Who should be offered HRT?
- Peri- and postmenopausal women with symptoms attributable to the menopause.
- Follicle-stimulating hormone (FSH) measurements are not indicated prior to HRT treatment but may be considered to diagnose menopause only in women aged 40 to 45 years with menopausal symptoms or in women under 40 in whom menopause is suspected.
- Adopt an individualised approach at all stages of diagnosis, investigation and management of menopause.
Should first choice be oral or transdermal?
- Oral treatment is cost-effective and is well tolerated.
- Start with lower dose regimes and reappraise need on an annual basis. Do not change preparation before an adequate trial has been completed, as side-effects are common in the first 3 months but usually subside.
- The risk of venous thromboembolism (VTE) associated with HRT is greater for oral than transdermal preparations. The risk associated with transdermal HRT given at standard therapeutic doses is no greater than baseline population risk.
- Consider transdermal rather than oral HRT for menopausal women who are increased risk of VTE, including those with a BMI over 30kg/M².
When can bleed-free regimes be used?
- Women who have had no periods for at least 1 year prior to starting HRT or after 2 years on a sequential regimen.
What are the contra-indications to HRT?
- Active arterial or venous thromboembolic disease.
- Unexplained vaginal bleeding.
- Oestrogen-dependent tumours, eg breast, uterus.
- Recent myocardial infarction and/or active coronary heart disease.
Risks of HRT
- HRT does not increase cardiovascular risk when started in women aged under 60 years. Cardiovascular risk factors are not a contraindication to HRT as long as they are optimally managed.
- Oral HRT (not transdermal) is associated with a small increase in the risk of stroke although the baseline population risk of stroke in women aged under 60 years is very low.
- Risk of VTE is increased by oral HRT compared to baseline population. If HRT is to be used by women at increased risk of thromboembolism, use a transdermal preparation.
- HRT with oestrogen and progestogen can be associated with an increase risk in breast cancer but any increase is related to the treatment duration and reduces on stopping HRT. HRT with oestrogen alone is associated with little or no change in the risk of breast cancer.
- If 1000 women age 50 to 59 used combined HRT for 5 years, it is estimated that an extra 3 breast cancers will be diagnosed.
- If HRT is commenced at a young age then the use of HRT up to age 50 does not increase breast cancer risk any more than in a woman who continues to have periods up to age 50.
- HRT is not contraceptive. See guidance from the FSRH on Contraception for Women over 40 years (https://www.fsrh.org/documents/cec-ceu-guidance-womenover40-jul-2010/).
- Mirena® is licensed for use as progestogen phase of HRT but should be replaced within 5 years.
There is no clear consensus on how to discontinue HRT, and symptoms may recur regardless of whether HRT is stopped slowly or suddenly. It is not usually appropriate to start women over the age of 60 on HRT but it does not mean that those who have started it earlier need to stop it on reaching 60.
Alternatives to HRT for menopausal symptoms
- Do not routinely offer selective serotonin reuptake inhibitors (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI) type drugs or clonidine as first-line treatment for vasomotor symptoms alone. There is no clear evidence for SSRI or SNRI to ease low mood in menopausal women who have not been diagnosed with depression.
- Consider HRT to alleviate low mood that arises from the menopause
- Relaxation therapy, mindfulness-based therapies and cognitive behavioural therapy (CBT) may alleviate low mood and anxiety arising as a result of the menopause.
- There is some evidence that isoflavones or black cohosh may relieve vasomotor symptoms but safety is uncertain and interactions with other medicines have been reported.
- Vaginal oestrogen effectively treats urogenital atrophy (including those on systemic HRT (see section 7.2). Continue treatment for a long as needed to relieve symptoms.
- Vaginal oestrogens may be considered in women in whom systemic HRT is contra-indicated.
- Non-hormonal options such as moisturisers and lubricants can be used alone or in addition to vaginal oestrogens.
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