen-only patches for 2 weeks of the cycle followed by the combined patches for a further 2 weeks, to ensure endometrial protection.
• Continuous combined HRT tablets or patches: reduce the dose gradually every 1–2 months to the lowest strength tablet or patch. Then, take half a tablet or patch daily for a further 1–2 months.
• If symptoms are severe after HRT is stopped or persist for several months after stopping, the woman may wish to restart HRT after reassessment and counselling. Often a lower dose of HRT can be used (e.g. estradiol 1 mg) if HRT is restarted.

In depth

• Offer lifestyle advice to control symptoms; if this is not effective, consider other treatments.
• For vasomotor symptoms, consider:
• A trial (2 weeks) of paroxetine (20 mg daily), fluoxetine (20 mg daily), citalopram (20 mg daily), or venlafaxine 37.5 mg twice a day (unlicensed).
• A trial (2–4 weeks) of clonidine 50 to 75 micrograms twice a day (licensed use).
• A progestogen such as norethisterone or megestrol (both unlicensed). Seek specialist advice.
• For vaginal dryness, prescribe a vaginal lubricant or moisturizer, such as Replens MD^®.
• Manage psychological symptoms, such as mood disturbances, anxiety, and depression on an individual basis. They may be addressed using self-help groups, psychotherapy, other forms of counselling, or antidepressants.
• CKS does not recommend the use of complementary therapies (e.g. soy, red clover, black cohosh).

In depth

• Advise the woman to return if:
• Lifestyle measures alone have been of insufficient benefit or her symptoms have worsened.
• She does not respond to antidepressant treatment within 2 weeks.
• Clonidine was started and her symptoms have not improved in 4 weeks, or she is experiencing adverse effects, such as dizziness or constipation.
• Review all women at least annually.

In depth

• Consider stopping treatment if a woman is symptom-free on treatment; a trial withdrawal can be undertaken after 1–2 years of treatment.
• Advise that symptoms sometimes recur once treatment is stopped.
• Use of vaginal moisturizers and lubricants may be continued indefinitely.

In depth